Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an otolaryngology (ENT) office visit 
provided on February 17, 2020. 
 
You asked the Plan to waive the copayment for specialist visit. You say that you only say the doctor for 5 
minutes and were told that everything was fine. The Plan denied your request. The Plan says the copayment 
amount you are being charged is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $40 
copayment for in-network specialist visit.  
 
You have been asked to pay $40 copayment for specialist visit. Specialist visit falls within the 
Physician/Practitioner Services, Including Doctor's Office Visits benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for an otolaryngology (ENT) office visit provided on February 17, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services (G0299) provided on October 25, 2019. 
 
You asked the Plan to pay for home health services. You say that you were told this would be covered. The 
Plan denied your request. The Plan says this service was custodial. 
 
The Plan must follow Medicare rules. Medicare rules say that custodial care is not covered. 
 
We looked at the file and Medicare rules. Although this was billed as skilled nursing care, the records show 
that the service provided was help with activities of daily living such as grooming and meal preparation, which 
are custodial in nature. Based on this information, we decided that Medicare rules for coverage of home health 
services have not been met. Therefore, we decided that the Plan does not have to pay for home health services 
(G0299) provided on October 25, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that due to the complex medical needs, the 
best course of treatment is to admit the enrollee to a LTACH setting. The Plan denied your request. The Plan 
says admission to a LTACH is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not require any services at the proposed LTACH that are not 
already being provided in the current facility. Our reviewer found that there are no services at the proposed 
LTACH that the enrollee requires that are not already provided and covered at the current facility. Our 
physician reviewer also found that this request for LTACH services will be considered not medically 
necessary. Continued care at the current facility appears most appropriate until the enrollee is able to transfer to 
a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for contrast injections (36598) provided on February 10, 2020. 
 
You asked the Plan to pay for the contrast injections. You say that you would like reconsideration because this 
is not a bundled service. The Plan denied your request. The Plan says that this code is reimbursed only when 
there are no separate physician fee schedule codes billed on the date of service of submission. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
 
We find that CPT code 36598 is supported in the record. Specifically, per the Physician Fee Schedule, CPT 
code 36598 has a status indicator of T. This means that there are RVUs and payment amounts for these 
services, but they are only paid if there are no other services payable under the physician fee schedule billed on 
the same date by the same provider. If any other services payable under the physician fee schedule are billed on 
the same date by the same provider, these services are bundled into the physician services for which payment is 
made. In this case, the record does not indicate that there are any other services payable under the physician fee 
schedule billed on the same date by the same provider. Based on this information, we decided that Medicare 
rules for coverage of the contrast injections have been met. Therefore, we decided that the Plan has to pay for 
contrast injections (36598) provided on February 10, 2020.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee's medical and therapy needs can be met at skilled nursing 
facility level. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The 
complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient does require physical therapy and 
occupational therapy services but based on the medical records provided the patient does not require an 
intensive inpatient rehabilitation therapy program. There is concern that the patient will not be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient 
rehabilitation facility. Our physician reviewer found that the enrollee's condition does not meet Medicare 
criteria for IRF care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care from March 10, 
2020 through March 16, 2020 provided by an in-network provider. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you believe you had the 
coronavirus. The Plan denied your request. The Plan says there are no coronavirus diagnoses or testing codes 
on the claim. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  
 
Review of the file shows that you were admitted on March 10, 2020 and discharged on March 16, 2020. You 
were asked to pay a $325 copayment per day from March 10, 2020 through March 15, 2020, days 1-6 of your 
inpatient hospital care. You were discharged on March 16, 2020 and there was no copayment charge for the 
day of discharge. Per your contract there is a $325 copayment per day required for days 1-6 for in-network 
inpatient hospital care. Furthermore, there is no mention of you being tested or diagnosed with the coronavirus 
in the medical record. The claim does not contain a primary or secondary diagnosis of COVID-19. This means 
that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for inpatient hospital care from March 10, 2020 through March 16, 2020 
provided by an in-network provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a Ranibizumab injection (J2778) received 
on April 16, 2020. 
 
You asked the Plan to waive the coinsurance for a Ranibizumab injection. You say that treatment for macular 
degeneration is covered, according to Plan documents. The Plan denied your request. The Plan says the correct 
coinsurance was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Medicare Part B covered drugs. 
 
You have been asked to pay $354.23 (20% of the Plan's allowed amount of $1,771.15) for a Ranibizumab 
injection. A Ranibizumab injection falls within the Medicare Part B prescription drugs benefit category. This 
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the coinsurance for a Ranibizumab injection (J2778) received on April 16, 
2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the BLS emergency ambulance (A0429) and ground mileage 
(A0425) provided January 1, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that the medical records provided support the 
necessity of the services in dispute. The Plan denied your request. The Plan says the information provided does 
not support medical necessity for the ambulance transport. 
 
Medicare pays for ambulance services only when an emergency exists or when other means of transport would 
endanger the patient?s health. The Plan follows the same rules.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the ambulance services. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case Our 
physician reviewer found the documentation does not support that other means of transport (such as stretcher 
van, wheelchair van, taxi, private car, or other type of vehicle) were contraindicated. The documentation does 
not support that the enrollee needed the expertise, services and lifesaving and life-sustaining equipment that 
only a fully-equipped ambulance can provide for safe transport on 1/1/2020. The documentation does not 
support that the ambulance transport on 1/1/2020 was medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the ambulance services have not been met. Therefore, we decided that the Plan 
does not have to pay for the BLS emergency ambulance (A0429) and ground mileage (A0425) provided 
January 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the two provisional retainer crowns and provisional pontic provided on January 31, 2020.
You asked the Plan to pay more for the provisional retainer crowns and provisional pontic. You say that when the claims were processed, they were not processed by plan year, and some of the line items were listed multiple times. The Plan denied your request. The Plan says the claim processed correctly according to your 2020 plan benefits. The Plan also says that you are responsible for the associated cost share.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, you are responsible for a 50% coinsurance for prosthodontic services. Therefore, we decided that the Plan does not have to pay more for the two provisional retainer crowns and provisional pontic provided on January 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a punch biopsy provided on March 12, 
2020. 
 
You asked the Plan to waive the copayment for a punch biopsy. You say that you feel that the charges are too 
high. The Plan denied your request. The Plan says the claims were processed correctly and you are being 
charged the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $225 
copayment for outpatient surgery.  
 
You have been asked to pay the allowed amount of $168.45, which is less than the $225 copayment for a punch 
biopsy. A punch biopsy falls within the outpatient surgery benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for a punch biopsy provided on March 12, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not medically necessary. Our physician reviewer found the records show that you were 
admitted to the hospital on August 12, 2020 for spine surgery. The procedure had no complications. You had 
some post-operative urinary urgency and incontinence that has since resolved. You are walking with a wheeled 
walker and assistance and need varied levels of assistance with activities of daily living. You have no complex 
medical, nursing, or rehabilitation needs that require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care. You may benefit from further therapy, but do not require an intensive therapy 
program in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the durable medical equipment rendered on February 6, 
2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim was not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 37606 is ligation; internal or common carotid artery, with 
gradual occlusion, as with Selverstone or Crutchfield clamp. 
 
We find that CPT code 37606 is not supported in the medical record. Specifically, there is no documentation 
that a surgical ligation was performed; the services should have been billed with code K0606. Based on this 
information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we 
decided that the Plan does not have to pay for the durable medical equipment rendered on February 6, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the endoscopy provided on February 10, 
2020. 
 
You asked the Plan to waive the copayment for the endoscopy. You say that you should not be responsible for 
the $350 copayment for an annual preventive colonoscopy. The Plan denied your request. The Plan says you 
have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $350 
copayment per date of services for an outpatient hospital facility.  
 
You have been asked to pay a $350 copayment for the endoscopy. The endoscopy falls within the Outpatient 
surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit 
category. The record shows you were billed for the endoscopy and not for the colonoscopy. 
 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for the endoscopy provided on February 10, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the tongue biopsy (41100) provided on 
March 7, 2019. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $100 
copayment per day for outpatient procedures and services.  
 
You have been asked to pay a $100 copayment for the outpatient service provided. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for the tongue biopsy (41100) provided on March 7, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for endodontic therapy, molar tooth (excluding final restoration) 
(D3330) provided on April 10, 2020. 
 
You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the 
denied charges. The Plan denied your request. The Plan says the service is not a covered benefit under the plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. This service is not listed in your EOC as a covered benefit; therefore, it 
is not covered. Therefore, we decided that the Plan does not have to pay for endodontic therapy, molar tooth 
(excluding final restoration) (D3330) provided on April 10, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care from March 15, 2020 through March 
16, 2020. 
 
You asked the Plan to pay for inpatient hospital care. You say that the stay was medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for inpatient hospital care. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the review has determined that inpatient hospital services March 15, 2020 through 
March 16, 2020 were not medically necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient hospital care have not been met. Therefore, we decided that the Plan 
does not have to pay for inpatient hospital care from March 15, 2020 through March 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve right side medial branch blocks (MBBs). 
 
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MBBs are covered when specific criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has cervical spondylosis 
without myelopathy or radiculopathy. She underwent cervical left MBBs on November 21, 2019 and left 
cervical radiofrequency ablation on May 6, 2020. The records do not show that the enrollee meets the criteria 
for coverage of the requested right MBBs. The services are not reasonable or medically necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve right side medial branch blocks (MBBs).