Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit you had on May 28, 2019. 
 
You asked the Plan to waive the copayment. The Plan denied your request. The Plan says there is a $30 
copayment for these services. 
 
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 $30 
copayment for specialist services.  
 
Review of the file shows that you were provided specialist services on May 28, 2019. You have been asked to 
pay a $30 copayment for the visit. The visit falls within the physician services 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 the office visit you had on May 28, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient stay provided from June 8, 
2020, through June 9, 2020. 
 
You asked the Plan to waive the copayment for the inpatient stay. You say that only one patient is allowed per 
room. You say that the bill is a hardship and you want it paid. The Plan denied your request. The Plan says the 
copayment applied correctly. 
 
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 $600 
copayment per day, days 1 to 3 at an in-network inpatient hospital. 
 
You have been asked to pay a $600 copayment for the inpatient stay. The inpatient stay falls within the 
"Inpatient hospital care" 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 the inpatient 
stay provided from June 8, 2020, through June 9, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ER visit provided on July 29, 2020. 
 
You asked the Plan to waive the copayment for the ER visit. You say that you weren't in the ER or observation. 
You say that you were in a room for 2 nights and there is a $0 copayment for inpatient stays. The Plan denied 
your request. The Plan says the copayment applied correctly. 
 
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 $50 for 
each Medicare-covered emergency room visit. If you are held for observation, the $50 copayment still applies. 
 
You have been asked to pay a $50 copayment for the ER visit. The ER visit falls within the "Emergency care" 
benefit category. The medical records show that you were in outpatient observation, which still applies the ER 
copayment. 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 ER visit provided on July 29, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient hospital services provided from September 4, 2020 to 
September 6, 2020. 
 
You asked the Plan to pay for the inpatient hospital services. You say that these services were medically 
necessary. The Plan denied your request. The Plan says that that you could have been taken care of in an 
alternate level of care such as a short stay (observation). 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for the inpatient hospital services by a contract provider. The file does not show that the 
Plan provided notice that the inpatient hospital services would not be covered. Under Medicare rules, this 
means the inpatient hospital services is considered approved by the Plan. Therefore, we decided that the Plan 
has to pay for the inpatient hospital services provided from September 4, 2020 to September 6, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to provide an ultra lightweight wheelchair. 
 
You asked the Plan to provide an ultra lightweight wheelchair (K0005). You say that the enrollee needs an ultra 
lightweight wheelchair. The Plan denied your request. The Plan says there is no documentation the enrollee is a 
full time wheelchair user or cannot use a manual standard or lightweight wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that a wheelchair will not be covered if the patient does 
not have mobility deficit that impairs their participation in MRADLs, the patient?s condition can be 
ameliorated by a walker or cane, or the home cannot accommodate the wheelchair.  
 
The file does not show that the enrollee has a mobility deficit that impairs their participation in MRADLs, their 
condition cannot be improved by a walker or cane, or that the home provides adequate access between rooms 
and has maneuvering space. There is no record of a specialty evaluation or home assessment. This means that 
Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to 
provide an ultra lightweight wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on May 26, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained. The 
Plan says that the referring facility is also out-of-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for physician services provided on May 26, 2020 by 
an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve a continuous glucose monitor. You say that the enrollee needs a CGM due 
to uncontrollable diabetes and frequent finger sticks are painful. The Plan denied your request. The Plan says 
the enrollee does not meet criteria for a CGM. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The enrollee is not insulin treated by injection three or more times a 
day so the Medicare coverage criteria for a CGM is not met. Based on this information, we decided that 
Medicare rules for coverage of a continuous glucose monitor have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services (A0429) received 
on February 16, 2020. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that this charge is 
astronomical to you. The Plan denied your request. The Plan says you were charged this cost sharing correctly. 
 
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 $300 
copayment for each ambulance trip. You had 1 ambulance trip. The Plan charged you $300 for these services. 
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 ambulance services (A0429) received on February 16, 
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the core buildups provided on July 9, 2020. 
 
You asked the Plan to pay for the core buildups. You say that this should be covered since it's related to a 
medical condition. The Plan denied your request. The Plan says that this is not a covered service. 
 
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. Therefore, we decided that the Plan does not have to pay for the core 
buildups provided on July 9, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MILD procedure for the enrollee. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is considered experimental, investigational, and unproven. 
 
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 pre-approve the procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the MILD procedure is experimental. More research is needed to show safety and efficacy. 
 
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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the MILD procedure for the enrollee.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the bilateral ophthalmoscopy provided on September 23, 2019, billed 
with code 92226-50. 
 
You asked the Plan to pay for the bilateral ophthalmoscopy. You say that these services are shown to be 
rendered and should be paid. The Plan denied your request. The Plan says that the documentation submitted 
does not support that this service was performed on the right side. Of note, the medical records submitted do 
not include a retinal drawing (e.g., for retinal detachment, melanoma), with interpretation and report for the 
right eye. 
 
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 92226 is Ophthalmoscopy, extended, with retinal drawing (e.g., for retinal detachment, melanoma), with 
interpretation and report; subsequent. 
 
We asked our coding 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 bilateral ophthalmoscopy. Our reviewer 
says that the billed code with the bilateral modifier is supported in this case. Our coding reviewer found the 
documentation supports Ophthalmoscopy on both eyes with drawings on page 2 of 3 of the report.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the bilateral ophthalmoscopy have been met. Therefore, we decided that the 
Plan has to pay for the bilateral ophthalmoscopy provided on September 23, 2019, billed with code 92226-50.  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a SNF admission. 
 
You asked the Plan to pre-approve the SNF admission. You say that you would like the enrollee to receive 
therapy so he can get strong enough to return home. The Plan denied your request. The Plan says the medical 
records do not indicate that the enrollee would be able or willing to actively participate in 1 to 1.5 hours of 
active rehab services 5 days per week. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is 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 pre-approve the SNF admission. Our reviewer says 
that the enrollee does not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee 
does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a 
skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized 
skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled 
nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
  
We looked at this physician's review, the file, and Medicare rules. Although the enrollee has skilled therapy 
needs, these needs are not on a daily basis. Based on this information, we decided that Medicare rules for 
coverage of the SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-
approve a SNF admission.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a respiratory virus DNA/RNA panel with 12-25 targets 
provided on May 9, 2020. 
 
You asked the Plan to pay for the extended viral DNA/RNA panel. You say that all services provided should be 
covered. The Plan denied your request. The Plan says CPT code 87633 (12-25 targets) is non-covered by 
Medicare and excluded from coverage. 
 
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 the extended viral DNA/RNA panel. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee was a male with a history of COPD who was evaluated in the 
emergency room. Use of extended panel is restricted to when more limited panels would not be medically 
appropriate (e.g. patient critically ill, etc. The review has determined that the items/services at issue in this case 
were not medically reasonable or 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 extended viral DNA/RNA panel have not been met. Therefore, we decided 
 
 
that the Plan does not have to pay for a respiratory virus DNA/RNA panel with 12-25 targets provided on May 
9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital care (99220, 99497) provided on April 7, 2020. 
 
You asked the Plan to pay for hospital care. You say that the billed diagnosis is supported. The Plan denied 
your request. The Plan says these services were not billed with a correct primary diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that, the ICD-10-CM has a coding convention that 
requires the underlying condition be sequenced first, if applicable, followed by the manifestation.  Wherever 
such a combination exists, there is a 'use additional code' note at the etiology code, and a 'code first' note at 
the manifestation code. 
 
We looked at the file and Medicare rules. The billed primary diagnosis, F07.81, has a 'code first' note, 
requiring the etiology code to be listed first. Based on this information, we decided that Medicare rules for 
coverage of hospital care have not been met. Therefore, we decided that the Plan does not have to pay for 
hospital care (99220, 99497) provided on April 7, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the enrollee does not 
require an intensive, complex, multidisciplinary approach to daily therapy. 
 
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 physician reviewer found 
that the enrollee is at a minimal assist level for transfers, supervision for toileting, minimal assist for dressing, 
and supervision for hand washing. The enrollee does not require the intensity of services provided at an IRF.  
Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular 
physician evaluation. 
 
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2740) and core buildup, including any pins 
when required (D2950). 
 
You asked the Plan to pre-approve the crown and core buildup. You say that you have a broken tooth that 
needs to be fixed. You also say that you thought you had the enhanced dental plan. The Plan denied your 
request. The Plan says these services are not covered under your benefit 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. Therefore, we decided that the Plan does not have to pre-approve a 
crown (D2740) and core buildup, including any pins when required (D2950).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay on August 18 to 
August 20, 2020. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you cannot afford to 
pay. The Plan denied your request. The Plan says the correct copayment 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 a $350 
copayment for each day for days 1-5 of each admission to an acute care hospital.  
 
You have been asked to pay $700, or a $350 copayment for 2 days of an inpatient hospital stay. An inpatient 
hospital stay falls within the "Inpatient hospital care" 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 inpatient hospital stay on August 18 to August 20, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the enrollee's medical needs are being met in the current acute 
setting. 
 
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. Long term 
acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide 
clinical services that are materially different than those of short term acute care hospitals. The enrollee is 
receiving acute hospital care, and acute care services have not been denied. The documentation does not 
support that the enrollee in this case requires services at the LTACH that are not available at the acute care 
hospital where he is currently receiving care. Our physician reviewer found that the enrollee's condition does 
not meet Medicare criteria for LTACH services. 
 
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 long term acute care hospital (LTACH) services for the enrollee.