Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 6 additional physical therapy visits. 
 
You asked the Plan to pre-approve 6 additional physical therapy visits. You say that the enrollee has joint pain 
and limited ability to transfer from a normal sized bed. You say that the services should be covered. The Plan 
denied your request. The Plan says additional visits are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 6 additional physical therapy visits. Our 
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration 
of the enrollee's condition. Our physician reviewer found that the enrollee had extensive therapy and will be 
trained in a home exercise program upon completion of all authorized therapy. Our reviewer says that the 
unique skills of a professional therapist are not required to safely and effectively provide ongoing treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 6 additional physical therapy visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 6 additional physical therapy visits.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an x-ray of the ankle (73600) provided March 12, 2020. 
 
You asked the Plan to pay for the x-ray. You say that the services were medically necessary. The Plan denied 
your request. The Plan says the claim was missing a required modifier. 
 
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 73600 is not supported in the medical record. Specifically, the claim submitted did not 
include a required anatomical modifier. Based on this information, we decided that Medicare rules for coverage 
of the x-ray have not been met. Therefore, we decided that the Plan does not have to pay for an x-ray of the 
ankle (73600) provided March 12, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the mammogram provided on May 11, 
2020. 
 
You asked the Plan to waive the copayment for the mammogram. You say that this was your first mammogram 
of this year and were charged a $20 copayment when this should be a free service. 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 $20 
copayment for most x-rays and ultrasounds except as specified below.  
 
You have been asked to pay a $20 copayment for the mammogram. The mammogram falls within the 
"Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The medical record shows 
a personal history of breast cancer. 
 
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 mammogram provided on May 11, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the SNF stay provided from February 1, 
2010 to February 11, 2020. 
 
You asked the Plan to reduce the copayment for the SNF stay. You say that you were unaware that the provider 
was out-of-network. You say you should be charged the in-network benefit amount. The Plan denied your 
request. The Plan says your claim was reprocessed to the in-network benefit and 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 $0 
copayment per day for days 1-20 and a $145 copayment per day for days 21-100 for in-network skilled nursing 
facility care.  
 
You have been asked to pay a $1,595 copayment for the SNF stay. ($145 x 11 days = $1,595). The SNF stay 
falls within the ?Skilled nursing facility (SNF) care? benefit category. The record shows days 1-20 were 
received in January 2020. 
 
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 reduce the copayment for the SNF stay from February 1, 2010 to February 11, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided March 2, 2020 to March 11, 
2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that inpatient care was medically 
necessary. The Plan denied your request. The Plan says that the enrollee could have been managed in the 
observation setting. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the record showed that at the time of inpatient admission the admitting physician reasonably 
expected that the patient's necessary hospital care (including earlier emergency and/or observation care) would 
span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided March 2, 2020 to March 11, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the crowns provided on January 14, 2020. 
 
You asked the Plan to pay for the crowns. You say that you didn't know pre-authorization was needed. You say 
that you can't pay the full amount. The Plan denied your request. The Plan says that the procedure requires 
prior authorization.  
 
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. 
 
The crowns were provided by a contract provider. The contract says that crowns are covered up to two every 
calendar year. The dental contract does not clearly indicate that prior authorization is required for all services or 
which services it is required for. There is no evidence that the network provider gave notice that the crowns 
provided would not be covered. Under Medicare rules, this means the crowns are considered approved by the 
Plan. Therefore, we decided that the Plan has to pay for the crowns provided on January 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the maxillary partial denture (D5211) and mandibular partial 
denture (D5212) provided on April 2, 2020. 
 
You asked the Plan to pay for the maxillary and mandibular partial dentures. You say that your fixed bridges 
became unserviceable and the abutments teeth required removal. You also say that partial dentures were a 
necessity to reestablish masticatory capability. The Plan denied your request. The Plan says these services are 
not covered benefits under your dental 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 pay for the 
maxillary partial denture (D5211) and mandibular partial denture (D5212) provided on April 2, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing provided on August 27, 2019. 
 
You asked the Plan to pay for drug test. You say that you have submitted a valid physician laboratory 
requisition form. The Plan denied your request. The Plan says the denial of payment for this service is correct, 
because the documentation submitted does not include a valid physician order, lab requisition, or medical 
records stating exactly which tests were to be performed. 
 
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific 
lab services is required for covered lab services.  
 
We looked at the file and Medicare rules. The documentation submitted does not include a physician order or 
clear intent to order the specific lab service billed on this claim. Based on this information, we decided that 
Medicare rules for coverage of drug test have not been met. Therefore, we decided that the Plan does not have 
to pay for drug testing provided on August 27, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the denture adjustments (D5410/D5411) and consultation 
(D9310) provided on May 7, 2020. 
 
You asked the Plan to pay for the denture adjustments (D5410/D5411) and consultation (D9310). You say that 
you tried to save money by seeking a reline instead of new dentures. You say that the service should be 
completely covered. The Plan denied your request. The Plan says the services are not covered benefits. 
 
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 
denture adjustments (D5410/D5411) and consultation (D9310) provided on May 7, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for chemical cauterization provided on 
February 3, 2020 and February 24, 2020. 
 
You asked the Plan to waive the copayments for chemical cauterization. You say that you disagree with the 
surgery charges as no surgery took place. 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 $250 
copayment for outpatient surgery, including services provided at hospital outpatient facilities. 
 
You received chemical cauterization on February 3, 2020 at an outpatient hospital facility. Chemical 
cauterization is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $250 
copayment.   
 
You received chemical cauterization on February 24, 2020 at an outpatient hospital facility. Chemical 
cauterization is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $250 
copayment.   
 
The total amount you owe is: $500.  
 
You have been asked to pay the total copayment amount of $500 for chemical cauterization. Chemical 
cauterization falls within the outpatient surgery, including services provided at hospital outpatient facilities and 
ambulatory surgical centers 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 copayments for chemical 
cauterization provided on February 3, 2020 and February 24, 2020.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to waive the copayment for an emergency room visit provided by a participating 
provider on April 17, 2020 to April 19, 2020. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that you were admitted to 
the hospital. You say that your emergency room copayment should be waived. The Plan denied your request. 
The Plan says that the correct copayment has been applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that enrollees must pay a $90 copayment for emergency care.  
 
The Plan says you must pay a $90 copayment for an emergency room visit. An emergency room copayment is 
waived if you are admitted to the hospital within 24 hours with the same condition. Since a hospital admission 
did occur, the $90 copayment should be waived, leaving the enrollee with a $0 copayment. Therefore, we 
decided that the Plan has to waive the copayment for an emergency room visit provided by a participating 
provider on April 17, 2020 to April 19, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two therapeutic parenteral drugs (D9610 x2) provided on 
March 9, 2020. 
 
You asked the Plan to pay for the therapeutic parenteral drugs. You say that you had to get both procedures 
done on the same day because there was a risk of infection. The Plan denied your request. The Plan says this 
service is not a covered benefit under your dental 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 pay for the two 
therapeutic parenteral drugs (D9610 x2) provided on March 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nurse practitioner services provided on April 16, 2020. 
 
You asked the Plan to pay for the nurse practitioner services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require prior authorization. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for nurse practitioner services provided on April 16, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic radiology services provided on April 2, 2020. 
 
You asked the Plan to pay for the diagnostic radiology services. The Plan denied your request. The Plan says 
non-emergent, non-urgent services with out-of-network providers require prior authorization. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for diagnostic radiology services provided on April 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided by a 
participating provider on January 14, 2019. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you would like this 
copayment taken care of. The Plan denied your request. The Plan says the correct copayment has been 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 $40 
copayment for physician/practitioner services/specialist visit.  
 
You have been asked to pay a $40 copayment for a specialist office visit. The correct copayment has been 
applied to the services that were provided. A specialist office visit falls within the physician/practitioner 
services/specialist visit 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 specialist 
office visit provided by a participating provider on January 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the determination of refractive state (92015) provided on 
February 21, 2020. 
 
You asked the Plan to pay for the determination of refractive state. You say that you would like reconsideration 
because you did not have to pay for this service in January. The Plan denied your request. The Plan says you 
received a refraction a month prior during your covered routine eye exam. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers one supplemental routine eye exam (including eye refraction) per year. 
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the determination of refractive state have not been met. Specifically, the record indicates that you 
received this service in January. The Plan covers one supplemental eye refraction per year. Therefore, we 
decided that the Plan does not have to pay for the determination of refractive state (92015) provided on 
February 21, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing rendered on September 12, 2019. 
 
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 there is no valid physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a 
physician. 
 
We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 
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 drug testing rendered on September 12, 2019.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist office visit provided on 
March 3, 2020. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that you should not be 
responsible for the copayment because this was a follow-up visit for a surgery.  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 $50 
copayment for provider and professional services at an in-network specialist's office.  
 
You have been asked to pay a $50 copayment for the specialist office visit. The specialist office visit fal ls 
within the Physician/Practitioner services, including doctor's office visit's benefit category. Please note, there 
is no provision in the contract which indicates a copayment would be waived if performed as a follow-up to a 
surgical procedure. 
 
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 specialist office visit provided on March 3, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing rendered on October 9, 2019. 
 
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 there is no valid physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a 
physician. 
 
We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 
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 drug testing rendered on October 9, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing coded G0483 provided on December 20, 
2019. 
 
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the services billed are not supported by the documentation. 
 
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 G0483 is not supported in the medical record. Specifically, the documentation 
submitted did not include a valid physician order/lab requisition form or medical records signed by the ordering 
physician to show exactly what tests were to be performed. Based on this information, we decided that 
Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not 
have to pay for the drug testing coded G0483 provided on December 20, 2019.