Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pontic (D6245) and two retainer crowns (D6740 x2). 
 
You asked the Plan to pre-approve the pontic and retainer crowns. You say that you would like to appeal these 
services. The Plan denied your request. The Plan says these services are not covered under your 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 
pontic (D6245) and two retainer crowns (D6740 x2).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for durable medical equipment provided on February 17, 2020 
by an out of network (OON) provider. 
 
You asked the Plan to pay for durable medical equipment. You say that you were not aware that they were out-
of-network. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says 
that there are in-network providers available for these services. 
 
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 durable medical equipment provided on February 
17, 2020 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has towaive the copayment fornuclear imaging of bones provided on March 4, 2020.You asked the Plan to waive the copayment fornuclear imaging of bones. You say that you feel that you should only owe one $200 copayment, not two.The Plan denied yourrequest. The Plan says that 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. Your contract with the Plan says that enrollees must pay a $200 copayment for diagnostic radiology services.The record shows that you have already been charged a $200 copayment for diagnostic radiology services on March 4, 2020. Therefore, you cannot be asked to pay an additional $200 copayment.  The plan contract does not specify that you must pay a $200 copayment per each diagnostic radiology service.The Plan says you must pay a $200 copayment for nuclear imaging of bones. Based on the Plan contract, however, you cannot be asked to pay more than one $200 copayment for diagnostic radiology services.Therefore, we decided that the Plan has to waive the copayment fornuclear imaging of bones provided on March 4, 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 toopen 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 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 is receiving appropriate care at the current acute 
care facility. 
 
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. 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.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you received a bill form 
the ambulance company. You cannot afford the bill and is not going to pay it. 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 $225 
copayment for each ambulance trip. You had 1 ambulance trip(s). The Plan charged you $225 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.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient hospital services provided by a 
participating provider on June 5, 2020. 
 
You asked the Plan to waive the copayment for outpatient hospital services. You say that you had this waived 
before. You say that you would like this paid for by the Plan. 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 $200 
copayment for outpatient surgery/other services.  
 
You have been asked to pay $180.08 which is less than your copayment amount of $200 copayment for 
outpatient hospital services. Outpatient hospital services fall within the outpatient surgery/other 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 outpatient hospital services provided by a 
participating provider on June 5, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services provided from January 12, 2019 to 
December 11, 2019. 
 
You asked the Plan to pay for these services. You say that these claims should be paid by the Plan. The Plan 
denied your request. The Plan states that according to pages 143-144 of the 2019 Evidence of Coverage, 
enrollees must submit their Part C (medical) claims within 12 months of the date they received the services. 
The Plan states some claims denied correctly as they were submitted outside the 12-month window. The Plan 
states that for dates of Service June 19, 2019, through December 29, 2019, those claims were applied to the 
$750 deductible.  
 
The Plan follows Medicare rules. The rules say that claims for services must be filed no later than one calendar 
year after the date of service. The rules say that the Plan contract must clearly explain cost share and 
deductibles. Your Plan contract clearly states that claims for service must be submitted within 12 months of the 
date of service. Your Plan contract also indicates there was a $750 deductible for 2019. The record shows that a 
portion of the claims filed were untimely as they were not filed until May 21, 2020. This means that more than 
one calendar year from the date of service had passed before a claim was filed. The records also show for those 
claims applied to the deductible; this was done so correctly as the deductible had not been met at the time of 
service. Therefore, we decided that the Plan does not have to pay for psychotherapy services provided from 
January 12, 2019, to December 11, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 there is no evidence that the enrollee requires services that are not currently available. 
As LTACHs and acute care hospitals (ACHs) are licensed to provide the same level of care, there is no 
advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such 
time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for 
any ongoing long term care (LTC) needs. 
 
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.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion of astigmatism correcting intraocular 
lenses (V2787 and A9270). 
 
You asked the Plan to pre-approve the insertion of astigmatism correcting intraocular lenses. You say that the 
insertion of an astigmatism correcting intraocular lens would reduce your dependency on glasses. The Plan 
denied your request. The Plan says this is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare does not pay for the astigmatism-
correcting functionality of an intraocular lens (IOL) implanted following cataract surgery. 
 
We looked at the file and Medicare rules. Though astigmatism correcting intraocular lenses may be benefitial, 
they are not covered by Medicare. Based on this information, we decided that Medicare rules for coverage of 
the insertion of astigmatism correcting intraocular lenses have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the insertion of astigmatism correcting intraocular lenses (V2787 and 
A9270).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Pan Cancer Panel rendered on October 23, 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 the services were not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that next generation sequencing is 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 pay for these services. Our reviewer says that the 
services were not medically necessary. Our physician reviewer found the enrollee had a diagnosis of prostate 
cancer in the records but there was no documentation of either recurrent, relapsed, refractory, metastatic, or 
advanced stage III or IV cancer nor is there documentation of a clinical indication for germline (inherited) 
testing of hereditary cancers. The criteria for coverage are not met and the testing was therefore not reasonable 
or medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the Pan Cancer Panel rendered on October 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for office visits and contact lens fittings 
provided from September 18, 2018, to December 21, 2018. 
 
You asked the Plan to waive the copayments for office visits and contact lens fittings. You say that you believe 
the Plan missed something that should be corrected. The Plan denied your request. The Plan says the 
copayment amounts you are being charged are 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 $20 
copayment for each in-network specialist visit and $20 copayment for each in-network contact lens fittings. 
There were 4 office visits, resulting in a copayment amount of $80. There were 3 contact lens fittings, resulting 
in a copayment amount of $60. Therefore, your total copayment obligation is $140. 
 
You have been asked to pay $20 copayment for each office visit and $20 copayment for each contact lens 
fitting. Office visits and eyewear fittings fall within the "Physician/Practitioner Services, Including Doctor's 
Office Visits" and "Vision Care" benefit categories. 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 
office visits and contact lens fittings provided from September 18, 2018, to December 21, 2018.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the COVID-19 testing (U0003) provided on July 6, 2020 to 
July 14, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for COVID-19 testing. You say that the executive order from the Governor is that 
testing was mandated and would be covered by all insurance companies. The Plan denied your request. The 
Plan says prior authorization must be obtained for services rendered by an out-of-network provider. 
 
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 the COVID-19 testing (U0003) provided on July 
6, 2020 to July 14, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that these services are medically necessary.The Plan denied your request. The Plan says that ongoing skilled services can be provided at a lower level of care.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 your nursing, medical and rehabilitation needs do not requirean acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for surgical repair of a femur fracture after a fall. Your medical problems are stable. There are no identified problems that need inpatient medical management. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The medical record supports a need for physical and occupational therapy but it does not support a need for an intensive rehabilitation therapy program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitationtherapy program provided in an IRF. Our physician reviewer found that your 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction provided on January 20, 2020. 
 
You asked the Plan to pay for the extraction. You say that you paid for the service in full. You also say that the 
claim for reimbursement that you are requesting is for you, and not the provider. The Plan denied your request. 
The Plan says the treating provider has opted out of Medicare. The Plan also says that Medicare cannot pay for 
any services provided by an individual that has opted out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. This 
provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
the extraction provided on January 20, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the magnetic resonance imaging (MRI) services 
provided on June 21, 2020. 
 
You asked the Plan to waive the copay for the services provided. You say that you never paid such a price 
before. The Plan denied your request. The Plan says the claim was processed correctly applying the copay. 
 
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 $200 
copay per visit for all other outpatient diagnostic services, such as MRIs.  
 
You have been asked to pay a $200 copay for the MRI. The MRI falls within the outpatient diagnostic tests 
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 copay for the magnetic resonance imaging 
(MRI) services provided on June 21, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient services provided on February 5, 2019 through 
February 6, 2019. 
 
You asked the Plan to pay for the inpatient services. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says the submitted claim is missing the required 
POA indicator. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the inpatient services have not been met. Specifically, the submitted claim does not include the 
required POA indicator. Therefore, we decided that the Plan does not have to pay for inpatient services 
provided on February 5, 2019 through February 6, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient medical services provided from February 11, 
2020, to February 18, 2020. 
 
You asked the Plan to pay for the inpatient care. The Plan denied your request. The Plan says the Medicare 
rules have not been met. 
 
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 looked at the file and the rules. The records show that the enrollee's care began on February 11, 2020, and 
was admitted as an inpatient on February 15, 2020. Based on this information, we decided that Medicare rules 
for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the inpatient 
medical services provided from February 11, 2020, to February 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist services provided by a non-
participating provider on April 23, 2020. 
 
You asked the Plan to waive the copayment for specialist services. You say that you do not agree with this 
copayment. 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/out-of-network.  
 
You have been asked to pay a $40 copayment for specialist services. Specialist services fall within the 
physician/practitioner services/out-of-network 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 specialist services provided by a non-participating provider on April 23, 2020.