Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient post-stabilization services provided to the enrollee 
on March 29, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says all inpatient care was unauthorized post-stabilization care 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
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 services. Our reviewer says that the 
services at issue in this case were not medically reasonable or necessary. Our physician reviewer found the 
review indicates that by 2:51 p.m. on 3/29/20, the enrollee was stable to transfer to the nearest Plan facility via 
safe ambulance transfer. The ED MD noted that the enrollee's diffuse abdominal pain was resolved,and he was 
in no acute distress. The enrollee was alert and hemodynamically stable. Labs and diagnostic imaging  
confirmed the enrollee was not experiencing an acute gastroenterology event, and he had been treated with IV 
fluids and IV pain medication. The review has determined that the post-stabilization care services after 2:51 
p.m. on 3/29/20 were not medically necessary or reasonable. The treating physician did not document (in the 
physician notes, on a form, or in an order) that the enrollee was not stable for transfer on any dates of service. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for inpatient post-stabilization services provided to the enrollee on March 29, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for continuous intraoperative neurophysiology monitoring and 
neuromuscular junction testing provided on December 20, 2019. 
 
You asked the Plan to pay for continuous intraoperative neurophysiology monitoring in the operating room, 
one on one monitoring requiring personal attendance (95940) and neuromuscular junction testing (95937). You 
say that the Plan should pay this claim. The Plan denied your request. The Plan says the monitoring MD was 
outside the OR and the technical report did not include documentation of neuromuscular junction testing. 
 
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 codes 95940 and 95937 are not supported in the medical record. Specifically, the record 
shows the monitoring was not done with personal attendance and there is no documentation of the junction 
testing. Based on this information, we decided that Medicare rules for coverage of continuous intraoperative 
neurophysiology monitoring in the operating room, one on one monitoring requiring personal attendance 
(95940) and Neuromuscular junction testing (95937) have not been met. Therefore, we decided that the Plan 
does not have to pay for continuous intraoperative neurophysiology monitoring and neuromuscular junction 
testing provided on December 20, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on January 28, 2020. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says the Plan 
requires utilization of network providers when possible and available, and requires authorization for certain 
services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has 
been documented.   
 
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 
laboratory services. 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 laboratory services provided on January 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the custom fabricated abutment (D6057) and the abutment 
supported crown (D6058) provided on June 4, 2020. 
 
You asked the Plan to pay for the dental services. You say that you are having trouble eating food. You say that 
you had a broken tooth. You also say that this procedure was not done for cosmetic reasons. The Plan denied 
your request. The Plan says custom fabricated abutment is not listed as a covered service. The Plan says that 
abutment supported crown is not listed as a covered service either. The Plan also says that any dental services 
not specifically listed are not covered. 
 
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 dental services you received are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
custom fabricated abutment (D6057) and the abutment supported crown (D6058) provided on June 4, 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. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is 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 considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found 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's 
medical status does not currently require intensive physician and nursing oversight only in an IRF. The patient's 
anemia, hypophophatemia, leukocytosis, and renal function all improved and her condition does not require 
intensive IRF monitoring. The patient may benefit from multiple therapies such as physical and occupational 
therapy but the documentation does not support that the patient's endurance level can tolerate an intensive 
rehabilitation therapy program provided 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 IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing rendered on November 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 the services were not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that genetic testing 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 is diagnosed with 
Alzheimer's disease with late onset and Parkinson's disease.  
The case file contains a Genetics Test Requisition and the results of the testing. There are no clinical records 
supporting the medical necessity of the testing. The documentation does not support that the Parkinson-
Alzheimer-Dementia NGS Panel was medically reasonable and necessary for the enrollee in this case. 
 
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 genetic testing rendered on November 9, 2019.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing services rendered on December 13, 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 procedure code 95951 is not supported. 
 
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 95951 is monitoring for localization of cerebral seizure 
focus by cable or radio, 16 or more channel telemetry, combined electroencephalographic (EEG) and video 
recording and interpretation (eg, for presurgical localization), each 24 hours. 
 
We find that CPT code 95951 is not supported in the medical record. Specifically, there is no documentation of 
electroencephalogram (EEG) recording times. 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 
testing services rendered on December 13, 2019.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided from February 6, 2020, 
to February 12, 2020. 
 
You asked the Plan to pay for the self-administered drugs. You say that the drugs should be covered by the 
Plan. You say that the enrollee was not permitted by the hospital to bring in her own medications. You say that 
the hospital required that they dispense the medications to the enrollee. The Plan denied your request. The Plan 
says the drugs are considered self-administered. The Plan also says self-administered drugs are eligible for 
coverage under Part D Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs that the enrollee received are not among the types which are 
covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered 
drugs provided from February 6, 2020, to February 12, 2020.  
 
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the esophagogastroduodenoscopy and 
biopsy (43239) provided on June 1, 2020. 
 
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 was 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 $175 
copayment for each Medicare-covered surgery at an ambulatory surgical center.  
 
You have been asked to pay a $175 copayment for the Medicare-covered surgery provided at an ambulatory 
surgical center. 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 esophagogastroduodenoscopy and 
biopsy (43239) provided on June 1, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on January 13, 
2020. 

You asked the Plan to pay for the services. You say that Medicare pays for this service. The Plan denied your 
request. The Plan says the records reflect that this testing was not for an emergency. 
 
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 laboratory services provided to the enrollee on 
January 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on June 30, 2020. 
 
You asked the Plan to pay for the physician's 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 
physician's services. 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 physician's services provided on June 30, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visits provided on May 23, 2019 and November 
18, 2019. 
 
You asked the Plan to reimburse you for the office visits. You say that the Plan should pay this claim. The Plan 
denied your request. The Plan says the provider is a privately contracted provider ineligible for payment. 
 
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 
reimburse you for the office visits provided on May 23, 2019 and November 18, 2019.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a Skilled Nursing Facility (SNF) stay 
provided from February 1, 2019 to February 20, 2019. 
 
You asked the Plan to waive the copayment for SNF stay. You say that you are appealing based on the 
enrollee's experiences with this facility. The Plan denied your request. The Plan says the copayment amount the 
enrollee is 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). The enrollee's contract with the Plan clearly says that enrollees 
must pay $0 copayment per day for days 1 to 20 and $167.50 copayment per day for days 21 to 100 for in-
network SNF stay. At the time this claim was processed, $3,930 of the $6,200 in-network maximum out-of-
pocket amount had been met. The enrollee previously received 15 days of SNF care from January 17, 2019 to 
January 31, 2019. This period of the SNF stay lasted 19 days, which are days 16 to 34 of the stay, resulting in a 
copayment obligation of $2,270 because this amount meets the $6,200 maximum out-of-pocket amount for 
2019. 
 
The enrollee has been asked to pay $0 copayment per day for days 1 to 20 and $167.50 copayment per day for 
days 21 to 100 for SNF stay. SNF stay falls within the Skilled Nursing Facility (SNF) Care benefit category. 
This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This 
cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for a Skilled Nursing Facility (SNF) stay provided 
from February 1, 2019 to February 20, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation and periodontal maintenance 
provided on February 25, 2020. 
 
You asked the Plan to pay for the periodic oral evaluation and periodontal maintenance. You say that you have 
been going to this dentist for two years for periodontics. You say that you are owed $221. The Plan denied your 
request. The Plan says payment cannot be issued for services performed by a provider 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 periodic oral evaluation and periodontal maintenance provided on February 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on February 13, 2020 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the OON medical services. You say that this claim should be paid without 
authorization due to medical necessity. The Plan denied your request. The Plan says out of network providers 
must obtain prior authorization to provide medical care to this enrollee. This was not an emergency visit and 
was not referred by a 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 medical services provided on February 13, 
2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient hospital services rendered on 
April 27, 2020. 
 
You asked the Plan to waive the copayment for these services. You say that you disagree with the charges. The 
Plan denied your request. The Plan says the copayment was 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 $350 
copayment for each Medicare-covered non-surgical visit in an outpatient clinic, after you meet your $250 
deductible.  
 
Review of the file shows that you received outpatient hospital services on April 27, 2020. Per the contract with 
the Plan, there is a $350 copayment for each Medicare-covered non-surgical visit in an outpatient clinic, after 
you meet your $250 deductible. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. However, the Medicare allowed amount for these services was $140.45. Given that the 
allowed amount was less than the $350 copayment, you have been asked to pay $140.45 for these services. 
Therefore, we decided that the Plan does not have to waive the copayment for the outpatient hospital services 
rendered on April 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on April 29, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for physician visit. You say that your physician was making rounds at the facility 
where the enrollee resides and was asked to see the enrollee. The Plan denied your request. The Plan says the 
denial of payment for these services is correct, because this provider is out-of-network with the Plan and 
authorization was not obtained. 
 
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 medical services provided on April 29, 2020 
by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an epidural injection provided on October 
29, 2019. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that you have had this service 
plenty of times and only paid a $50 copayment previously. 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 $500 
copayment for epidural injection at an outpatient hospital.  
 
You have been asked to pay $500 copayment for outpatient surgery. Outpatient surgery 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 copayment for an epidural injection 
provided on October 29, 2019.