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

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee's ongoing skilled therapy and nursing needs 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 the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for respiratory failure 
and COVID 19 pneumonia. The enrollee's medical conditions are stable. There are no medical needs requiring 
inpatient admission. There are no complex nursing or rehabilitation needs. The patient does not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While the medical record documents a need for physical and occupational 
therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable 
expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation 
therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet 
Medicare criteria for IRF care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for urinary catheters provided from August 
19, 2020, to September 18, 2020. 
 
You asked the Plan to waive the coinsurance for urinary catheters. You say that these supplies were covered in 
full in the past. The Plan denied your request. The Plan says the coinsurance 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 20% 
coinsurance for urinary catheters. The allowed amount of this claim is $954, resulting in a coinsurance 
obligation of $190.80. 
 
You have been asked to pay 20% coinsurance for urinary catheters. Urinary catheters fall within the Durable 
Medical Equipment (DME) and Related Supplies benefit category. This means that you have been asked to pay 
the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
coinsurance for urinary catheters provided from August 19, 2020, to September 18, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on July 
29, 2020. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you feel you should not 
be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan 
denied your request. The Plan says you received ambulance services on the date of service at issue in this 
appeal. The Plan says that the correct copayment has applied per your contract with the Plan. 
 
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 Ambulance services.  
 
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received ambulance 
services on July 29, 2020. You have been asked to pay a $350 copayment for the ambulance services. The 
ambulance services fall within the Ambulance 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 ambulance services provided on July 29, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the paring or cutting of a benign hyperkeratotic lesion 
(11055) provided on January 21, 2019. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not payable as the claim was 
submitted untimely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for this service was not filed until September 28, 2020. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for the paring or cutting of a benign hyperkeratotic lesion (11055) provided on 
January 21, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a walker purchased on June 4, 2020, from 
an out-of-network provider. 
 
You asked the Plan to waive the deductible for a walker. You say that you should be reimbursed 80% of this 
cost. The Plan denied your request. The Plan says the deductible applied correctly. 
 
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 there is a $1000 deductible for out-of-network services excluding ambulance 
services.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category out-of-
network services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a 
$1000 deductible for out-of-network services excluding ambulance services. This cost sharing is a contractual 
obligation that had not been met at the time a walker was received on June 4, 2020. Therefore, we decided that 
the Plan does not have to waive the deductible for a walker purchased on June 4, 2020, from an out-of-network 
provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cardiovascular risk assessment panel testing provided on 
August 13, 2020. 
 
You asked the Plan to pay for cardiovascular risk assessment testing. You say that you are appealing with 
records to support the codes billed. The Plan denied your request. The Plan says the denial of payment for this 
testing is correct, because Medicare denies coverage for all cardiovascular risk assessment panels except the 
basic lipid panel. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
Although Medicare does cover certain cardiovascular disease screening tests, the tests billed are not among 
those covered by Medicare for screening. Therefore, we decided that the Plan does not have to pay for 
cardiovascular risk assessment panel testing provided on August 13, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the two denosumab injections (J0897) and 
collection of blood specimen (36591) provided on January 2, 2020, to January 30, 2020. 
 
You asked the Plan to waive the coinsurance for the two denosumab injections and collection of blood 
specimen. You say that you would like this claim reprocessed and approved for payment. The Plan denied your 
request. The Plan says the cost share has applied correctly in this case. 
 
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% 
coinsurance for Medicare Part B prescription drugs.  
 
You have been asked to pay a total cost share of $787.29 for the two injections of denosumab and collection of 
blood specimen. The collection of the blood specimen has a copayment of $110.73 which is less than the 
required $250 copayment. The two injections of denosumab have been charged each at $338.28 (1,691.40 
allowed amount x 20%). These services provided fall within the Medicare Part B prescription drugs benefit 
category and the outpatient surgery or procedure category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance 
for the two denosumab injections (J0897) and collection of blood specimen (36591) provided on January 2, 
2020, to January 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and complete 
mandibular denture (D5120). 
 
You asked the Plan to pre-approve the complete dentures. You say that your previous dentures do not fit. You 
also say that you need new dentures because you are unable to eat. The Plan denied your request. The Plan says 
these services are allowed one time every 60 months. The Plan also says that you have had these services less 
than 60 months ago. 
 
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, maxillary dentures and mandibular 
dentures are limited to once per 60 months. The record shows that you received a complete maxillary denture 
(D5110) and complete mandibular denture (D5120) on May 7, 2019, and your maxillary denture and 
mandibular denture benefits have been exhausted. Therefore, we decided that the Plan does not have to pre-
approve a complete maxillary denture (D5110) and complete mandibular denture (D5120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation and resin-based 
composite provided on August 26, 2020. 
 
You asked the Plan to pay for the problem focused limited oral evaluation and resin-based composite. You say 
that you should not have received a bill for these services. The Plan denied your request. The Plan says the 
problem focused limited oral evaluation is not covered. The Plan also says that you were charged correctly for 
the resin-based composite. 
 
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 problem focused limited oral 
evaluation is not among those covered under this benefit. The contract also clearly states that you must pay a 
50% coinsurance for resin-based composites. Therefore, we decided that the Plan does not have to pay for the 
problem focused limited oral evaluation and resin-based composite provided on August 26, 2020.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on March 15, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says Original 
Medicare would be responsible for payment of all Medicare covered services related or unrelated to the 
member?s terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all 
hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-
for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until 
the first day of the month following the month in which hospice was revoked or discharged. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on March 13, 2020. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for physician's services 
provided on March 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing applied for the periodontal scaling and root 
planing (D4341) rendered by the out-of-network (OON) provider on September 22, 2020. 
 
You asked the Plan to waive the cost sharing. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the cost sharing has been applied correctly to 
the service provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $100 
deductible each year. Additionally, you pay 55% of the cost for each visit for covered periodontic services 
rendered by an out of network provider. You are responsible for balances up to the dentist?s charge.  
 
You have been asked to pay $327.98 for the periodontic services provided. This amount includes a $100 
deductible, a 55% coinsurance for the Plan allowable charge of $248.92, including an additional charge of 
$91.08 for the out-of-network provider balance. 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 cost sharing applied for the 
periodontal scaling and root planing (D4341) rendered by the out-of-network (OON) provider on  
September 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) provided on September 
3, 2020, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the periodic oral evaluation. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says services are only covered for in-
network dentists. There are multiple in-network providers available to meet your medical needs. 
 
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.  
 
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. Based 
on this information, we decided that the Plan's rules for coverage of the periodic oral evaluation have not been 
met. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120) 
provided on September 3, 2020, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home visit services provided to the enrollee on July 16, 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 the services were not authorized by network/primary care providers. 
 
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 home visit services provided to the enrollee on 
July 16, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric hospital services. 
 
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that you are not in the 
mental frame to return to the nursing home until your physician is finished changing your dosage of 
medication. The Plan denied your request. The Plan says that you can be treated in a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric hospital services. 
Our reviewer says that inpatient psychiatric hospital services are not medically reasonable and necessary. You 
are not shown to be a danger to yourself or others. You are not showing any auditory or visual hallucinations 
and are cooperative/compliant with treatment while not showing any threats the safety. Our physician reviewer 
found that your condition does not meet Medicare criteria for inpatient psychiatric hospital 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 inpatient psychiatric hospital services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve inpatient psychiatric hospital services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychiatric evaluation provided on March 7, 2019. 
 
You asked the Plan to pay for the psychiatric evaluation. You say that this claim was not filed within a year 
because you were not able to obtain the enrollee's benefit information in a timely manner. The Plan denied your 
request. The Plan says Medicare rules state that claims filed more than one year after the date of service are not 
payable. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the psychiatric evaluation was not filed until August 28, 2020. This means 
that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the psychiatric evaluation provided on March 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care (99308) rendered by the 
out of network (OON) provider on April 29, 2020 and May 6, 2020. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without 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 provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the services at issue in this appeal. 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 the subsequent nursing facility care (99308) rendered by the out of network (OON) 
provider on April 29, 2020 and May 6, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on August 24, 
2020. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you feel that you should not be 
responsible for the charges because nothing has fixed your condition. 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 $160 
copayment for each radiological diagnostic service.  
 
You have been asked to pay the allowed amount of $125.23, which is less than the $160 copayment for an 
ultrasound. An ultrasound falls within the outpatient diagnostic procedures and therapeutic services and 
supplies 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 ultrasound provided on 
August 24, 2020.