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

We decided that the Plan does not have to pre-approve the dental services (D7210, D0140, D0330, D9222) 
provided from August 25, 2020, to August 27, 2020, by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the dental services. You say that you would like these claims reprocessed 
and approved for payment. The Plan denied your request. The Plan says they do not provide coverage for 
services rendered by an OON provider. 
 
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. The Plan covers the dental 
services when the services are provided by an in-network provider.  
 
We looked at the file and Medicare rules. The services were provided by a dentist who is OON and no 
coverage is available. Based on this information, we decided that the Plan's rules for coverage of the dental 
services have not been met. Therefore, we decided that the Plan does not have to pre-approve the dental 
services (D7210, D0140, D0330, D9222) provided from August 25, 2020, to August 27, 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 the inpatient hospital care provided from September 25, 
2020, to September 28, 2020. 
 
You asked the Plan to pay for the inpatient care. You say that you do not understand why this claim was denied 
but feel payment should be made. The Plan denied your request. The Plan says this claim was denied for lack 
of authorization. Medical records were not submitted with the appeal. A request for medical records was made, 
but none were received. As such, the denial cannot be reversed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must submit sufficient documentation 
to determine whether payment is due. 
 
The Plan documented that a request for medical records was made. There were no medical records submitted 
by the provider. Without medical records, it cannot be determined whether the services were reasonable and 
necessary and should be paid. Therefore, we decided that the Plan does not have to pay for the inpatient 
hospital care provided from September 25, 2020, to September 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve stem cell treatments. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says knee 
arthritis is not a covered condition for stem cell treatment. 
 
The Plan follows Medicare rules. Medicare rules say that stem cell transplantation is only covered under certain 
medical indications.  
 
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 requested services. Our physician 
reviewer found that you have osteoarthritis of the knee. You have had physical therapy, chiropractic therapy, 
massage, and treatment with THC. The requested service is an experimental/ investigational procedure. 
Therefore, the request is deemed not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve stem cell treatments.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for periodic oral evaluation (D0120), intraoral periapical, first 
radiographic image (X-Ray) (D0220), and prophylaxis (D1110) provided on August 27, 2020. 
 
You asked the Plan to pay for oral evaluation, intraoral X-Ray and prophylaxis. You say that the services 
should be covered. The Plan denied your request. The Plan says members must visit a contracted provider to 
utilize 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. Specifically, you obtained services from an out-of-network provider. 
This means the services are not covered. Therefore, we decided that the Plan does not have to pay for periodic 
oral evaluation (D0120), intraoral periapical, first radiographic image (X-Ray) (D0220), and prophylaxis 
(D1110) provided on August 27, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a right partial finger passive prosthesis. 
 
You asked the Plan to pre-approve a right partial finger passive prosthesis. You say that the requested right 
partial finger passive prosthesis is medically necessary. The Plan denied your request. The Plan says that the 
requested right partial finger passive prosthesis is not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, it is the plan's responsibility to show that its decision to deny 
coverage is correct. Records from a plan provider are considered to be within the control of the plan. In cases 
where the plan has not supplied records from a plan provider that are critical to its decision, we may properly 
find that the denial is not medically appropriate or justifiable. Enrollees should not be penalized for a plan's 
failure to obtain records that are within the plan's control. The plan did not provide sufficient medical records 
in order to determine if the enrollee meets Medicare criteria for the right partial finger passive prosthesis. 
Therefore, we decided that the Plan has to pre-approve a right partial finger passive prosthesis.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a genetic cardiac panel (81407, 81408, 81479) provided on 
June 25, 2020. 
 
You asked the Plan to pay for a genetic cardiac panel. You say that this was medically necessary. The Plan 
denied your request. The Plan says this is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that (CV) risk assessment panels, except the basic 
lipid panel, for symptomatic (with signs and symptoms) patients with suspected or documented CV disease 
because panel testing is not specific to a given patient?s lipid abnormality or disease. 
 
We looked at the file and Medicare rules. The record shows that the enrollee was symptomatic and the services 
at issue were not a basic lipid panel. Based on this information, we decided that Medicare rules for coverage of 
a genetic cardiac panel have not been met. Therefore, we decided that the Plan does not have to pay for a 
genetic cardiac panel (81407, 81408, 81479) provided on June 25, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long-term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee would benefit from having 
care provided in the LTACH setting. The Plan denied your request. The Plan says LTACH care is not clinically 
superior to continued care in the current 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. Our 
physician reviewer found the patient is currently undergoing treatment at an ACH for a posterior stroke. The 
enrollee was intubated/ventilated and subsequently received a tracheotomy. It is noted that the enrollee will 
likely require long-term nighttime ventilation. There is no evidence that the enrollee requires services that are 
not currently available. As LTACHs and 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.  
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the ophthalmic imaging provided on 
February 26, 2020. 
 
You asked the Plan to waive the coinsurance for the ophthalmic imaging. You say that you had service last 
year and was charged nothing. 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 20% 
coinsurance for diagnostic tests and procedures.  
 
You have been asked to pay $193.37 which is 20% of the allowed amount for the ophthalmic imaging. The 
allowed amount is $966.86. ($966.86 x 20% = $193.37). The ophthalmic imaging falls within "Outpatient 
diagnostic tests 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 coinsurance for the ophthalmic imaging provided on February 26, 2020. 
  
Our decision is only about the February 26, 2020 service. If you have any questions about prior years billing, 
please contact the plan directly.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency care provided on August 22, 
2020. 
 
You asked the Plan to waive the copayment for emergency care. You say that you feel that the charges were 
too high. 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 $90 
copayment for emergency care.  
 
You have been asked to pay a $90 copayment for emergency care. Emergency care falls within the emergency 
care benefit category. This means that you have been asked to pay the correct amount based on your contract 
with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for emergency care provided on 
August 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital care (99222) provided on August 19, 2019. 
 
You asked the Plan to pay for hospital care. You say that these medically necessary services were provided to 
the enrollee in good faith and you feel the provider is entitled to reimbursement for the services rendered. The 
Plan denied your request. The Plan says rules for payment have not been met. 
 
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 hospital care was not filed until September 24, 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 hospital care (99222) provided on August 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nurse practitioner services provided on September 4, 2020. 
 
You asked the Plan to pay for the nurse practitioner services. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent 
or emergent, nor were they approved in advance. 
 
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 September 4, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the cystourethroscopy provided on October 
9, 2020. 
 
You asked the Plan to waive the copayment for the cystourethroscopy. You say that you should not be 
responsible for the $50 copayment because you have not been charged for this procedure in the past. 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 per visit.  
 
You have been asked to pay a $50 copayment for the cystourethroscopy. The cystourethroscopy falls within the 
?Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical 
centers? benefit category. The record shows the cystourethroscopy is considered an outpatient hospital facility 
service. 
 
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 cystourethroscopy provided on October 9, 2020. 
  
Our decision is only about the October 9, 2020 service. If you have any questions about prior years billing, 
please contact the plan directly.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for specialist visits provided on August 31, 
2020, and September 3, 2020. 
 
You asked the Plan to waive the copayments for specialist visits. You say that these were follow-up visits and 
you should not have any cost-sharing charges. 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 $45 
copayment for specialist visits. 
 
You had a specialist visit on August 31, 2020. Follow-up visits are subject to cost-sharing charges. Therefore, 
you are responsible to pay the allowed amount of $22.50, which is less than the $45 copayment.  
 
You had a specialist visit on September 3, 2020. Follow-up visits are subject to cost-sharing charges. 
Therefore, you are responsible to pay the $45 copayment.  
 
The total amount you owe is: $77.50. 
 
You have been asked to pay the total copayment amount of $77.50 for specialist visits. Specialist visits fall 
within the physician/practitioner services, including doctor's office visits 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 specialist visits provided on August 31, 2020, and September 3, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is not enough evidence that shows this procedure is as safe and effective as 
standard treatments. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found cooled RFA is considered experimental by CMS and is not a covered benefit. Genicular nerves RFA is 
considered experimental/investigational and is the subject of on-going clinical trials. Therefore, the request is 
considered not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve genicular nerve radiofrequency ablation.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on August 26, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or 
provider must corroborate the documentation in the beneficiary's medical documentation and confirm that 
Medicare coverage criteria have been met.  
 
We looked at the file and Medicare rules. The services in question were billed with POS 22 (outpatient 
hospital). However, the records show that the enrollee was an inpatient on the date of service in question. The 
records do not support the use of POS 22. 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 the 
services provided on August 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (S1015, S8301) provided on August 21, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are not 
covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a status indicator of "I" under the Physician Fee 
Schedule indicates that the code in question is not valid for Medicare purposes.  
 
We looked at the file and Medicare rules. Codes S1015 and S8301 are assigned a status indicator of ?I? under 
the Physician Fee Schedule, which means that these codes are not valid for Medicare purposes. Medicare uses 
another code for reporting of, and payment for, these services. 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 the services (S1015, S8301) provided on August 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for supplies and materials provided on July 10, 2020. 
 
You asked the Plan to pay for supplies and materials (99070). You say that the Plan should pay this claim. The 
Plan denied your request. The Plan says this claim exceeds units allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied.  
 
In this case, the MUE for CPT code 99070 is 1. You billed four units of this code, exceeding the MUE. 
Therefore, the Plan is not required to pay this claim. Based on this information, we decided that Medicare rules 
for coverage of supplies and materials have not been met. Therefore, we decided that the Plan does not have to 
pay for supplies and materials provided on July 10, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says the 
enrollee's medical needs are being met in the current acute setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our physician 
reviewer found that the enrollee presented to the hospital with acute hypoxic respiratory failure secondary to 
COVID-19 pneumonia. The enrollee is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where he is 
currently receiving care. There are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. The requested LTACH services medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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.