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

 
We decided that the Plan does not have to pay for the inpatient post-stabilization services provided May 19, 
2020 to May 20, 2020. 
 
You asked the Plan to pay for the post-stabilization services. You say that attached to this claim is a copy of 
DRG Code pricing sheet and medical records to review the medical necessity for the denied day. The Plan 
denied your request. The Plan says inpatient care at non-plan facility was not medically necessary to stabilize 
the enrollee. 
 
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 post-stabilization services. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the review indicates that by 10:25am on 5/19/20 the enrollee was hemodynamically 
stable and appropriate for ambulance transportation with monitoring to a Plan facility for continued hospital 
services. All inpatient care provided after 10:26 am on 05/19/20 through 3:36 pm on 05/20/20 at the non-plan 
facility was not medically necessary or reasonable. The treating physician did not document (in the physician 
notes, on a form, or in an order) that the patient 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 post-stabilization services have not been met. Therefore, we decided that the 
Plan does not have to pay for the inpatient post-stabilization services provided May 19, 2020 to May 20, 2020.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to reimburse you for the hospital deposit and pay for the hospital services 
provided from January 29, 2020, to January 31, 2020. 
 
You asked the Plan to reimburse you for the hospital deposit and pay for the hospital services. You say that you 
want to be reimbursed for the deposit and want the hospital bill paid to the provider. The Plan denied your 
request. The Plan says that you have not sent the required documents. 
 
The Plan must follow Medicare rules. Medicare rules say that Plans may offer a Worldwide Emergency/Urgent 
Coverage benefit. Under this benefit enrollees may obtain only services that would be classified as emergency 
and urgently needed services had they been covered inside the United States.  
 
We looked at the file and Medicare rules. Medical records, itemized bills and receipts are in the case file. Based 
on this information, we decided that Medicare rules for coverage of the emergency hospital services have been 
met. Therefore, we decided that the Plan has to reimburse you for the hospital deposit and pay for the hospital 
services provided from January 29, 2020, to January 31, 2020. Hotel accommodations are not a covered 
benefit. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cataract surgery to be provided by an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve the OON cataract surgery. You say that the medical records provided 
support the need for the requested services. The Plan denied your request. The Plan says medically necessary 
care is available in network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
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. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
cataract surgery to be provided by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve intravenous (IV) Orencia. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee is noted to have 
rheumatoid arthritis. He has not tried and failed the Plan's required drugs of Remicade or Inflectra and Simponi 
Aria. The records do not support that the required drugs would be contraindicated or less effective; therefore, 
Orencia is not reasonable or medically necessary at this time. 
 
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 pre-approve intravenous (IV) Orencia.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a CT scan provided by a non-participating 
provider on August 13, 2020. 
 
You asked the Plan to waive the deductible for a CT scan. You say that you do not agree with these charges. 
The Plan denied your request. The Plan says the correct deductible amount has been applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $750 deductible for outpatient diagnostic tests.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient 
diagnostic tests. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 
deductible for outpatient diagnostic tests. This cost sharing is a contractual obligation that had not been met at 
the time a CT scan was received on August 13, 2020. The total amount you are being asked to pay is $130.81. 
Therefore, we decided that the Plan does not have to waive the deductible for a CT scan provided by a non-
participating provider on August 13, 2020.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay for the periodontal maintenance. We decided that the Plan does not have to 
pay for the interim caries arresting medicament applications and additional intraoral periapical x-ray.  
 
You asked the Plan to pay for the periodontal maintenance, three interim caries arresting medicament 
applications, and additional intraoral periapical x-ray. You say that you have dental insurance, and your bills in 
the past have been paid. The Plan says that periodontal maintenance and interim caries arresting medicament 
application are not covered benefits. The Plan also says that one intraoral x-ray has already been covered. 
 
We decided that the Plan has to pay for the periodontal maintenance.  
 
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 EOC lists periodontal maintenance as a covered service. The Plan?s argument that periodontal maintenance 
is not covered is not confirmed by the EOC, because the EOC clearly states that periodontal maintenance is 
covered. Therefore, we decided that the Plan has to pay for the periodontal maintenance.  
 
We also decided that the Plan does not have to pay for the interim caries arresting medicament 
applications and additional intraoral periapical x-ray. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
interim caries arresting medicament applications and additional intraoral periapical x-ray. 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the leg (73718). 
 
You asked the Plan to pre-approve an MRI of the leg. 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. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
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 an MRI of the leg. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found based on the medical records 
provided there is no documentation that an MRI is medically reasonable and necessary in this case. The records 
do not document any symptoms or examination findings that would necessitate an MRI scan. Plain x-ray 
imaging would be the standard next evaluation for your symptoms and then possibly an MRI scan depending 
on results of the x-ray and your symptoms and examination findings. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI of the leg have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a magnetic resonance imaging (MRI) of the leg (73718).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the unspecified preventive service (D1999) provided on 
August 19, 2020. 
 
You asked the Plan to pay for the dental service. You say that the hygienist never told you about code D1999. 
You say that you were charged an extra $15 for the visit. You say that you never even saw the dentist. You also 
say that you should only be paying a $5 copayment per your benefit. The Plan denied your request. The Plan 
says the unspecified preventive services is not listed as a covered service. 
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 unspecified preventive service is 
not among those covered under this benefit. The record shows that code D1999 represents the additional 
personal protective equipment (PPE) that was used due to Covid-19. This is not listed as a covered service 
either. Therefore, we decided that the Plan does not have to pay for the unspecified preventive service (D1999) 
provided on August 19, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the train of four testing provided on February 7, 2020. 
 
You asked the Plan to pay for train of four testing (95999). You say that the Plan should pay this claim. The 
Plan denied your request. The Plan says this service is considered a bundled procedure included in the cost of 
the primary procedure. 
 
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 95999 is unlisted neurological or neuromuscular 
diagnostic procedure. 
 
We find that CPT code 95999 is not supported in the medical record. Specifically, Medicare does not make 
separate payment for this service. Based on this information, we decided that Medicare rules for coverage of 
train of four testing have not been met. Therefore, we decided that the Plan does not have to pay for the train of 
four testing provided on February 7, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen therapy. 
 
You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your 
request. The Plan says you do not have an indication for this request. 
 
 
 
The Plan must follow Medicare rules. Medicare rules say that hyperbaric oxygen therapy is covered for specific 
indications.  
 
Your diagnosis for this request is "Central perforation of tympanic membrane, bilateral." This is not listed as an 
accepted indication for HBO therapy. Based on this information, we decided that Medicare rules for coverage 
of the therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve hyperbaric 
oxygen therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided to the enrollee on February 20, 
2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
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 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 physician services provided 
to the enrollee on February 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the durable medical equipment. You say that you would like reconsideration 
because you were told the equipment from this provider would be covered. The Plan denied your request. The 
Plan says a customer service representative informed you that this provider is not in-network. 
 
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 by 
an out of network (OON) provider.  
 
Your complaint about being given incorrect information is not a valid appeal for medical coverage. This part of 
your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the risk assessment panel provide on April 6, 2020. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says this is not a 
covered service. 
 
The Plan must follow Medicare rules. Medicare rules say that coverage for all CV risk assessment panels, 
except the basic lipid panel, is denied 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. Per LCD L36523, the requested risk assessment panel is a non-
covered service. Based on this information, we decided that Medicare rules for coverage of the lab services 
have not been met. Therefore, we decided that the Plan does not have to pay for the risk assessment panel 
provide on April 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral device rendered on May 12, 2020. 
 
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 provider is not Medicare certified. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for services only when they are 
furnished by a provider or supplier enrolled in the Medicare program. 
 
The file shows that the provider was not Medicare-certified during the dates of service at issue in this appeal. 
Therefore, we decided that the Plan does not have to pay for the oral device rendered on May 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a platelet rich plasma injection (0232T). 
 
You asked the Plan to pre-approve the plasma injection. You say that the injection is medically necessary. The 
Plan denied your request. The Plan says this service is non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that the evidence is not adequate to conclude that 
autologous PRP is reasonable and necessary and remains non-covered outside of clinical trials. 
 
We looked at the file and Medicare rules. The service requested is not covered. Based on this information, we 
decided that Medicare rules for coverage of the plasma injection have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a platelet rich plasma injection (0232T).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance transport provided on June 
8, 2020. 
 
You asked the Plan to waive the copayment for the ambulance transport. The Plan denied your request. The 
Plan says the copayment 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 $225 
copayment for each one-way Medicare-covered ground trip. 
 
You have been asked to pay a $225 copayment for the ambulance transport. The ambulance transport falls 
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 transport provided on June 8, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the walker with a seat (E0144). 
 
You asked the Plan to pre-approve the walker. You say that you would like reconsideration because you have 
issues walking and require the seat for when you feel uneasy and tired. The Plan denied your request. The Plan 
says medical necessity for this walker has not been established 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at your request, the file, and Medicare rules. Based on this information, we decided that Medicare 
rules for coverage of the walker have not been met. Specifically, per Medicare guidance, the medical necessity 
for the requested walker has not been established and should be denied as not reasonable and necessary. 
Therefore, we decided that the Plan does not have to pre-approve the walker with a seat (E0144).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that the enrollee's doctor recommended these 
orthotics. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
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. 
 
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 your 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. You 
do not require the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen 
hours per week of rehabilitative services and regular physician evaluation. Your care needs can be met at a 
lower level of care. 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-approve acute inpatient rehabilitation facility (IRF) admission and services.