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

We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that a lower level of care would be 
inadequate for the enrollee. The Plan denied your request. The Plan says rules for LTACH care have not been 
met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee appears to be stabilizing, but requires additional short term acute 
care services which can safely be completed in the current facility. The enrollee does not require services in the 
LTACH that are not already available at the current facility. There are no services at the LTACH that are not 
already available and covered at the current facility. 
 
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 the LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided by a participating 
provider. 
 
You asked the Plan to waive the copayment for an office visit. You say that you went for your annual wellness 
exam. The Plan denied your request. The Plan says these office visit was for the management and evaluation of 
an existing condition. 
 
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 $10 
copayment for physician/practitioner services/primary care doctor.  
 
You have been asked to pay a $10 copayment for an office visit. An office visit falls within the 
physician/practitioner services/primary care doctor 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 office visit provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the dental services provided. 
 
You asked the Plan to pay more for the dental services. You say that there was a lack of information in the 
book and missing information when you called for answers. You say that you want to be reimbursed for the 
total amount paid. The Plan denied your request. The Plan says the services are not 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, you also have an annual maximum of 
$1,000. The Plan paid $1,000 toward the dental services you received, which exhausted 
your benefit. Therefore, we decided that the Plan does not have to pay more for the dental services provided.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0675, E0673). 
 
You asked the Plan to pay for a pneumatic compression device. You say that the device is necessary to prevent 
deep vein thrombosis. The Plan denied your request. The Plan says PCDs billed by E0675 are not covered. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism is a preventive service. PCDs billed by E0675 are not 
covered. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided 
that the Plan does not have to pay for a pneumatic compression device (E0675, E0673).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the X-ray of chest (71046) provided on 
August 6, 2020. 
 
You asked the Plan to waive the copayment for the X-ray of chest. You say that the X-ray should be considered 
part of your annual physical and would like the copayment dropped. The Plan denied your request. The Plan 
says the copayment 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 $10 for 
outpatient hospital services including X-rays.  
 
You have been asked to pay a $10 for the X-ray of chest. The service falls within the outpatient hospital 
services including X-rays 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 X-ray of 
chest (71046) provided on August 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for arthrocentesis, aspiration and/or injection (20611) provided 
April 20, 2020. 
 
You asked the Plan to pay for the arthrocentesis. You say that the records provided should support the necessity 
of the service in dispute. The Plan denied your request. The Plan says the records do not support service billed. 
 
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 20611 is arthrocentesis, aspiration and/or injection. 
 
We find that CPT code 20611 is not supported in the medical record. Specifically, records do not contain 
documentation of permanently recorded images to support the billed charge. The plan made multiple attempts 
to obtain the needed records without success. Based on this information, we decided that Medicare rules for 
coverage of the arthrocentesis have not been met. Therefore, we decided that the Plan does not have to pay for 
arthrocentesis, aspiration and/or injection (20611) provided April 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the occlusal guard provided on June 18, 2020. 
 
You asked the Plan to pay for the occlusal guard. You say that you would like the Plan to pay for your night 
guard. The Plan denied your request. The Plan says occlusal guards are not covered by Medicare or the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
occlusal guard provided on June 18, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need intensive care to get back on your feet. The 
Plan denied your request. The Plan says rules for IRF care have not been met. 
 
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 that you do not require the intensity of services provided at an IRF. Specifically, you 
have not been shown to require fifteen hours per week of rehabilitative services and regular physician 
evaluation. 
 
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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to waive the $25 copayments. We decided that the Plan does not have to reduce 
the $200 copayments.  
 
You asked the Plan to reduce the copayments for wound care. You say that you had no reason to believe this 
would be considered outpatient hospital procedures. You say that the copayment should be $25 not $200. The 
Plan says that the copayments applied correctly. 
 
We decided that the Plan has to waive the $25 copayments.  
 
The Plan contract says that the $25 copayment is for specialist services. The specialist physician copayments 
cannot be applied to these claims because these claims do not represent professional services performed by a 
physician. Therefore, we decided the Plan must waive the $25 copayments on May 27, 2020 and June 26, 2020. 
  
 
 
We also decided that the Plan does not have to reduce the $200 copayments. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a $200 
copayment for Medicare-covered outpatient hospital services. The records show that the wound care was billed 
by the hospital as treatment room services. Therefore, we decided that the Plan does not have to reduce the 
$200 copayments. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the cataract surgery you had on December 
5, 2019 
 
You asked the Plan to reduce the copayment for the cataract surgery. You say that you believe you had this 
surgery at an ambulatory surgery center, so your copayment should only be $100. The Plan denied your 
request. The Plan says you were charged this copayment correctly. The Plan says that it reduced your 
copayment for your first surgery as a one-time courtesy. 
 
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 $150 
copayment for surgical procedures in an outpatient hospital facility.  
 
You have been asked to pay a $150 copayment for the cataract surgery. The billing records from this surgery 
explicitly state that these were hospital services. That is why the cataract surgery falls within the surgical 
procedures in an outpatient hospital facility 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 reduce the copayment 
for the cataract surgery you had on December 5, 2019
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need IRF care and that a lower level of care is 
inadequate. The Plan denied your request. The Plan says rules for IRF care have not been met. 
 
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 that you do not require the intensity of services provided at an IRF. Specifically, you 
have not been shown to require fifteen hours per week of rehabilitative services and regular physician 
evaluation. 
 
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 IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation and intraoral x-ray provided by an 
out-of-network provider on April 22, 2020. 
 
You asked the Plan to pay for the limited oral evaluation and intraoral x-ray. You say that you were informed 
the provider was in-network. You say that you wouldn't have gone if you knew they were not in-network. The 
Plan denied your request. The Plan says out-of-network dental services are not 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, out-of-network dental services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
limited oral evaluation and intraoral x-ray provided by an out-of-network provider on April 22, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient surgery provided. 
 
You asked the Plan to pay for the outpatient surgery. You say that you knew the provider was out-of-network 
so you thought you would be responsible for 35% of the bill. You say that you counted on being reimbursed by 
insurance after surgery. 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 who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the 
outpatient surgery provided.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy provided by a 
participating provider on March 10, 2020, to March 30, 2020. 
 
You asked the Plan to waive the copayment for physical therapy. You say that you shouldn't have been 
discharged before you were fully ready. The Plan denied your request. The Plan says the correct copayment has 
been applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for outpatient rehabilitation services/physical therapy.  
 
You have been asked to pay a $40 copayment for physical therapy. The total amount you are being asked to 
pay is $1,040 ($40 x 26 visits = $1,040). Since physical therapy services were provided, the correct copayment 
has been applied. Physical therapy falls within the outpatient rehabilitation services/physical therapy 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 physical therapy provided by a participating 
provider on March 10, 2020, to March 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for arthrocentesis, aspiration and/or injection 
(20610) and Hyaluronan or derivative injection (J7321) provided July 14, 2020. 
 
You asked the Plan to waive the copayment for the injection services. You say that you thought that the $35 
copayment had been waived. You had agreed to pay that one time but not for all 5 sessions. In the past you 
were only charged a 1 time fee and the cost of medication. The Plan denied your request. The Plan says the 
claim processed correctly with the correct cost share applied per the plan benefits. 
 
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 Medicare Part B prescription drugs and $35 copayment per visit to a specialist. for Medicare 
Part B prescription drugs and Physician/Practitioner services, including doctor's office visits.  
 
You have been asked to pay $50.15 for the injection services. The injection services fall within the Medicare 
Part B prescription drugs and 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 copayment for arthrocentesis, aspiration and/or injection (20610) and 
Hyaluronan or derivative injection (J7321) provided July 14, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital discharge management (99239) provided January 8, 
2020 to January 15, 2020. 
 
You asked the Plan to pay for the hospital discharge management services. You say that the services were 
medically necessary. The Plan denied your request. The Plan says the records do not support the services 
billed. 
 
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 99239 is hospital discharge day management, more than 
30 minutes. 
 
We find that CPT code 99239 is not supported in the medical record. Specifically, the provide records do not 
note that more than 30 minutes was spent on this service. Based on this information, we decided that Medicare 
rules for coverage of the hospital discharge management services have not been met. Therefore, we decided 
that the Plan does not have to pay for hospital discharge management (99239) provided January 8, 2020 to 
January 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fora revascularization procedure (37226) provided June 9, 2020.You asked the Plan to pay forthe revascularization procedure. You say that the services are medically necessary.The Plan denied your request. The Plan says units billed exceed the allowable amount.The Plan mustfollow 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 37226 is 1. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the revascularization procedure have not been met.Therefore, we decided that the Plan does not have to pay fora revascularization procedure (37226) provided June 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crowns for tooth #'s 8 and 12. 
 
You asked the Plan to pre-approve the crowns. The Plan denied your request. The Plan says crowns are not a 
covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
crowns for tooth #'s 8 and 12.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pre-operative screening testing provided on October 8, 2019. 
 
You asked the Plan to pay for laboratory test. You say that you are appealing based on medical necessity. The 
Plan denied your request. The Plan says the denial of payment for this service is correct, because this testing is 
not separately covered apart from the Medicare prospective payment for the procedure. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The test at issue in this appeal, laboratory test, was requested for screening purposes. Medicare does not cover 
this test for screening purposes. Therefore, we decided that the Plan does not have to pay for pre-operative 
screening testing provided on October 8, 2019.