Persius/hicric huggingface dataset:
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 these services are medically necessary. 
The Plan denied your request. The Plan says that you are receiving appropriate in-patient acute care and do not 
require transfer to LTACH. 
 
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. Your status 
is slowly stabilizing and you are receiving appropriate care at the present acute care hospital. You do not 
require services at the LTACH that are not available at the acute care hospital where you are currently 
receiving care. Our physician reviewer found that your condition does not meet Medicare criteria for LTACH 
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 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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on September 9, 2019. 
 
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 
members 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the first day of the month following the month in which hospice was revoked or discharged.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 September 7, 2019. 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 September 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided by an out of 
network provider. 
 
You asked the Plan to pay for the hospitalist physician service. You say that the facility did not get 
authorization. The Plan denied your request. The Plan says you did not request prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. The Plan did not pre-approve the service 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 medical services provided by an out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite for four or more surfaces (D2394) 
provided on August 6, 2020. 
 
You asked the Plan to pay for the resin-based composite. You say that you were unaware that you were over 
the benefit limit of $1,000 for dental services. The Plan denied your request. The Plan says you have exceeded 
your maximum 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. The Plan covers the resin-
based composite when the services are medically necessary and reasonable.  
 
We looked at the file and Medicare rules. The file indicates that you have reached the maximum benefit limit 
of $1,000 and the remaining charges are your responsibility. Based on this information, we decided that the 
Plan's rules for coverage of the resin-based composite have not been met. Therefore, we decided that the Plan 
does not have to pay for the resin-based composite for four or more surfaces (D2394) provided on August 6, 
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the extraction (D7140) provided on June 23, 2020. 
 
You asked the Plan to reimburse you for the extraction. You say that your benefits include bone grafts in 
preparation for implants. You also say that prior authorization is recommended but not required for out of 
network providers. The Plan denied your request. The Plan says the extraction is not 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 requested items or services are not 
among those covered under this benefit. Additionally, the service you are asking the Plan to reimburse you for 
involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting 
your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that 
the Plan does not have to reimburse you for the extraction (D7140) provided on June 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physician's services provided on August 25, 
2020. 
 
You asked the Plan to waive the copayment the physician's services. The Plan denied your request. The Plan 
says the claim was processed 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 $35 
copayment for Medicare-covered vision care.  
 
You have been asked to pay a $35 copayment for the physician's services. The physician's services falls within 
the Medicare-covered vision 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 
physician's services provided on August 25, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided July 11, 2020, 
through July 12, 2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the member could have been cared for at an observational level of 
care. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the records did not show that at the time of inpatient admission the admitting 
physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or 
observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Specifically, it was not 
reasonably expected the enrollee's care would span two midnights. Therefore, we decided that the Plan does 
not have to pay for the acute inpatient hospital care provided July 11, 2020, through July 12, 2020.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to waive the cost share for the echocardiography with CPT code 93306 provided 
on July 22, 2020. 
 
You asked the Plan to waive the cost share for CPT code 93306. 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 that you received an echocardiography on the date of service at issue in this appeal. 
The Plan says that the correct cost share 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 does not say in clear and accurate terms 
how much you should expect to pay for Outpatient diagnostic tests.  
 
We looked at your contract with the Plan. The Plan contract does not clearly say how much enrollees must pay 
for Outpatient diagnostic tests. The Plan contract provides a range from a coinsurance to a max copay; 
however, the Plan contract does not say in clear and accurate terms how much you would expect to pay for the 
echocardiography. This means that the Plan did not follow Medicare rules for disclosure of cost sharing 
information. Therefore, we decided that the Plan has to waive the cost share for the echocardiography with 
CPT code 93306 provided on July 22, 2020.  
 
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 pay for a tetanus, diphtheria, and acellular pertussis (TDAP) vaccine 
provided on May 18, 2020. 
 
You asked the Plan to pay for TDAP vaccine. You say that this was provided to you during the normal course 
of your medical examination. The Plan denied your request. The Plan says the denial of payment for this is 
correct, because this immunization is not covered by Medicare Part B and may be covered by your Medicare 
Part D pharmacy benefits. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide TDAP vaccine. The 
Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to TDAP vaccine. 
Therefore, we decided that the Plan does not have to pay for a tetanus, diphtheria, and acellular pertussis 
(TDAP) vaccine provided on May 18, 2020.  
 
Benefits for TDAP vaccine may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit (99215) provided on 
January 2, 2020. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you should not be charged 
for this. The Plan denied your request. The Plan says this processed 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 $25 
copayment for each visit to a specialist.  
 
You have been asked to pay a $25 copayment for a specialist office visit. 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 a specialist office visit (99215) provided on January 2, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on September 16, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were treated in place by the medics. 
The Plan denied your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on September 16, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on September 16, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of the Superion interspinous spacer. 
 
You asked the Plan to pre-approve the Superion procedure. You say that this should be allowed to help the 
enrollee with his pain. The Plan denied your request. The Plan says this is an experimental procedure. 
 
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 Superion procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the device is experimental. More research is needed to show safety and efficacy.  
 
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 Superion procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve placement of the Superion interspinous spacer.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the wound care services provided in an 
outpatient hospital setting on July 7, 2020. 
 
You asked the Plan to waive the copayment for the wound care 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 wound care services in an outpatient hospital facility setting 
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 $150 
copayment for each Medicare-covered outpatient hospital facility visit, clinic, outpatient treatment room, 
observation room, or outpatient surgery services.  
 
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received wound care 
services in an outpatient hospital setting on July 7, 2020. You have been asked to pay a $150 copayment for the 
wound care services. The wound care services fall within the Outpatient Hospital 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 wound care services provided in an outpatient hospital 
setting on July 7, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on March 24, 
2020, and March 28, 2020. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that the member states they 
have never paid this much. The Plan denied your request. The Plan says the claims were processed accordingly 
with the member's 2020 EOC 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).  
 
Review of the file show that the member received ambulance services on March 24, 2020, and March 28, 2020. 
The member is asked to pay a $325 copayment per date of service for the ambulance services. The member's 
EOC states that enrollees must pay a $325 for Medicare-covered ambulance services per trip. 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 ambulance services provided on March 24, 2020, and March 28, 
2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the catheter procedures provided from 
April 6, 2020, to June 8, 2020. 
 
You asked the Plan to waive the copayments for the catheter procedures. You say that you cannot afford this 
copayment every time the enrollee needs to have his catheter changed. You say you were told this procedure 
would be covered. 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). The enrollee's contract with the Plan clearly says that enrollees 
must pay a $250 copayment for surgery services at an in-network outpatient hospital. For each date of service, 
you have been asked to pay the allowed amount of the claim because these amounts are less than the $250 
copayment for the catheter procedures in an outpatient hospital. 
 
The enrollee has been asked to pay a $109.06 copayment for the catheter procedure on each date of service. 
The catheter procedures fall within the Outpatient surgery, including services provided at hospital outpatient 
facilities and ambulatory surgical centers benefit category. This means that the enrollee has been asked to pay 
the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee 
agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayments for the catheter procedures provided from April 6, 2020, to June 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous intraoperative neurophysiology monitoring 
services coded 95941 and the unlisted neurological or neuromuscular diagnostic procedure coded 95999 
provided on June 9, 2020. 
 
You asked the Plan to pay for the continuous intraoperative neurophysiology monitoring services and the 
unlisted neurological or neuromuscular diagnostic procedure. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered 
benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 95941 and 95999 are not supported in the medical record. Specifically, code 95941 has 
a status code of "I". A status code of I means that this code is not valid for Medicare purposes. Medicare uses 
another code for reporting of, and payment of these services. Review of the file shows that train of four testing 
was provided and billed with code 95999. This service is considered a bundled procedure as the cost is 
included in the cost of the primary procedure. Therefore, code 95999 cannot be separately paid. 
Based on this information, we decided that Medicare rules for coverage of the continuous intraoperative 
neurophysiology monitoring services and the unlisted neurological or neuromuscular diagnostic procedure have 
not been met. Therefore, we decided that the Plan does not have to pay for the continuous intraoperative 
neurophysiology monitoring services coded 95941 and the unlisted neurological or neuromuscular diagnostic 
procedure coded 95999 provided on June 9, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ozurdex (J7312). 
 
You asked the Plan to pre-approve Ozurdex. You say that you would like reconsideration because this drug is 
medically necessary. The Plan denied your request. The Plan says 6 months has not elapsed since this drug was 
last administered. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Ozurdex. Our reviewer says that there 
is only very limited information on repeat dosing intervals of Ozurdez less than 6 months. A 2-year 
observational study has shown that the use of more than two consecutive administrations is associated with 
increases in some adverse reactions. Our physician reviewer found no more than two consecutive Ozurdex 
injections should be used, and an interval of approximately 6 months should be allowed between the two 
injections. The time interval in this case is just over 4 months. It is too soon for a second intravitreal implant. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Ozurdex have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Ozurdex (J7312).