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

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from November 10, 2019 to 
November 11, 2019. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the care provided was medically 
necessary. The Plan denied your request. The Plan says that inpatient care was not medically necessary and 
care could have been provided at observation level. 
 
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 supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found this patient was sufficiently unstable with seizures and large swings in blood sugar that 
admission was medically reasonable and appropriate in judging that 2 or more nights would be necessary for 
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 acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from November 10, 2019 to November 11, 2019.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral exam rendered on October 1, 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 services exceed the benefit limit. 
 
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 one 
comprehensive oral exam every three years. 
 
The file shows that you had a comprehensive oral exam on October 1, 2020. You previously received these 
services on August 6, 2020 for which the Plan approved and paid. The exam on October 1, 2020 was 
performed fewer than three years from your previously covered exam. Therefore, we decided that the Plan does 
not have to pay for the comprehensive oral exam rendered on October 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network physician services provided on October 10, 
2020. 
 
You asked the Plan to pay for this service. You say that this service should be covered by the Plan. The Plan 
denied your request. The Plan says you 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 had network providers available who could have provided 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 out of network 
physician services provided on October 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan of the 
maxillofacial area (70486) and nasal endoscopy (31231) provided on May 14, 2020. 
 
You asked the Plan to waive the copayment for the CT scan of the maxillofacial area and nasal endoscopy. You 
say that you should only be responsible for the copayment for the specialist office visit. The Plan denied your 
request. The Plan says based on Medicare billing criteria, the claim was billed 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 $125 
copayment for Medicare-covered diagnostic radiology services.  
 
You have been asked to pay $125 for the CT scan of the maxillofacial area and nasal endoscopy. 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 computed tomography (CT) scan of the maxillofacial area 
(70486) and nasal endoscopy (31231) provided on May 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown provided on August 4, 2020. 
 
You asked the Plan to pay for the crown. You say that the Plan has denied your reimbursement because your 
dentist is an out-of-network provider. You also say that you were not aware that this provider had opted out of 
Medicare. The Plan denied your request. The Plan says that this claim was not denied because the provider is 
out-of-network. The Plan also says that this service was rendered by a privately contracted provider who has 
opted out of Medicare effective February 25, 2016, to February 25, 2020. 
 
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 crown 
provided on August 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for outpatient hospital services provided on 
July 31, 2020. 
 
You asked the Plan to waive the coinsurance for outpatient hospital services. You say that the providers 
website shows that they are in-network. 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 50% 
coinsurance for out-of-network outpatient surgery, including services provided at hospital outpatient facilities 
and ambulatory surgical centers.  
 
You received outpatient hospital services on July 31, 2020, from an out-of-network provider. Therefore, you 
are responsible to pay your share of the out-of-network cost-sharing charges. The total allowed amount is 
$6,419.44 and 50% of that is $3,209.72.  
 
You have been asked to pay the total coinsurance amount of $3,209.72 for outpatient hospital services. 
Outpatient hospital services fall within the outpatient surgery, including services provided at hospital outpatient 
facilities and ambulatory surgical centers 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 outpatient hospital services provided on July 31, 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 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. 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 there are no services at the LTACH that the enrollee requires that is not already 
available and covered at the current facility. Therefore, this request for LTACH services will be considered not 
medically necessary at this time. Transfer to a lower level of care may be considered soon when treatment has 
completed. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on April 3, 2019. 
 
You asked the Plan to pay for the services provided. You say that the physician provided medically necessary 
services in good faith. The Plan denied your request. The Plan says a corrected claim was received past the 
allowed time frame. 
 
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 valid claim for the services provided was not filed until August 27, 2020. This means 
that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the medical services provided on April 3, 2019.
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 you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested admission is not medically necessary. 
 
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 the enrollee was admitted for surgical repair of a hip fracture after a fall. The 
enrollee's medical conditions are stable. The documentation does not support that the enrollee requires an 
interdisciplinary approach to rehabilitation care. The documentation does not support that the enrollee requires 
an intensive rehabilitation therapy program. The enrollee's care needs can be met at a lower level of 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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for magnetic resonance imaging (MRI) brain 
(including brain stem) (70553) chemistry Procedures, creatinine (82565) Injection, gadolinium-based magnetic 
resonance contrast agent (A9579) magnetic resonance imaging (MRI) spinal canal and contents (72141) 
provided September 17, 2020. 
 
You asked the Plan to waive the copayment for the advanced imaging services. You say that These films are 
not of diagnostic quality and unreadable to your neurosurgeon. You must have the MRI's retaken and you 
refuse to pay $275 copay twice. The Plan denied your request. The Plan says this claim has been processed 
correctly per the Evidence of coverage 
 
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 $275 
copayment for advanced imaging services.  
 
You have been asked to pay $275 copayment for advanced imaging services. The advanced imaging 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 magnetic resonance imaging (MRI) brain (including brain stem) (70553) chemistry Procedures, creatinine 
(82565) Injection, gadolinium-based magnetic resonance contrast agent (A9579) magnetic resonance imaging 
(MRI) spinal canal and contents (72141) provided September 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction by neurolytic agent, paravertebral facet joint 
nerve(s), with imaging guidance (64636). 
 
You asked the Plan to pre-approve destruction by neurolytic agent, paravertebral facet joint nerve(s), with 
imaging guidance. 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 follows Medicare rules. Medicare rules say that for each covered spinal region (cervical/thoracic or 
lumbar), no more than two (2) thermal RF sessions will be reimbursed in any calendar year, involving no more 
than four (4) joints per session, e.g., two (2) bilateral levels or four (4) unilateral levels. 
 
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 destruction by neurolytic agent, 
paravertebral facet joint nerve(s), with imaging guidance. Our reviewer says that the services are not medically 
necessary. Our physician reviewer found utilization criteria limit each session to just 4 joints. Therefore, only 3 
radiofrequency ablation (RFA) per session are deemed medically reasonable and 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 destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging 
guidance have not been met. Therefore, we decided that the Plan does not have to pre-approve destruction by 
neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (64636).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network physician services provided from September 
10, 2019 to October 29, 2019. 
 
You asked the Plan to pay for this service. You say that these services should be covered by the Plan. 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 had network providers available who could have provided 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 out of network 
physician services provided from September 10, 2019 to October 29, 2019.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve a negative pressure wound therapy pump with accessories. 
 
You asked the Plan to pre-approve the device. The Plan denied your request. The Plan says that this is not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a negative pressure wound therapy pump is covered 
when the above criteria are met. 
 
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 device. Our reviewer says that the 
requested wound therapy pump and supplies are medically reasonable and necessary. Our physician reviewer 
found that the enrollee is noted to have an ulceration with exposed adipose tissue to the lateral aspect of the 
right ankle. The ulceration demonstrates recent healing with the use of offloading of pressure to the ulcerative 
area, sharp wound debridement, wound care with dressings, and negative pressure wound therapy. The enrollee 
is noted to have arterial insufficiency, has had documentation in the medical record of evaluation, care, and 
wound measurements by a licensed medical professional, has had application of dressings to maintain a moist 
wound environment, and has undergone debridement of necrotic tissue and nonviable tissue from the ulcerative 
area. Provisions have been made for nutritional status. For these reasons, the requested negative pressure 
wound therapy is medically reasonable and necessary for this enrollee, and meets coverage guidelines. 
 
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 device have been met. Therefore, we decided that the Plan has to pre-
approve a negative pressure wound therapy pump with accessories.  
 
 
 
 
 
 
 
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 the hospital services provided on June 4, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are not 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that Indian Health Service (IHS) providers are paid 
by Medicare for covered outpatient services based upon an all-inclusive outpatient per visit rate (AIR). All 
charges, except for therapies, telehealth originating site facility fee, PPV, influenza virus vaccine, hepatitis B 
vaccine and hospital-based ambulance services are combined and reported under revenue code 0510 (clinic 
visit) on TOB 13X (hospital outpatient). 
 
We looked at the file and Medicare rules. The services in question were not billed in accordance with 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 pay for the hospital services provided on June 4, 
2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for outpatient rehabilitation services provided 
from July 30, 2020, to August 13, 2020. 
 
You asked the Plan to waive the deductible for outpatient rehabilitation services. You say that you disagree 
with the charges because you were told that you had visits left over at no cost to you. 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. Your 
contract with the Plan says that there is a $750 deductible for outpatient rehabilitation services.  
 
You received outpatient rehabilitation services from July 30, 2020, to August 13, 2020. The record shows that 
you had only paid $136.91 toward the $750 deductible prior to receiving the services. Therefore, you are 
responsible to pay the total deductible amount of $414.11.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient 
rehabilitation services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a 
$750 deductible for outpatient rehabilitation services. This cost sharing is a contractual obligation that had not 
been met at the time outpatient rehabilitation services were received on July 30, 2020 to August 13, 2020. 
Therefore, we decided that the Plan does not have to waive the deductible for outpatient rehabilitation services 
provided from July 30, 2020, to August 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient services provided on August 1, 2020, to August 
22, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for outpatient services. You say that you would like this claim reprocessed and paid. 
The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the 
rendering facility is also out-of-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 had network providers 
available who could have provided 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 outpatient services provided on August 1, 2020, to 
August 22, 2020 by an out of network (OON) provider.