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

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are 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 medically necessary. Our physician reviewer found the enrollee was admitted to the hospital on October 31, 2020 with sepsis. The occupational therapy note dated January 12, 2021 states she needs varied levels of assistance with facial grooming, oral hygiene, bathing, and dressing. She does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require 15 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-approveacute 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 the specialist office visit provided on September 12, 2020.
You asked the Plan to waive the copayment for the specialist office visit. You say that that Covid testing should be covered in full and you should not have a copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $15 copayment per visit for an in-network specialist. You have been asked to pay a $15 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The record shows the billed code for the Covid-19 testing was covered and the applicable copayment was applied.
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 specialist office visit provided on September 12, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan provided by a participating provider on September 20, 2020, to September 21, 2020.You asked the Planto waive the copayment for a CT scan. You say that this should only be $85. 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 $200 copayment for outpatient diagnostic tests/advanced imaging service. You have been asked to pay a $200 copayment for a CT scan. The correct copayment has been applied to the CT scan that was provided. A CT scan falls within the outpatient diagnostic tests/advanced imaging service benefitcategory. 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 CT scan provided by a participating provider on September 20, 2020, to September 21, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services (81552) provided on September 18, 2020.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan
denied your request. The Plan says there were network providers available. The services were not preauthorized.
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 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 lab services (81552) provided on September 18, 2020.
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 IRF care is medically necessary. 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 the complexity of your nursing, medical and rehabilitation needs does not require an
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. In addition, you do not
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an
intensive rehabilitation therapy program. While the medical record documents a need for physical and
occupational therapy, it does not document a need for an intensive rehabilitation program. Finally, there is not a
reasonable expectation that this patient will be able to fully participate in and benefit from the intensive
rehabilitation therapy program provided in an IRF.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the in network rate forthe periodontal scaling and root planing (D4341) for all 4 quadrants provided on July 28, 2020.You asked the Plan to pay the in network rate forthe dental services. You say that you purchased the optional dental coverage. You say that according to the information that you had, periodontal scaling and root planing is covered at 30% in network and 20% out of network. You also say that there is no in network periodontist close to your residence and would like to be reimbursed at the in network rate.The Plan denied your request. The Plan says periodontal scaling and root planing is not listed as a covered service. The Plan also says you did not contact them to verify your benefits or provider eligibility.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 the in network rate forthe periodontal scaling and root planing (D4341) for all 4 quadrants provided on July 28, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to hold you harmless for the tetanus-diphtheria-acellular pertussis (Tdap) vaccine
provided on August 18, 2020.
You asked the Plan to hold you harmless for the Tdap vaccine. You say that you were seen by the doctor, and it
was felt that you needed a tetanus shot due to cuts on your leg from mountain biking. You state that you were
told this would be covered since it was due to having cuts. The Plan denied your request. The Plan says that
this was not billed with a valid diagnosis to have this covered by Medicare Part B.
The Plan must follow Medicare rules. Medicare rules say that vaccinations may be covered due to direct
exposure or injury. It is noted that services provided by contract provider are deemed approved by the Plan
unless notification of non-coverage was made. Plans must also forward all necessary information to the IRE to
support its denial.
In this case, you were provided with the Tdap vaccine by a contract provider. You state that you were told it
would be covered since you have injuries. Although this may not have been billed with an appropriate
diagnosis code, there is no evidence that you were informed that Medicare coverage criteria were not met. The
Plan failed to forward medical records to the IRE which would allow for independent review of the information
given during visit at issue. Based on this information, we find that the Tdap vaccine is considered approved by
the Plan. Therefore, we decided that the Plan has to hold you harmless for the tetanus-diphtheria-acellular
pertussis (Tdap) vaccine provided on August 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for allergy/immunology office services
provided on July 16, 2020.
You asked the Plan to waive the copayment for specialist visit. You say that you should not have to pay this
amount because the provider did not bill for an office visit. The Plan denied your request. The Plan says the
copayment amount you are being charged is correct.
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 $35
copayment for specialist visit.
You have been asked to pay $35 copayment for specialist visit. Specialist visit falls within the
Physician/Practitioner Services, Including Doctor's Office Visits benefit category. This means that you have
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the P
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair (E0240).
You asked the Plan to pre-approve a shower chair. You say that a shower chair is necessary for the enrollee.
The Plan denied your request. The Plan says a shower chair is not a covered benefit under the enrollee's
contractual policy or by Medicare.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are
not primarily medical in nature.
While a shower chair may be appropriate for the enrollee in this case, neither the Plan nor Medicare offers
coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair
(E0240).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for allergy/immunology services provided on
June 9, 2020.
You asked the Plan to waive the copayment for specialist visit. You say that the cost-share for this was not in
the Evidence of Coverage or Annual Notice of Change for 2020. The Plan denied your request. The Plan says
the copayment amount you are being charged is correct.
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 $35
copayment for specialist visit.
You have been asked to pay $35 copayment for specialist visit. Specialist visit falls within the
Physician/Practitioner Services, Including Doctor's Office Visits benefit category. This means that you have
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have
to waive the copayment for allergy/immunology services provided on June 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive or reimbursethe cost share for several claims for services provided from May 17, 2019, to October 9, 2019.You asked the Plan to waive or reimbursefunds you believe were overpaid for services provided in 2019. You say that you believe you have overpaid the maximum out of pocket (MOOP) for 2019. The Plan denied your request. The Plan says the claims in question were reviewed. The Plans portion of the services in question have been paidfor each service leaving your contractual copayment expectation of $25.00 and $50.00 for services rendered based on the service provided. 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 in 2019 there was a maximum out of pocket of $4500. The Plan has provided claim and payment information for each service in question. Both the records and the Explanation of Benefits (that you would also have a copy of)for each service clearly show thebalance of the maximum out of pocket at the time of service. You have been asked to pay the correct amount for each service 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 or reimbursethe cost share for several claims for services provided from May 17, 2019, to October 9, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a walker purchased out of network on June 11, 2020.
You asked the Plan to pay for out of network equipment. You say that the Plan should pay for this equipment.
The Plan denied your request. The Plan says you did not follow your Plan rules when you purchased this
equipment.
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 Plan contract says that durable medical equipment requires
prior authorization. You did not follow the Plan contract rules by purchasing this equipment out of network.
Theref
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transportation service
(A0429, A0425) provided on August 9, 2020.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to
the service provided.
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 $125 for
Medicare-covered ambulance services per day.
You have been asked to pay a $125 copayment for the ambulance transportation service provided. 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 transportation service (A0429, A0425) provided on
August 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foracupuncture services provided on October 19, 2020, by an out-of-network provider.You asked the Plan to pay forthe acupuncture services. You say that the magnetic resonance imaging you had showed permanent spasms and the neurologist recommended acupuncture.The Plan denied your request. The Plan says acupuncture is not covered even though it may be necessary.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 services are not covered by Medicare. There are no medical records and you say these services were recommended, not referred and there is no proof of a referral from a Plan provider.Therefore, we decided that the Plan does not have to pay foracupuncture services provided on October 19, 2020, by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the durable medical equipment rendered on
September 9, 2020.
You asked the Plan to waive the deductible for these services. You say that you feel the deductible had been
met. The Plan denied your request. The Plan says the deductible was applied correctly.
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 $1,000 yearly deductible for your covered medical services.
The item or service you asked the Plan to waive the deductible for falls within the durable medical equipment
benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $1,000
yearly deductible for your covered medical services. This cost sharing is a contractual obligation that had not
been met at the time these services were received on September 9, 2020. Therefore, we decided that the Plan
does not have to waive the deductible for the durable medical equipment rendered on September 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extractions provided on July 31, 2020.
You asked the Plan to pay for the extractions. You say that you had chemotherapy and radiation which broke
off your teeth and left roots in your gums. The Plan denied your request. The Plan says the Plan has already
paid for two extractions.
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 Plan also has a maximum benefit
of two extractions per calendar year. The Plan paid for two extractions provided on July 13, 2020, which
exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the extractions provided
on July 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fornuclear medicine provided on July 22, 2020, by an out-of-network (OON) provider.You asked the Plan to pay fornuclear medicine. You say that you would like this claim reprocessed and paid.The Plan denied your request. The Plan says prior authorization was not obtained.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 fornuclear medicine provided on July 22, 2020, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a wellness evaluation/visit provided on August 10, 2020.
You asked the Plan to pay for the wellness evaluation/visit. The Plan denied your request. The Plan says the
Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent
care and pre-approved care. The Plan says that the Plan has also determined that these services are not urgent
or emergent, nor were they approved in advance.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the
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 a wellness evaluation/visit provided on August 10, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on June 26, 2020 to July 9,
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 claims were billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that inpatient services must be billed with POS code
21.
We looked at the file and Medicare rules. The file shows that the enrollee was under inpatient status for the
dates of service at issue and the claims were incorrectly billed with POS code 22 for an outpatient hospital
facility. 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 pay for the laboratory services rendered on June 26,
2020 to July 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the core build up (D2950) and crown (D2752)
provided from August 4, 2020, to August 20, 2020.
You asked the Plan to reimburse you for the dental services. You say that you got elbowed in the jaw resulting
in a broken molar. You say that you were advised you would need a crown. You also say that you paid out of
pocket for the crown. The Plan denied your request. The Plan says core build up is not listed as a covered
service. The Plan also says that the crown 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 requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse you for
the core build up (D2950) and crown (D2752) provided from August 4, 2020, to August 20, 2020.