Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network physical therapist. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says you are contractually required to obtain the service from network providers. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a referral to an out-of-network physical therapist.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve Excimer laser therapy and photochemotherapy. 
 
You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your 
request. The Plan says that there is no diagnosis of psoriasis. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the therapy. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee has vitiligo, which is an indication for Excimer laser therapy and photochemotherapy based 
on community standards. 
 
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 therapy have been met. Therefore, we decided that the Plan has to pre-
approve Excimer laser therapy and photochemotherapy.  
 
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 reduce the copayment for the intravitreal injection provided on July 
16, 2020. 
 
You asked the Plan to reduce the copayment for the intravitreal injection. You say that you have always paid 
about $90 until this visit and you had no reason to believe the amount would change. You say that the prior $90 
charge should be honored. The Plan denied your request. The Plan says the $300 copayment applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $300 
copayment for all other services at an outpatient hospital. 
 
You have been asked to pay a $300 copayment for the intravitreal injection. The intravitreal injection falls 
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 reduce the copayment for the intravitreal 
injection provided on July 16, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing for an inpatient hospital admission and the 
administration of chemotherapeutic drugs on June 26, 2020. 
 
You asked the Plan to waive the cost-sharing for an inpatient hospital admission and the administration of 
chemotherapeutic drugs. You say that this charge will put you over your out-of-pocket expense. The Plan 
denied your request. The Plan says the correct cost-sharing was 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 $310 
copayment for each day for days 1-5 for Medicare-covered hospital care and 20% coinsurance for each 
Medicare-covered Part B and chemotherapy drug.  
 
The Plan has documented that you did not reach your out-of-pocket maximum on June 26, 2020. You have 
been asked to pay a $170.80 copayment for an inpatient hospital admission. An inpatient hospital admission 
falls within the "Inpatient Hospital Care" benefit category. You have also been asked to pay $162.31, or 20% of 
the Plan-allowed amount of $811.54, for the administration of chemotherapeutic drugs. The administration of 
chemotherapeutic drugs falls within the "Medicare Part B Prescription Drugs" benefit category. This means 
that you have been asked to pay less than or equal to 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 cost-sharing for an inpatient hospital admission and the 
administration of chemotherapeutic drugs on June 26, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy services to be provided by the out-of-
network provider. 
 
You asked the Plan to pre-approve the physical therapy services. The Plan denied your request. The Plan says 
that the Plan has physical therapist in-network that can provide a treatment plan and you are contractually 
required to obtain this service from network providers. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physical 
therapy services to be provided by the out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical pathology services provided on November 11, 2019. 
 
You asked the Plan to pay for the surgical pathology services. The Plan denied your request. The Plan says the 
services were not authorized by the Plan. 
 
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 
surgical pathology services. 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 surgical pathology services provided on 
November 11, 2019.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve anesthesia for a dental procedure (41899). 
 
You asked the Plan to pre-approve the anesthesia services. You say that the services are medically necessary. 
The Plan denied your request. The Plan says the requested service is not covered under the Part B medical 
benefit. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pre-approve 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 pre-approve anesthesia for a dental 
procedure (41899).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two crowns (D2750 x2) and two extractions (D7210 x2) 
provided from May 4, 2020, to June 3, 2020. 
 
You asked the Plan to pay for the crowns and extractions. You say that your tooth was sticking into your gums 
and was cracked. You also say that you could not live without front teeth. The Plan denied your request. The 
Plan says these services are not covered benefits under your dental plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans 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 two 
crowns (D2750 x2) and two extractions (D7210 x2) provided from May 4, 2020, to June 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided on March 5, 2020. 
 
You asked the Plan to pay for the chiropractic services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require 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 did not pre-approve the 
chiropractic services. 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 chiropractic services provided on March 5, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Lab Services (80053, 85025, 85027, P9604) provided 
October 7, 2019 to October 14, 2019. 
 
You asked the Plan to pay for the Lab Services. You say that these services were medically necessary. The Plan 
denied your request. The Plan says the documentation does 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. 
 
We find that CPT codes 80053, 85025, 85027, & P9604 are not supported in the medical record. Specifically, 
the documentation did not include a valid physician order or supporting medical records. The plan requested 
additional information and it was not received. Based on this information, we decided that Medicare rules for 
coverage of the Lab Services have not been met. Therefore, we decided that the Plan does not have to pay for 
Lab Services (80053, 85025, 85027, P9604) provided October 7, 2019 to October 14, 2019.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service provided on May 25, 2019. 
 
You asked the Plan to pay for the ambulance service. You say that you had a difficult time obtaining the correct 
insurance carrier. The Plan denied your request. The Plan says the claim was untimely. 
 
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 claim for the ambulance service was not filed until July 7, 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 ambulance service provided on May 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician's services to be provided by the out-of-
network provider. 
 
You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says the 
enrollee's contract with the Plan covers care from in-network providers with the exception of emergency or 
urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an 
in-network provider, which requires prior authorization from the plan.  
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve 
physician's services to be provided by the out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the diabetic shoe and insert (A5500, A5512) to be 
provided by an out of network (OON) provider. 
 
You asked the Plan to pre-approve the diabetic shoe and insert. You say that you prefer getting the durable 
medical equipment from an OON provider. The Plan denied your request. The Plan says the plan has multiple 
in-network providers able to provide the requested services. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the diabetic shoe and insert (A5500, A5512) to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the office visit you had with an out-of-
network doctor on July 22, 2020. 
 
You asked the Plan to waive the coinsurance for the office visit with an out-of-network doctor. You say that 
since this doctor's specialty is not available with your in-network group, this should be paid as a network 
provider. The Plan denied your request. The Plan says you were charged this coinsurance 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 50% 
coinsurance for out-of-network physician services.  
 
You have been asked to pay 50% coinsurance for the office visit with an out-of-network doctor. The doctor 
who provided these services is out-of-network. 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. You may contact your Plan to ask about in-network alternatives to this provider. 
Therefore, we decided that the Plan does not have to waive the coinsurance for the office visit you had with an 
out-of-network doctor on July 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99214) provided June 18, 2020. 
 
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says coverage rules were not met. 
 
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 code 99214 is not supported in the medical record. Specifically, a claim as already paid for 
an evaluation and management service performed on the same date of service for the same problem by another 
physician from the same group. Based on this information, we decided that Medicare rules for coverage of the 
physician services have not been met. Therefore, we decided that the Plan does not have to pay for physician 
services (99214) provided June 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on June 25, 2020. 
 
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says 
prior authorization was not obtained by the provider or the facility. 
 
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 
services 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 subsequent nursing facility care provided on June 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for prosthetic devices and related supplies 
provided on August 8, 2020, and September 4, 2020. 
 
You asked the Plan to waive the coinsurance for prosthetic devices and related supplies. You say that you were 
told that you would not owe anything for the supplies. The Plan denied your request. The Plan says [Enter plan 
denial rationale, e.g. "...rules for SNF care have not been met."] 
 
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 prosthetic devices and related supplies.  
 
You received prosthetic devices and related supplies on August 8, 2020. The allowed amount is $460.16 and 
20% of that is $92.03.  
 
You received prosthetic devices and related supplies on September 4, 2020. The allowed amount is $460.16 
and 20% of that is $92.03. 
 
The total amount you owe is: $184.06. 
 
You have been asked to pay the total coinsurance amount of $184.06 for prosthetic devices and related 
supplies. Prosthetic devices and related supplies fall within the prosthetic devices and related supplies 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 prosthetic devices and related supplies 
provided on August 8, 2020, and September 4, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay 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 complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted for surgical treatment of an ankle fracture. Medical problems are stable. There are no identified 
problems that need inpatient medical management. There are no complex nursing or rehabilitation needs. The 
patient does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. The medical record supports a need for physical and 
occupational therapy but it does not support a need for an intensive rehabilitation therapy program. 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician's services to be provided by the out-of-
network provider. 
 
You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says there 
are providers within the Plan's network who can provide these services. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve 
physician's services to be provided by by the out-of-network provider.