Persius/hicric huggingface dataset:
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 required moderate assistance with eating. The enrollee required stand-by 
assistance with grooming. The enrollee required stand-by assistance/moderate assistance with upper body and 
lower body dressing and bathing. The enrollee required maximum assistance with toileting. The enrollee 
required minimal assistance to walk 100 feet using a rolling walker. The documentation does not support that 
the enrollee requires an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
The documentation does not support that the enrollee requires an intensive rehabilitation therapy program. 
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that you require custodial care and that it is not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is 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 SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that your condition does not meet 
Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve the SNF services. You say that SNF services are not medically necessary. 
The Plan denied your request. The Plan says SNF care is not medically necessary at this time. The Plan says 
that the enrollee's needs can be met with nursing or therapy services provided at home or in a provider's office. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is 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 SNF services. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral 
medications and insulin. The enrollee had stable vital signs. The enrollee received physical therapy and 
occupational therapy in the acute hospital. The enrollee was at a stand by assist to contact guard assist level 
with functional mobility, including gait to 90 feet x2 with a cane. The enrollee required varying assist with 
activities of daily living. There are no identifiable skilled nursing service needs. There are identifiable skilled 
therapy service needs, but they are not required on a daily basis. The enrollee does not meet severity of illness 
or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 
 
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 SNF services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic care provided on January 3, 2020. 
 
You asked the Plan to pay for this service. You say that this care should be covered by the Plan. The Plan 
denied your request. The Plan says maintenance chiropractic care is not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance 
care. Based on the records provided, this was chiropractic maintenance care which is not covered. Therefore, 
we decided that the Plan does not have to pay for chiropractic care provided on January 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiation treatments provided from January 24, 2020 
through January 28, 2020. 
 
You asked the Plan to pay for the radiation treatments. You say that the claim should be paid. The Plan denied 
your request. The Plan says the claims are duplicates. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the radiation treatments have not been met. The claims are 
duplicates of previously paid claims. Therefore, we decided that the Plan does not have to pay for the radiation 
treatments provided from January 24, 2020 through January 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 13 dental extractions (99070) provided January 13, 2019. 
 
You asked the Plan to pay for the dental services. You say that you were not made aware that you needed to 
pay upfront and that the oral surgeon did not accept Medicare until after all hospital arrangements had already 
been made. The Plan denied your request. The Plan says this request exceeds the benefit limitation. 
 
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 health plan contract 
allows coverage for 2 extractions per year. The plan has covered for 2 extractions. The additional 13 
extractions exceeds the plan benefit. 
 
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 13 dental 
extractions (99070) provided January 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the telephone evaluation and management service (99442) 
rendered by the out of network (OON) provider on April 2, 2020. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without 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 provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the service 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 this service. Therefore, we decided that the Plan does not 
have to pay for the telephone evaluation and management service (99442) rendered by the out of network 
(OON) provider on April 2, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency department visit (99284) 
provided on June 4, 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 a $110 
copayment for each covered emergency room visit.  
 
You have been asked to pay a $110 copayment for the emergency room visit 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 emergency department visit (99284) provided on June 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650), a knee orthosis with 
suspension sleeve (L1851, L2397), and a shoulder-hand-wrist orthosis (L3960) provided to the enrollee on 
February 22, 2020. 
 
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your 
request. The Plan says the documentation does not indicate services are necessary for treatment of the 
enrollee's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
 
 
 
 
 
 
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are 
likewise noncovered. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis 
(L0650), a knee orthosis with suspension sleeve (L1851, L2397), and a shoulder-hand-wrist orthosis (L3960) 
provided to the enrollee on February 22, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the Buprenorphine injection (Q9992) 
provided on January 29, 2020. 
 
You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the coinsurance 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 a 20% 
coinsurance for Medicare Part B drugs provided.  
 
You have been asked to pay $352.68 ($1,763.39 allowed amount x 20% coinsurance) for the Medicare Part B 
drug 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 coinsurance for the Buprenorphine injection (Q9992) 
provided on January 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the hospital outpatient clinic visit (G0483) 
and the strapping of an Unna boot (29580) provided on March 5, 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 services 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 a $225 
copayment per visit for an outpatient surgery or procedure.  
 
You have been asked to pay a $225 copayment for the outpatient hospital services 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 hospital outpatient clinic visit (G0483) and the strapping of an 
Unna boot (29580) provided on March 5, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug provided on 
March 4, 2020. 
 
You asked the Plan to waive the coinsurance for a Medicare Part B drug. You say that you cannot afford the 
charges. 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 20% 
coinsurance for Medicare Part B prescription drugs.  
 
You received a Medicare Part B drug on March 4, 2020. The allowed amount is $4,517.10 and 20% of that is 
$903.42.  
 
You have been asked to pay the total coinsurance amount of $903.42 for a Medicare Part B drug. A Medicare 
Part B drug falls within the Medicare Part B prescription drugs 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 a Medicare Part B drug provided on March 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional intraoral periapical x-ray provided on May 6, 
2020. 
 
You asked the Plan to pay for the additional intraoral periapical x-ray. You say that you had to go to a different 
provider due to the pandemic. You also say that you told them if they wanted to review your x-ray, they could 
contact your regular dentist. The Plan denied your request. The Plan says the benefits for this service have been 
satisfied and the frequency limitation has been exceeded. 
 
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, intraoral x-rays are limited to one 
procedure per calendar year. The record shows that you received a first intraoral periapical x-ray on May 6, 
2020, which the Plan covered, and your intraoral x-rays benefit has been exhausted. Therefore, we decided that 
the Plan does not have to pay for the additional intraoral periapical x-ray provided on May 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on November 23, 2019. 
 
You asked the Plan to pay for the physician's services. You say that the service was for a telemedicine doctor's 
appointment and you would like the Plan to cover some or all of the cost. The Plan denied your request. The 
Plan says that the Plan will not reimburse charges incurred by Medicare opt out providers. 
 
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. This 
provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
the physician's services provided on  
November 23, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the post stabilization inpatient care provided from 11:51 AM 
on January 27, 2020 through January 29, 2020. 
 
You asked the Plan to pay for the post stabilization inpatient care. You say that these services were medically 
necessary. The Plan denied your request. The Plan says that the enrollee was stable for transfer. 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
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 the post stabilization inpatient care. Our 
reviewer says that post stabilization inpatient care was not medically reasonable and necessary for the enrollee 
in this case. The enrollee as of 11:50 AM on 1/27/20 was stable for ambulance transport with monitoring to a 
Plan facility. The treating physician did not document (in the physician notes, on a form, or in an order) that the 
patient was not stable for transfer on any dates of service. Our physician reviewer found that the enrollee's 
condition did not meet Medicare criteria for the post stabilization inpatient 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 the post stabilization inpatient care have not been met. Therefore, we decided 
that the Plan does not have to pay for the post stabilization inpatient care provided from 11:51 AM on January 
27, 2020 through January 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for computed tomography cerebral perfusion analysis (0042T) 
provided March 12, 2020. 
 
You asked the Plan to pay for cerebral perfusion analysis. You say that please review attached reports showing 
necessity for procedure and reconsider the claim for payment. The Plan denied your request. The Plan says 
cerebral perfusion analysis is considered not reasonable and necessary by Medicare and is excluded from 
coverage. 
 
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 pay for cerebral perfusion analysis. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee in this case was diagnosed with occlusion and stenosis of the right 
vertebral artery as well as facial weakness. He presented with right-sided facial droop, right-sided weakness. 
CT head showed no acute hemorrhage, and only changes consistent with chronic ischemic disease. According 
to the latest 2018 AHA/ASA Stroke Early Management Guidelines, CT perfusion imaging may be considered 
medically necessary for patients with a known large vessel occlusion to help identify if they are most likely to 
benefit from thrombolysis or thrombectomy. In this case, the CT scan showed no large vessel occlusion to 
justify CT-P. Therefore, this request for such will be considered not medically 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 cerebral perfusion analysis have not been met. Therefore, we decided that the 
Plan does not have to pay for computed tomography cerebral perfusion analysis (0042T) provided March 12, 
2020.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to reimburse you your 2019 wellness allowance. 
 
You asked the Plan to reimburse you your 2019 wellness allowance. You say that you did not use your 2019 
allowance yet because your request on March 22, 2019 was for 2018. The Plan denied your request. The Plan 
says that you were paid your 2019 allowance already. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers gym benefits 
and reimburses you up to $150 each calendar year towards your cost for membership in a qualified health club 
or fitness facility. 
 
The Plan's rules for coverage of gym benefits have been met because you requested your 2018 wellness benefit 
before March 31st of 2019 and the Plan mistakenly allowed it towards your 2019 benefit. Therefore, we 
decided that the Plan has to reimburse you your 2019 wellness allowance.  
 
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 laboratory services rendered by the out of network 
provider on January 27, 2020. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without 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 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 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 the laboratory services rendered by the out of network provider on January 27, 2020.