Persius/hicric huggingface dataset:
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient surgery provided on May 31, 
2022. 
 
You asked the Plan to waive the copayment for an outpatient surgery. You say that you received a bill via 
email and copayment was automatically deducted from your bank. You say that you requested the colonoscopy 
due to polyps found on previous colonoscopy. The Plan denied your request. The Plan says the copayment 
applied 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 a $150 
copayment for each Medicare-covered outpatient surgery or procedure at an outpatient hospital facility or 
ambulatory surgical center.  
 
 
  You have been asked to pay a $150 copayment for an outpatient surgery. An outpatient surgery 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 waive the copayment for an outpatient surgery 
provided on May 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the injection provided on May 3, 2022. 
 
You asked the Plan to waive the coinsurance for the injection. You say that you are doing chemotherapy 
sessions and are receiving bills. The Plan denied your request. The Plan says the coinsurance applied correctly 
because you met your out-of-pocket maximum. 
 
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% of 
the cost for Medicare Part B drugs administered in a physician's office or outpatient facility.  
  You have been asked to pay $1,042.04, which is less than the standard 20% coinsurance for the injection 
because you met your out-of-pocket maximum. The injection falls within the Part B 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 the injection provided on May 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the collection of autologous blood concentrate product 
(D7921) and bone replacement graft (D7953) for tooth #14 provided on March 31, 2022. 
 
You asked the Plan to pay for the dental services. You say that your provider told you the services would be 
covered and you out of pocket would be less than what was charged. The Plan denied your request. The Plan 
says the denial of payment for these services is correct, because the collection of autologous blood concentrate 
product and bone replacement grafts are not covered by the 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 
collection of autologous blood concentrate product (D7921) and bone replacement graft (D7953) for tooth #14 
provided on March 31, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for x-rays (72040) provided April 7, 2022. 
 
You asked the Plan to pay for the x-rays. You say that the services were medically necessary. The Plan denied 
your request. The Plan says this service is not covered when billed by a Chiropractor. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for x-rays (72040) provided April 7, 2022.
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 you are appealing the denial of inpatient 
rehabilitation admission. The Plan denied your request. The Plan says the medical needs 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 in the Medicare rules section. 
 
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 to an acute hospital on September 12, 2022, from a 
skilled nursing facility with pain and swelling of right knee. It is noted the enrollee had pneumonia and was 
treated with antibiotics. It is also noted the enrollee has a buttock wound, was anemic, and still has 
leukocytosis. No acute rehabilitation nursing needs identified or documented. There are no complex nursing or 
rehabilitation needs. While the enrollee has a need for physical or occupational therapy the rehabilitation needs 
can be safely provided in a lower intensity and alternate setting such as in a skilled nursing facility once 
medically stable. 
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. 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 Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section 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 care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have documented skilled nursing needs or skilled therapy needs. 
Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the 
enrollees condition. The enrollees care needs, custodial, intermittent and long-term can, as a practical matter, 
be provided 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
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 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 IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical status does not require intensive physician and nursing oversight in an IRF. While you may benefit from additional 
multiple therapies, including physical and occupational therapy, the documentation does not reveal that you 
require therapy on an intensive IRF level. 
 
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: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that that you are without sufficiently complex medical needs. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 found to be medically reasonable and necessary for this enrollee. Below the knee 
amputation is an IRF compliant diagnosis. Clinical documentation shows that you require continued close 
medical monitoring on an inpatient basis. Evaluating therapists (physical and occupational therapy) both 
recommend intense therapy thus IRF criteria has been met and is medically necessary. Our physician reviewer 
found that your condition meets Medicare criteria for IRF 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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to hold you harmless for the electric scooter and accessory received on February 
4, 2022, minus any cost share requirement. 
 
You asked the Plan to pay for the electric scooter and accessory. You say that this chair satisfies your needs. 
The Plan denied your request. The Plan says that the items received are not a covered benefit. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
According to the Explanation of Benefits provided to you, you were provided the electric scooter and accessory 
by a contract provider. The file does not show that the Plan provided notice that the electric scooter and 
accessory would not be covered. Under Medicare rules, this means the electric scooter and accessory is 
considered approved by the Plan. Therefore, we decided that the Plan has to hold you harmless for the electric 
scooter and accessory received on February 4, 2022, minus any cost share requirement.  
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 16 physical therapy visits. 
 
You asked the Plan to pre-approve therapy visits. You say that additional therapy is medically necessary. The 
Plan denied your request. The Plan says these services are not medically necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy visits. Our reviewer says that 
skilled services are not necessary to restore or maintain function or to prevent deterioration of your condition. 
Our physician reviewer found that you had prior therapy and the documentation does not reveal that you 
require the unique skills of a professional therapist to provide treatment safely and effectively. You are 
competent in a home exercise 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 therapy visits have not been met. Therefore, we decided that the Plan does not 
have to pre-approve 16 physical therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a wheelchair accessory, an Able Assy SD Card Q6 Edge 
3 Program (K0108). 
 
You asked the Plan to pre-approve a wheelchair accessory. You say that the joystick is broken, and you are not 
able to use your wheelchair. You need your wheelchair repaired since you cannot move without it. The Plan 
denied your request. The Plan says this item does not serve a medical purpose. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
 
 The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a wheelchair accessory, an Able Assy SD Card Q6 Edge 3 
Program (K0108).
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for extractions (D7140) provided on April 14, 2022. 
 
You asked the Plan to pay for extractions. You say that you want the Plan to cover these services. The Plan 
denied your request. The Plan says that the services at issue are not covered benefits. 
 
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.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of extractions have been met. Specifically, the Plan has not supported that extractions are non-
covered. An enrollee could reasonably expect non-routine services to include dental extractions. Therefore, we 
decided that the Plan has to pay for extractions (D7140) provided on April 14, 2022.  
 
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 a periodic oral evaluation (D0120) and prophylaxis (D1110) 
provided by an out-of-network provider on April 28, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were unaware that your dental coverage had 
changed. The Plan denied your request. The Plan says the dental services were received from an out-of-
network provider and are not covered by your supplemental benefits. 
 
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. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a periodic oral evaluation (D0120) and prophylaxis (D1110) provided by an out-of-network provider 
on April 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve maxillary and mandibular partial dentures (D5225 
D5226) 
 
You asked the Plan to pre-approve the maxillary and mandibular partial dentures. You say that the services 
should be covered as you disagree with the denial. The Plan denied your request. The Plan says the services 
denied correctly as they do not fall within your dental benefits. 
 
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 pre-approve 
maxillary and mandibular partial dentures (D5225 D5226 )
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional rental months of an oxygen concentrator 
(E1390) and a portable gaseous oxygen system (E0431). 
 
 You asked the Plan to pre-approve additional rental months of an oxygen concentrator and a portable gaseous 
oxygen system. You say that it is medically necessary that the enrollee continues to receive additional months 
of use of the requested items/devices. The Plan denied your request. The Plan says records show that the 
enrollee has been using oxygen since November 07, 2019. Medicare rules state oxygen equipment is limited to 
36 months of rental payments. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The records show that you have been using the requested items since 
November 7, 2019. Medicare rules say that reimbursement for oxygen equipment is limited to 36 monthly 
rental payments. After 36 months, your supplier can then continue to provide your oxygen equipment and 
related supplies for an additional 24 months. The records also show that the Plan has approved your oxygen 
equipment until November 7, 2022. Based on this information, we decided that Medicare rules for coverage of 
an oxygen concentrator and a portable gaseous oxygen system have not been met. Therefore, we decided that 
the Plan does not have to pre-approve additional rental months of an oxygen concentrator (E1390) and a 
portable gaseous oxygen system (E0431).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation - established patient (D0120), 
topical application of fluoride  excluding varnish (D1208), and prophylaxis - adult (D1110) provided March 3, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the dental services. You say that you cannot afford the cost of these services. The 
Plan denied your request. The Plan says the dental services were received from an out-of-network provider and 
are not covered by your supplemental benefits. 
 
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. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for the periodic oral evaluation - established patient (D0120), topical application of fluoride  excluding 
varnish (D1208), and prophylaxis - adult (D1110) provided March 3, 2022, by an out-of-network (OON) 
provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mass spectrometry and tandem mass spectrometry (83789) 
provided on February 22, 2022. 
 
You asked the Plan to pay for mass spectrometry services. You say that these services were necessary and are 
supported as billed. The Plan denied your request. The Plan says they have agreed to pay for the drug testing 
services; however, this service is specimen validity testing which is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of mass spectrometry services have not been met. Specifically, we find that the testing described by 
the billed code is considered specimen validity testing which is not separately payable. Therefore, we decided 
that the Plan does not have to pay for mass spectrometry and tandem mass spectrometry (83789) provided on 
February 22, 2022.