Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral x-ray and core build-up services (D0220, D2950) 
provided on June 15, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your benefit for the intraoral x-ray (D0220) has 
already been exhausted and coverage for the core build-up services (D2950) 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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service April 20, 2022. 
Therefore, we decided that the Plan does not have to pay for an intraoral x-ray and core build-up services 
(D0220, D2950) provided on June 15, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on September 07, 
2022. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that this was the same visit (a visit + an 
us) and should only have one copayment. The Plan denied your request. The Plan says this cost sharing was 
charged 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 $20 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $20 copayment for an ultrasound. This item/service falls within the outpatient 
diagnostic tests and therapeutic services and 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 
copayment for an ultrasound provided on September 07, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for an x-ray of the knee and specialist visit 
provided on September 14, 2022, by an out-of-network provider (OON). 
 
You asked the Plan to reduce the coinsurance for an x-ray of the knee and specialist visit. You say that your 
plan states a specialist visit is a $35 copayment, but you are being charged $54.11. The Plan denied your 
request. The Plan says this cost sharing was charged 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 30% 
coinsurance for an out-of-network x-ray service and specialist visit.  
 
 
  You have been asked to pay a total coinsurance of $54.11, which is 30% of the allowed amount for an x-ray of 
the knee and specialist visit. This total includes $22.71 for an x-ray of the knee ($75.70 x 30% = $22.71) and 
$32.06 for a specialist visit ($106.87 x 30% = $32.06). The x-ray falls within the Outpatient Diagnostic Tests 
benefit category. The specialist visit falls within the Physician/Practitioner Services benefit category. This 
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to reduce the coinsurance for an x-ray of the knee and specialist visit provided on 
September 14, 2022, by an out-of-network provider (OON).
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 rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation care. There is not a reasonable expectation that this individual will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an inpatient rehabilitation facility. You can receive further services 
at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for an intraoral x-ray (D0230) provided on October 19, 
2022 
 
You asked the Plan to pay more for the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says you are responsible for any charged 
amount above the Plans cost-sharing amount when your services are received from an out-of-network 
provider. 
 
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. 
 
 
  You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for an intraoral x-ray (D0230) provided on 
October 19, 2022
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional accessories for a prosthetic (L5781, L5984, 
L5988). 
 
You asked the Plan to pre-approve the items. You say that this is medically necessary. The Plan denied your 
request. The Plan says the use of vacuum pumps for residual limb volume management and moisture 
evacuation systems among amputees is unproven and not medically necessary due to insufficient evidence of 
safety and/or efficacy. 
 
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 pre-approve the items. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that per the records and an independent literature review, in randomized trials the vacuum assist system 
has not improved outcome when compared to usual devices. It is not the standard of care, and not necessary to 
meet the enrollee's needs. 
 
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 items have not been met. Therefore, we decided that the Plan does not have 
to pre-approve additional accessories for a prosthetic (L5781, L5984, L5988).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of sacroiliac joint. 
 
You asked the Plan to pre-approve RFA of the sacroiliac joint. You say that RFA of the sacroiliac joint is 
medically necessary. The Plan denied your request. The Plan says RFA of the sacroiliac joint is considered 
experimental or investigational. 
 
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 pre-approve RFA of the sacroiliac joint. Our 
reviewer says that the requested RFA of the sacroiliac joint is not considered medically reasonable and 
necessary. Our physician reviewer found that according to the literature, sacral lateral nerve branch blocks 
and/or ablations/neurotomies for the diagnosis and/or treatment of sacroiliac joint mediated pain is considered 
experimental and investigational. Per CMS NCD, surgically induced lesions of nerve tracts which involve 
destruction of nerve tissue are primarily indicated for controlling the chronic or acute pain arising from 
conditions such as terminal cancer or lumbar degenerative arthritis. Radiofrequency ablation for denervation, 
whether performed using traditional, cooled, or pulsed radiofrequency, is considered investigational and therefore, not medically necessary. The requested RFA of the sacroiliac joint has not been proven effective and 
is considered experimental/investigational.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of RFA of the sacroiliac joint have not been met. Therefore, we decided that the 
Plan does not have to pre-approve RFA of sacroiliac joint.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room services provided on May 
27, 2022. 
 
You asked the Plan to waive the copayment for emergency room services. You say that you want to appeal the 
amount being charged. The Plan denied your request. The Plan says this cost sharing was charged 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 $90 
copayment for emergency care. 
 
You have been asked to pay a $90 copayment for emergency room services. This item/service falls within the 
emergency care 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 emergency room services 
provided on May 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the injection(s), anesthetic agent(s) and/or steroid; 
transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, single level (64483). 
 
You asked the Plan to pre-approve the injection. You say that the enrollee reported reduced pain by 50%. You 
say that the enrollee's pain is severe despite continued home exercise, therapy and stretching. The Plan denied 
your request. The Plan says a repeat injection is not 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 injection. Our physician reviewer 
found the LCD requires documentation of greater than 50% pain relief for three (3) months. This was not 
achieved. Therefore, the request is deemed not medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging 
guidance (fluoroscopy or CT), lumbar or sacral, single level (64483).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a colonoscopy with lesion removal 
provided on September 13, 2022. 
 
You asked the Plan to waive the copayment for the colonoscopy. You say that you were not aware of charges 
for additional services provided. The Plan denied your request. The Plan says this cost sharing was charged 
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 $290 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
 
 
  You have been asked to pay $256.23, which is less than the $290 copayment for the colonoscopy. This 
item/service 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 a 
colonoscopy with lesion removal provided on September 13, 2022.
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 for the enrollee to achieve 
maximum gains towards functional independence. The Plan denied your request. The Plan says the enrollee 
could receive care in another setting such as a skilled nursing facility, outpatient setting or home health care. 
 
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 the members nursing, medical and rehabilitation needs do not require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
The member does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, at an intensive rehabilitation therapy program. There is not a reasonable expectation that this 
individual will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an inpatient rehabilitation facility. The member continues to have a need for skilled therapy with 
ongoing safety concerns and a potential for functional improvement however, the documentation doesnt 
support that she would meet criteria for admission to an acute inpatient rehabilitation facility.  There is no 
indication that the member would require skilled rehabilitation in an IRF, participating in rehab services 15 
hours a week, under the supervision of a physician with at least 3 visits weekly to regain or maintain her 
functional status.  The member can receive further services at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the medical eye exam provided on October 
14, 2022. 
 
You asked the Plan to waive the copayment for the medical eye exam. You say that you were seen for your 
yearly eye exam and should be covered in full by your insurance. The Plan denied your request. The Plan says 
this cost sharing was charged 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 $30 
copayment for a medical eye exam.  
 
You have been asked to pay a $30 copayment for the medical eye exam. The medical eye exam falls within the 
vision care benefit category. The medical record shows a diagnosis of conjunctivitis which makes the eye exam 
medical in nature. 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 medical eye exam provided 
on October 14, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for CT scan provided on September 28, 2022. 
 
You asked the Plan to waive the copayment for CT scan. You say that you are disputing the share cost. The 
Plan denied your request. The Plan says this cost sharing was charged 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 $125 
copayment for Outpatient diagnostic tests and therapeutic services and supplies.  
 
You have been asked to pay $122.17 which is less than the $125 copayment for CT scan. This item/service 
falls within the Outpatient diagnostic tests and therapeutic services and 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 copayment for CT scan provided on September 28, 2022.
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 clinical documentation does not show that the enrollee has complex functional 
deficits or any active medical conditions/comorbidities. Thus, the complexity of the enrollee's documented nursing, medical and rehabilitation needs would not be expected to require an acute hospital inpatient stay with 
an interdisciplinary approach to rehabilitation care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that due to the enrollee's needs for increased 
monitoring, and daily physician involvement they have been refereed to an LTACH for complex medical 
management with an interdisciplinary treatment team. The Plan denied your request. The Plan says an LTACH 
admission is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the documentation does not support that the enrollee has a need for complex 
medical treatment. The enrollee does not require services at the LTACH that are not available at the acute care 
hospital or the skilled nursing facility. The requested treatments are not medically necessary at the LTACH 
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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
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 enrollee would like reconsideration because the 
services are medically necessary. The Plan denied your request. The Plan says an IRF admission is not 
medically necessary, and the enrollee can get the services they need in other settings. 
 
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 that the enrollee does not meet criteria for admission to an acute inpatient 
rehabilitation facility. The complexity of the enrollee's nursing, medical and rehabilitation needs do not require 
an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee can 
receive further services at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.