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

 
We decided that the Plan does not have to waive the coinsurance for the complete upper and lower dentures 
(D5110, D5120) provided on May 17, 2021, by an out-of-network provider. 
 You asked the Plan to waive the coinsurance for the dentures. You say that the dentures do not fit properly, and 
you do not feel you should be liable for this cost. The Plan denied your request. The Plan says you are 
responsible for 50% coinsurance for any covered dental services received from an out-of-network provider. 
The provider in question is not part of the Plan's network. 
 
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 supplemental preventative and comprehensive dental services received from an out-of-network 
provider.  
 
You have been asked to pay 50% coinsurance for the dentures. The provider billed the Plan a total of $1,300 
for both dentures, and you have been asked to pay $650 for the pair ($1,300 x 50% = $650). Documentation 
indicates that this provider is not part of the Plan?s network and you still have the dentures. 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 complete upper and lower dentures (D5110, D5120) provided 
on May 17, 2021, by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for aspiration and/or injection of fluid into 
joint (20610), fluoroscopic guidance for needle placement (77002), and injection of methylprednisolone acetate 
(J1030) provided on May 25, 2021. 
 
You asked the Plan to waive the copayment for the diagnostic administration of an injection. You say that you 
should only have to pay the $40 copayment for the surgery with the specialist. The Plan denied your request. 
The Plan says the cost-sharing was applied correctly. If you receive services other than surgery, including but 
not limited to diagnostic tests or Part B drugs, additional cost-sharing may apply. 
 
 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 Prescription Drugs, a $50 copayment for Outpatient Diagnostic Tests and 
Therapeutic Services and Supplies, and a $40 copayment for Outpatient Surgery, including services provided at 
Hospital Outpatient Facilities and Ambulatory Surgical Centers. 
 
You have been asked to pay a cost-share of $91.15 for diagnostic administration of an injection. The services 
received fall within different benefit categories. The drug (J1030) falls within the Medicare Part B Prescription 
Drugs benefit category. The administration of this injection (20610) falls within the Outpatient Surgery, 
including services provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit category. 
The fluoroscopic guidance needed for placement of the needle (77002) falls within the Outpatient Diagnostic 
Tests and Therapeutic Services and Supplies benefit category. See below for a breakdown of costs. 
 
20610: $40 copayment 
77002: $50 copayment 
J1030: Plan Allowed Amount = $5.74 ? 20% coinsurance = $1.15 
$40 + $50 + $1.15 = $91.15 
 
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 aspiration and/or injection of fluid into joint (20610), 
fluoroscopic guidance for needle placement (77002), and injection of methylprednisolone acetate (J1030) 
provided on May 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on 
August 12, 2021. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan must 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 had network providers available 
who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for out of network physician services provided to the 
enrollee on August 12, 2021.
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF 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 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. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While the documentation does support a need for physical and/or occupational 
therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on 
June 9, 2021. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan must pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for out of network physician services provided to the 
enrollee on June 9, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intracept procedure (CPT code 22899 and C9752), 
for the enrollee. 
 
You asked the Plan to pre-approve the intracept procedure. You say that the services are necessary. The Plan 
denied your request. The Plan says the clinical value and effectiveness of the intracept procedure in the setting 
of chronic low back pain have not been demonstrated in the peer-reviewed literature. The Plan states more 
research is needed to show safety and efficacy of the procedure. 
 
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 intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the intracept procedure is experimental. More research is needed. 
 
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 intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the intracept procedure (CPT code 22899 and C9752), for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a tooth extraction provided by an out-of-network dentist on 
May 10, 2021. 
 
You asked the Plan to pay for a tooth extraction. You say that this was an emergency service that was vital to 
your health. The Plan denied your request. The Plan says this is not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
  
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a tooth 
extraction provided by an out-of-network dentist on May 10, 2021.
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF 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 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. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While the documentation does support a need for physical and/or occupational 
therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided from November 1, 2020 to 
November 5, 2020. 
 
You asked the Plan to pay for inpatient hospital care. You say that secondary diagnosis code J96.01 is 
clinically valid and coded correctly. The Plan denied your request. The Plan says the denial of payment for this 
service is correct, because the documentation does not support the secondary diagnosis code J96.01. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with J96.01 acute respiratory failure with hypoxia. 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 inpatient hospital care. Our reviewer says 
that the requested diagnosis related group (DRG) does not meet criteria for payment. Our physician reviewer 
found the documentation does not clearly support treatment for this diagnosis during the hospital stay. 
Diagnosis code J96.01 is documented in the discharge visit; however, during the hospital stay this diagnosis 
with treatment is not documented and therefore cannot be confirmed.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital care provided from November 1, 2020 to November 5, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that you were approved for a lumbar 
discectomy and decompression with foraminotomies surgery and will need inpatient admission after surgery. 
The Plan denied your request. The Plan says there is no documentation provided to support the expectation you 
will require a greater than 2 midnight stay. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.   
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this 
case. Our physician reviewer found you are approved for a lumbar discectomy and decompression with 
foraminotomies surgery. The record does not document that the treating physician has a reasonable expectation 
of a length of stay spanning 2 or more midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve continuation of substance abuse residential treatment 
from November 11, 2021, forward. 
 
You asked the Plan to pre-approve the services. You say that you will relapse if you are not in the facility. The 
Plan denied your request. The Plan says Medicare rules say that you would qualify for continued treatment if 
you required observation and treatment of withdrawal symptoms. The Plan states you were having no 
symptoms.  
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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found based upon review the records provided, you do not meet the criteria for treatment in an acute 
inpatient mental health/detoxification treatment beyond the date in question of November 11, 2021, forward 
and could have been treated in a lesser restrictive setting as you were not showing any suicidal or homicidal 
ideation, auditory or visual hallucinations, delusions and was not showing any behaviors or aggression being 
cooperative and compliant while not showing any acute threats to safety as you were not going through any 
withdrawals. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continuation of substance abuse residential treatment from November 11, 2021, forward.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for laboratory services (80048) rendered on 
March 29, 2021. 
 
You asked the Plan to waive the copayment for laboratory services. You say that you do not believe you are 
responsible for this laboratory copayment since it was part of your physical exam. The Plan denied your 
request. The Plan says you were charged the correct copayment amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 
copayment per day for Medicare-covered laboratory tests.  
 
You have been asked to pay $8.46, which is less than the $10 copayment for laboratory services. Laboratory 
services fall 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 laboratory services (80048) rendered on March 29, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for laboratory services (82668, 80053, 80061, 
36415) rendered on August 3, 2021. 
 
You asked the Plan to waive the deductible for laboratory services. You say that you have never been billed for 
anything associated with your yearly physical. You also say that you need nothing but a routine yearly test and 
that there is nothing wrong with you. The Plan denied your request. The Plan says you were charged the correct 
cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The Plan contract says that there is a $400 deductible for all items 
and services except those specifically excluded by the Plan contract.  
 
 You have been asked to pay an $89.19 deductible for laboratory services. The records show the services 
provided went beyond the scope of an annual wellness checkup. The Plan has followed Medicare rules by 
clearly disclosing in the contract that there is a $400 deductible, which applies to Outpatient Diagnostic Tests 
and Therapeutic Services and Supplies. 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 that had not been met at the time 
laboratory services was received on August 3, 2021. Therefore, we decided that the Plan does not have to 
waive the deductible for laboratory services (82668, 80053, 80061, 36415) rendered on August 3, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Simponi Aria. 
 
You asked the Plan to pre-approve Simponi Aria. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the denial of authorization for this drug is correct, because the enrollee 
does not meet the criteria for Simponi Aria. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Simponi Aria. Our reviewer says that 
the enrollee does not meet the Medicare criteria for Simponi Aria. Our physician reviewer found Simponi Aria 
is only Food & Drug Administration (FDA) approved for rheumatoid arthritis which has been treated with 
leflunomide. It is not FDA-approved for the enrollee's diagnosis. The requested use is not supported by one of 
the major drug compendia or by clinical research appearing in a Medicare-approved clinical journal.   
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Simponi Aria have not been met. Therefore, we decided that the Plan does not 
have to pre-approve use of Simponi Aria.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomographic (CT) scan of the 
chest (71275) rendered on January 11, 2021. 
 
You asked the Plan to waive the copayment for a computed tomographic scan of the chest. You say that you 
were treated for blood clots in your lungs, and you were told the blood clots were a result of the coronavirus 
(Covid-19). You also say that this should have been fully covered by insurance and no out-of-pocket expense 
to you. The Plan denied your request. The Plan says you were charged the correct cost sharing amount. 
 
  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a $110 
copayment for Medicare-covered radiological diagnostic services, including computed tomographic scans.  
 
You have been asked to pay a $110 copayment for a computed tomographic scan of the chest. Computed 
tomographic scans of the chest fall 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 a computed tomographic 
(CT) scan of the chest (71275) rendered on January 11, 2021.