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

We decided that the Plan does not have to waive the copayment for an esophagogastroduodenoscopy (EGD)
performed on September 26, 2021.
You asked the Plan to waive the copayment for the EGD. You say that you feel that you should not be charged
the copayment because you had to go to a second emergency room. The Plan denied your request. The Plan
says you have been 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 $50
copayment for surgery or services provided at an outpatient hospital.
You have been asked to pay a $50 copayment for the EGD. The EGD 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 esophagogastroduodenoscopy (EGD)
performed on September 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on November
2, 2021.
You asked the Plan to pay for the dental service. You say that part of your tooth broke off when you were
flossing. You say that you had no choice but to go have it evaluated. You say that your tooth had a fracture and
needed a crown. You also say that this was not a regular evaluation. The Plan denied your request. The Plan
says 2 oral exams are covered per year. The Plan also says that the frequency limit 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 and oral exams are covered, the
frequency limit has been exceeded. The record shows that the Plan paid for oral exams you received on
February 4, 2021, and August 11, 2021. Therefore, we decided that the Plan does not have to pay for the
limited oral evaluation (D0140) provided on November 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anticoagulant management provided on November 9, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the anticoagulant management. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the service at issue was urgent or emergent.
Therefore, we decided that the Plan does not have to pay for anticoagulant management provided on November
9, 2021, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting
from March 9, 2021, to March 16, 2021.
You asked the Plan to pay for the self-administered drugs. You say that the provider advised hospital and
prescription drugs are covered under your plan. The Plan denied your request.
The Plan says the drugs you received in an outpatient setting are considered self-administered. The Plan says
self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says self-
administered drug provided in an outpatient setting are not covered under Medicare Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs
provided in an outpatient setting from March 9, 2021, to March 16, 2021.
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Odomzo.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says self-administered drugs are not covered.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Odomzo.
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D
benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion device.
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The
Plan denied your request. The Plan says that unproven and not medically necessary procedures are not covered
by Medicare due to insufficient evidence of 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 these services. Our reviewer says that
the requested services are not considered medically reasonable and necessary in this case. The vertiflex device
is experimental. More research is needed to show safety and efficacy. Our physician reviewer found that your
condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve the Vertiflex Superion device.
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 enrollee cannot get in and out of bed, and
requires physical assistance. You also say that the enrollee is unable to care for himself independently. The
Plan denied your request. The Plan says criteria for admission to the Acute Inpatient Rehabilitation setting 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 complexity of the patient's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer
found that the patient does not require treatment by multiple therapies, including either physical therapy or
occupational therapy, and an intensive rehabilitation therapy program. While the patient has a need for physical
and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. Our
physician reviewer also found that there is not a reasonable expectation that this patient will be able to fully
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for assistant surgeon services for a diagnostic knee arthroscopy
(29870) provided on June 18, 2021.
You asked the Plan to pay for assistant surgeon services. You say that the services at issue were a medical
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1,
assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current
Procedural Terminology (CPT) code 29870. The Medicare Fee Schedule Database contains a surgical indicator
of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically
necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for
assistant surgeon services have not been met. Therefore, we decided that the Plan does not have to pay for
assistant surgeon services for a diagnostic knee arthroscopy (29870) provided on June 18, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on March 11, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the testing is not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed in the Medicare rules section, are not covered.
The test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening
purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan
does not have to pay for the laboratory services rendered on March 11, 2021.
Appeal type: Hospice
Decision: Unfavorable

 We decided that the Plan does not have to pay for hospital services provided on July 22, 2021.
You asked the Plan to pay for the hospital services. The Plan denied your request. The Plan says Original
Medicare would be responsible for payment of all Medicare covered services related or unrelated to the
member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all
hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-
for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until
the first day of the month following the month in which hospice was revoked or discharged.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Original Medicare is responsible for payment for services until the first day of the month after the
hospice election has been revoked or terminated.
The enrollee ended Medicare Hospice benefits on July 13, 2021. The services in question were provided before
the end of that month. Therefore, we decided that the Plan does not have to pay for hospital services provided
on July 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the labial veneer (porcelain laminate) - indirect (D2962)
provided on September 15, 2021.
You asked the Plan to pay for the labial veneer. You say that your prior dentist had dental work previously
approved but retired before completing it. The Plan denied your request. The Plan says this service is not
covered under your benefits.
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 the labial
veneer (porcelain laminate) - indirect (D2962) provided on September 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on July 21, 2021.
You asked the Plan to waive the copayment for a specialist visit. You say that this was a follow-up visit so you
should not be responsible for 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 a $40
copayment for specialist visits.
You had a specialist visit on July 21, 2021. Follow-up visits are subject to cost-sharing charges. Therefore, you
are responsible to pay the $40 copayment.
You have been asked to pay a $40 copayment for a specialist visit. A specialist visit falls within the
physician/practitioner services, including doctor's office visits 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 specialist visit provided on July 21, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for IV therapy provided on June 7, 2021, and
July 20, 2021.
You asked the Plan to waive the copayments for IV therapy. You say that you previously only paid $30 and the
increase in charges did not happen until you switched doctors. 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 a $275
copayment for outpatient surgery and other medical services provided at hospital outpatient facilities.
You received IV therapy on June 7, 2021, at an outpatient hospital facility. Therefore, you are responsible to
pay the allowed amount of $206.99, which is less than the $275 copayment.
You received IV therapy on July 20, 2021, at an outpatient hospital facility. Therefore, you are responsible to
pay the allowed amount of $206.99, which is less than the $275 copayment.
The total amount you owe is: $413.98.
You have been asked to pay the total copayment amount of $413.98 for IV therapy. IV therapy falls within the
outpatient surgery and other medical 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 copayments for IV therapy provided on June 7,
2021, and July 20, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing for emergency room visits provided from
June 11, 2021, to June 13, 2021.
You asked the Plan to waive the cost-sharing for the emergency room visit. You say that the services should be
covered. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services
provided. The cost-sharing for emergency care services is only waived if you are admitted to the hospital
within 24 hours for the same condition.
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 $180 copayment for an emergency room visit ($90 x 2 = $180). 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 cost-sharing for emergency room visits provided from June 11, 2021, to June 13,
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0676) provided on July 7,
2021.
You asked the Plan to pay for a pneumatic compression device. You say that the item at issue was a medical
necessity for the enrollee. The Plan denied your request. The Plan says the item at issue is not a covered
benefit.
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the
purpose of prevention of venous thromboembolism (E0676) is a preventive service.
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan.
PCDs are not covered for preventions of venous thromboembolism, regardless of how they are billed on the
claim. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0676)
provided on July 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide additional payment for the comprehensive oral evaluation -
new or established patient (D0150), bitewings - four radiographic images (D0274), panoramic radiographic
image (D0330) and prophylaxis - adult (D1110) provided September 2, 2021, by an out-of-network provider.
You asked the Plan to provide additional payment for the comprehensive oral exam, bitewing x-rays,
panoramic x-rays, and dental cleaning. You say that you were told this provider was in-network and you don't
feel you should be held liable for any of the cost. The Plan denied your request. The Plan says they do not have
record of a call prior to the services providing any misinformation and the claims have processed correctly.
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 Plan states that for
services obtained Out-of-Network, the Plan only pays up to a certain amount. If you choose to see an Out-of-
Network dentist, you might be billed for charges above what the Plan pays, even for services listed as $0
copayment.
We looked at the file and Medicare rules. In this case the Plan provided documentation showing that they
covered the entire allowed amount for each of the services at issue according to the Plan's contract. Therefore,
we decided that the Plan does not have to provide additional payment for the comprehensive oral evaluation -
new or established patient (D0150), bitewings - four radiographic images (D0274), panoramic radiographic
image (D0330) and prophylaxis - adult (D1110) provided September 2, 2021, by an out-of-network provider.
Your complaint about potentially receiving misinformation from a plan representative is not a valid appeal for
medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does
not permit us to make a decision about these types of complaints.
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 inpatient rehab is medically necessary for this
enrollee. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The
enrollee does not have complex rehab needs and does not require an interdisciplinary team approach for
rehabilitation care. The necessary services can be provided in an alternate setting.
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 complexity of the enrollee's nursing, medical and rehabilitation needs
does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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. There is not a reasonable expectation that this
enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program
provided in an IRF.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.