Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for destruction of internal hemorrhoid(s) by thermal energy (46930) 
provided on September 28, 2021. 
 
You asked the Plan to pay for destruction of internal hemorrhoid(s) by thermal energy. You say that the 
services at issue are within the provider's scope of practice. The Plan denied your request. The Plan says that 
the provider type is not valid for the services billed. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the services at issue were provided by a physical therapist. The 
Plan has not provided evidence to show that these services are not within a physical therapist's scope of 
practice. Therefore, we decided that the Plan has to pay for destruction of internal hemorrhoid(s) by thermal 
energy (46930) provided on September 28, 2021.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan of the 
neck with contrast injection provided on January 6, 2021. 
 
You asked the Plan to waive the copayment for the CT scan with injection. You say that you feel that you 
should not have to pay since the imaging was unreadable. The Plan denied your request. The Plan says the 
correct copayments and coinsurance were applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $225 
copayment for advanced imaging services, including CT scans.  
 
 
 You have been asked to pay a total of $194.39, which is less than the $225 copayment for the CT scan with 
injection. The CT scan with injection 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 a computed tomography 
(CT) scan of the neck with contrast injection provided on January 6, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care provided on May 24, 2020. 
 
You asked the Plan to pay for the subsequent hospital care. You say that the provider was not able to submit 
the claims until the patient contacted the office to provide the correct billing information. You also say that the 
claim should be reprocessed because the services were medically necessary. The Plan denied your request. The 
Plan says this claim was not filed within the required timeframe. The Plan also says that specifically, original 
invoices must be submitted within 365 calendar days after the services were rendered. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
 
 
 The record shows that a claim for the subsequent hospital care was not filed until August 24, 2021. This means 
that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the subsequent hospital care provided on May 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the consultation (D9310) and panoramic x-ray (D0330) 
provided on December 15, 2021. 
 
You asked the Plan to pay for the dental services. You say that you were scheduled to receive an extraction. 
You say that you were not advised of a radiographic image charge. You say that the office where the procedure 
was to be done in was a disaster. You also say that you have no intention of paying this charge. The Plan 
denied your request. The Plan says consultation is not a covered service. The Plan says that 1 complete series 
or panoramic x-ray are covered every 5 years. 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 Plans coverage rules apply in this case. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the consultation is not among those 
covered under this benefit. Additionally, the frequency limit of 1 complete series or panoramic x-ray every 5 
years has been exceeded. The record shows that the Plan paid for a complete series x-ray that you received on 
the same date of service at a different dental office. Therefore, we decided that the Plan does not have to pay 
for the consultation (D9310) and panoramic x-ray (D0330) provided on December 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for minute clinic visits provided on October 13, 2021, to 
October 18, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the minute clinic visits. You say that you assumed the clinic was in-network 
because you had gone there years ago, and the same services were covered. 
 The Plan denied your request. The Plan says the provider is out-of-network. 
 
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 services at issue were urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for minute clinic visits provided on October 13, 2021, to October 18, 
2021, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient coronary care unit (CCU) stay 
provided from July 7, 2021, to July 9, 2021 
 
You asked the Plan to waive the copayment for an inpatient CCU stay. You say that you went the emergency 
room on July 3, 2021, and you were discharged. You also say that you went back on July 6, 2021, and were 
admitted for four days, and you should not be charged for both visits. 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 $100 
copayment for each inpatient hospital stay.  The records show you were admitted for an inpatient hospital stay from July 7, 2021, to July 9, 2021. You have 
been asked to pay a $100 copayment for an inpatient CCU stay. An inpatient CCU stay falls within the 
Inpatient Hospital 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 an inpatient 
coronary care unit (CCU) stay provided from July 7, 2021, to July 9, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99215) and the application of paste boot 
(29580) provided on September 17, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an office visit and the application of paste boot. You say that you are appealing 
with supporting records. The Plan denied your request. The Plan says the services were not authorized because 
the provider is a non-network provider who does not work with the Plan, and the member was referred by a 
provider who also does not work with the Plan. The Plan also says that the member's primary care physician 
(PCP) did not refer for services and no medical necessity for an out-of-network provider, such as an urgent or 
emergency situation, has been documented. The Plan also says that alternate network providers were found. 
 
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 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 an office visit (99215) and the application of paste 
boot (29580) provided on September 17, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on August 30, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Specifically, this claim was billed with the laboratory 
POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided 
that the Plan does not have to pay for the laboratory services provided on August 30, 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 these services are medically necessary. The Plan 
denied your request. The Plan says that you can safely receive the services you 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. You 
are medically stable and do not need physical medicine and rehabilitation physician supervision 3 times per 
week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. While you may benefit from physical and occupation therapy, you do not need intensive therapies, 
consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to 
daily therapy in an IRF. Your rehab can be safely provided at a lower intensity and alternate setting. Our 
physician reviewer found that your condition does not meet 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 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: Favorable

 
We decided that the Plan has to pre-approve facet joint injections for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that the member is in pain and need additional 
injections. The Plan denied your request. The Plan says that that there is no documentation as to why 
radiofrequency ablation is not medically appropriate for the enrollee. 
 
The Plan must follow Medicare rules. Medicare rules say that facet joint injections can be covered if Medicare 
criteria has been met.  
 
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 considered medically reasonable and necessary in this case. Given the time since the 
last set of radiofrequency ablation and the utilization limitations of Medicare rules, it is reasonable and prudent 
to try to isolate the most pain facet joints. Our physician reviewer found that the enrollee's condition meets 
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 been met. Therefore, we decided that the Plan has to pre-
approve facet joint injections for the enrollee.  
 
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 reimburse you under the Flex Benefit for a humidifier filter 
purchased on December 9, 2021. 
 
You asked the Plan to reimburse you under the Flex Benefit for a humidifier filter. The Plan denied your 
request. The Plan says a humidifier filter is not covered under the Plans Flex Benefits eligible items. 
 
The Plan contract covers a supplemental Flex Benefit.  We looked at the file and the Plans rules. The file shows that the Plans supplemental Flex Benefit does not 
provide coverage for a humidifier filter. Therefore, we decided that the Plan does not have to reimburse you 
under the Flex Benefit for a humidifier filter purchased on December 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2311, 
E2313, E2377, K0108) for the enrollee. 
 You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says upper limb strength and function are therefore adequate for the enrollee to be able to 
control the power options using their own switches which are included in the allowance of these power options. 
 
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 services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee does not require non-proportional input devices (e.g., sip and puff, head array, etc.). The 
enrollee does not require a separate display (i.e., for alternate control devices), other electronic devices (e.g., 
control of an augmentative speech device or computer through the chair's drive control), or an attendant 
control. The enrollee has three power options of tilt, recline, and power elevating leg rests but the enrollee does 
not need to control the power options through a joystick. The enrollee's upper extremity strength and function 
support that the enrollee can control any power options through their own switches. K0108 - Wheelchair 
component or accessory, gel pads for foot plate is not medically necessary as the documentation does not 
reveal why the enrollee is unable to use standard pads on a wheelchair. The request exceeds the enrollee's 
medical needs and does not meet Medicare medical necessity criteria. 
 
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 additional power wheelchair accessories (E2311, E2313, E2377, K0108) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are in the intensive care unit (ICU) 
and need to transfer to a long-term acute care hospital. The Plan denied your request. The Plan says the criteria 
for admission to the LTACH have not been met. 
 
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 you were admitted with altered mental status from acute on chronic subdural 
hematomas. The record indicates that you require ongoing acute care services. Our reviewer found that you 
continue to receive acute care services, and these have not been denied. The medical record does not indicate 
that you require services that you are not currently receiving but that would be available at the LTACH facility. 
Our physician reviewer also found that the elements of the coverage rules are not satisfied. The requested 
service cannot be recommended 
 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 long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary visit provided on August 2, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the domiciliary visit. You say that the provider relies on facility staff to verify 
eligibility and obtain authorization from the insurance company. 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 the domiciliary visit provided on August 2, 2021, by an out-of-
network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve the SNF services. You say that you believe the SNF services should be 
approved for coverage. The Plan denied your request. The Plan says this request is not medically necessary. 
 
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 the SNF services. Our reviewer says 
that the enrollee does not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee 
does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a 
skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized 
skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled 
nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the SNF services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for hearing aids provided on September 27, 2021. 
 
You asked the Plan to reimburse you for hearing aids. The Plan denied your request. The Plan says there is no 
coverage if hearing aids, or related services are received from an out-of-network provider. The hearing benefit 
is not covered if the services are not registered in advance. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when ordered through the Plans hearing provider. 
 
We looked at the file and the Plan's rules. The file shows that the hearing aids were not provided by the Plans 
hearing provider. Based on this information, we decided that the Plan's rules for coverage of hearing aids have 
not been met. Therefore, we decided that the Plan does not have to reimburse you for hearing aids provided on 
September 27, 2021.