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

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on May 13, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you have 
used Life Alert for close to five years which automatically dials 911 if you fall. You also say that the services 
have never been rejected. The Plan denied your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on May 13, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on May 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the extraction, of an erupted tooth requiring 
removal of bone and/or sectioning of tooth (D7210), deep sedation/general anesthesia-first 15 minutes 
(D9222), deep sedation/general anesthesia-each subsequent 15 minute increment (D9223), the infiltration of a 
sustained release therapeutic drug, per quadrant (D9613), and the comprehensive oral evaluation (D0150) 
provided on July 12, 2022 and July 25, 2022. 
 
You asked the Plan to issue reimbursement for these services. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says these services are 
not a covered benefit under your contractual policy.  
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 services provided are not among 
those covered under this benefit. Additionally, a comprehensive oral evaluation is only covered when rendered 
by an in-network provider. The services in this case were rendered by an out-of-network provider. Therefore, 
we decided that the Plan does not have to pay for the extraction, of an erupted tooth requiring removal of bone 
and/or sectioning of tooth (D7210), deep sedation/general anesthesia-first 15 minutes (D9222), deep 
sedation/general anesthesia-each subsequent 15 minute increment (D9223), the infiltration of a sustained 
release therapeutic drug, per quadrant (D9613), and a comprehensive oral evaluation (D0150) provided on  
July 12, 2022 and July 25, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an abscess procedure provided on 
September 06, 2022. 
 
You asked the Plan to waive the copayment for an abscess procedure. You say that you were not expecting this 
large copayment, you had this done before and didnt pay this much. 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 $350 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers. 
 
You have been asked to pay a $350 copayment for an abscess procedure. 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 an abscess procedure provided 
on September 06, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided on 
August 29, 2022, to September 5, 2022 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you do not understand 
why you are being charged for this inpatient stay. 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 $275 
copayment per day for days 1-8. There is a $0 copayment for days 9-90 for inpatient hospital care/in-network.  
 
You have been asked to pay a $275 copayment per day for days 1-7 for an inpatient hospital stay. The total 
amount you are being asked to pay is $1,925 ($275 x 7 days = $1,925). This item/service falls within the 
inpatient hospital care/in-network 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 hospital stay provided on August 29, 2022, to September 5, 2022
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an MRI on September 1, 2022. 
 
You asked the Plan to waive the copayment for an MRI. You say that you feel like this copayment is too high. 
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 $175 
copayment for outpatient diagnostic tests/advanced radiology service.  
 
You have been asked to pay a $175 copayment for an MRI. This item/service falls within the outpatient 
diagnostic tests/advanced radiology service 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 MRI on September 1, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are necessary for you to receive help 
with your daily needs. The Plan denied your request. The Plan says that the admission to a SNF 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you do not have documented skilled nursing or skilled therapy needs. Daily 
skilled services are not required to establish a maintenance program or to prevent deterioration of your 
condition. Your care needs, custodial and intermittent, can, as a practical matter, be provided at a lower level of 
care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to lower the copayment for the hospital stay that was provided on June 9, 2022. 
 
You asked the Plan to lower the copayment for the hospital stay. You say that you were charged as an 
inpatient; you do not think this is correct. You say you were discharged the same day so you should be billed as 
an outpatient. The Plan denied your request. The Plan says that this cost sharing was charged correctly. 
 
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 Plan has not provided medical records or other documentation 
to support that an inpatient admission took place. Therefore, we decided that the Plan has to lower the 
copayment for the hospital stay that was provided on June 9, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay provided on August 
29, 2022, to August 31, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that you should not have to pay 
for the inpatient stay. 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 $250 
copayment for Inpatient hospital coverage. 
 
You have been asked to pay a $250 copayment for inpatient hospital stay. This item/service falls within the 
Inpatient hospital coverage 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 inpatient 
hospital stay provided on August 29, 2022, to August 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy provided, on July 5, 2022, to July 28, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for physical therapy. You say that these services were medically necessary. The Plan 
denied your request. The Plan says there are in-network providers available who can provide the required 
services. 
 
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 physical therapy provided, on July 5, 2022, to July 
28, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility visit provided on October 18, 2022. 
 
You asked the Plan to pay for nursing facility visit. You say that you are appealing the claim payment denial. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for nursing facility visit 
provided on October 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing (G0480) provided on August 8, 2022. 
 
You asked the Plan to pay for the drug testing. You say that the records provided support the services in 
dispute. The Plan denied your request. The Plan says Medicare criteria for coverage have not been met. 
 
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 pay for the drug testing. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the enrollee has a history of chronic pain 
maintained on opiates. There was no documentation provided indicating medical necessity for the drug testing. 
 
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 drug testing have not been met. Therefore, we decided that the Plan does not 
have to pay for drug testing (G0480) provided on August 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services provided on October 
04, 2022. 
 
You asked the Plan to waive the copayment for laboratory services. You say that you disagree with the 
copayment and believe the Plan should pay for the services rendered in full. 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 $40 
copayment for laboratory services. 
 
You have been asked to pay a $40 copayment for laboratory services. This item/service falls within the 
laboratory 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 waive the copayment for laboratory services 
provided on October 04, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says IRF services are 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 that the documentation does not support that the enrollee would meet criteria for 
admission to an acute inpatient rehabilitation facility. 
 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 an IRF admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for duplex scan provided on October 03, 2022. 
 
You asked the Plan to pay for duplex scan. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for duplex scan provided on 
October 03, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the guided tissue regeneration-resorbable 
barrier, per site (D4266), bone replacement graft for ridge preservation-per site (D7953), removal of an 
impacted tooth-completely bony (D7240), extraction, of an erupted tooth requiring removal of bone and/or 
sectioning of tooth (D7210), consultation-diagnostic service provided by a dentist or physician other than 
requesting dentist or physician (D9310), removal of a benign odontogenic cyst or tumor-lesion diameter up to 
1.25 cm (D7450), and the panoramic radiographic image (D0330) provided on June 29, 2022. 
 You asked the Plan to issue reimbursement for these services. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says these services are 
not a covered benefit under your contractual policy. 
 
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 services provided are not among 
those covered under this benefit. Additionally, a panoramic radiographic image is only covered when rendered 
by an in-network provider. The services in this case were rendered by an out-of-network provider. Therefore, 
we decided that the Plan does not have to issue reimbursement for the guided tissue regeneration-resorbable 
barrier, per site (D4266), bone replacement graft for ridge preservation-per site (D7953), removal of an 
impacted tooth-completely bony (D7240), extraction, of an erupted tooth requiring removal of bone and/or 
sectioning of tooth (D7210), consultation-diagnostic service provided by a dentist or physician other than 
requesting dentist or physician (D9310), removal of a benign odontogenic cyst or tumor-lesion diameter up to 
1.25 cm (D7450), and the panoramic radiographic image (D0330) provided on June 29, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are necessary to help you rebuild your 
strength. The Plan denied your request. The Plan says that the 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 that the clinical documentation shows that you have some active medical issues 
however there are no complex functional deficits specified thus the complexity of your 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 IRF admission and services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an MRI provided on May 19, 2022. 
 
You asked the Plan to waive the deductible for an MRI. You say that this has been covered before. 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. Your 
contract with the Plan says that there is a $500 deductible which applies to what is your plan deductible.  
 
The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 deductible which 
applies to what is your plan deductible. This cost sharing is a contractual obligation that had not been met at the 
time an MRI was received on May 19, 2022. The total amount you are being asked to pay is $407.37. 
Therefore, we decided that the Plan does not have to waive the deductible for an MRI provided on May 19, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Part B drugs on July 21, 2022. 
 
You asked the Plan to waive the copayment for Part B drugs. 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 20% 
coinsurance for Medicare Part B covered drugs at primary care physicians (PCP) office, specialists office, and 
pharmacy. These drugs are covered under Part B of Original Medicare. Members of our plan receive coverage 
for these drugs through our plan. Covered drugs include drugs that usually aren't self-administered by the 
patient and are injected or infused while you are getting physician, hospital outpatient, or ambulatory surgical 
center services. The provider billed in the amount of $1,880 and the allowed amount is $1,509.80. $1,509.80 x 
20% = $301.96. Therefore, results in the total cost sharing amount of $301.96. 
 
 
 You have been asked to pay a 20% coinsurance for Part B drugs. This item/service falls within the Medicare 
Part B prescription drugs benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for Part B drugs 
on July 21, 2022.