Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient services provided from November 
8, 2021, to November 12, 2021. 
 
You asked the Plan to waive the copayment for inpatient services. You say that you think that you were not 
admitted until November 9, 2021, so you should not have to pay extra. The Plan denied your request. The Plan 
says the copayment amount you are being charged is correct. 
 
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 $490 
copayment for each Medicare-covered day for days 1-4 for inpatient services.  
 
 
  You have been asked to pay a $1,470 copayment for the inpatient services ($490/day x 3 days = $1,470). The 
inpatient services fall within the Inpatient hospital care benefit category. The records show you were only 
charged the inpatient copayment for November 9, 2021, November 10, 2021, and November 11, 2021. 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 services provided from 
November 8, 2021, to November 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 services are medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found at the current functional level, the enrollee's needs can be met at a lower level of care. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an inpatient hospital visit provided on 
January 7, 2021. 
 
You asked the Plan to waive the deductible for an inpatient hospital visit. You say that the doctor was maybe in 
the room for 30 seconds to check on you. 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. Your 
contract with the Plan says that there is $1,687 deductible which applies to in-network inpatient hospital care.  
 
The record shows your deductible had not been met at the time inpatient hospital care was received on January 
7, 2021. The item or service you asked the Plan to waive the deductible for falls within the Inpatient Hospital 
Care benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is 
$1,687 deductible which applies to inpatient hospital care. This cost sharing is a contractual obligation that had 
not been met at the time an inpatient hospital visit was received on January 7, 2021. Therefore, we decided that 
the Plan does not have to waive the deductible for an inpatient hospital visit provided on January 7, 2021.   
Your complaint about the amount of time the doctor was in the room 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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient mental health services provided on December 16, 
2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for Outpatient mental health services. You say that you would like to request 
reconsideration for payment. The Plan denied your request. The Plan says prior authorization is required for an 
out-of-network visit. 
 
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 Outpatient mental health services provided on 
December 16, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist visit provided on October 6, 
2021. 
 
You asked the Plan to waive the copayment for the specialist visit. You say that you saw another Primary Care 
Physician (PCP) in the same office because your assigned PCP was unavailable. The Plan denied your request. 
The Plan says the $35 copayment applied was correct. 
 
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 $35 
copayment per visit for specialist visits. Some specialist examples include oncologist, cardiologist, orthopedist 
and podiatrist. The Physician you saw is a cardiologist.  
 
 
 
 
 You have been asked to pay a $35 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 October 6, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary. The Plan 
denied your request. The Plan says an IRF admission 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 complexity of the enrollees nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee was admitted for surgical management of cholecystitis. Medical problems are stable. There are no 
complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
While the enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for 
an intensive 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 IRF admission and services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services. 
 
You asked the Plan to pre-approve SNF care. You say that you are still weak and need more help getting 
around. The Plan denied your request. The Plan says based on Medicare guidelines, the requested SNF services 
do not meet the requirements for approval. 
 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 daily 
skilled services are not necessary. Our physician reviewer found that based on the documentation provided, you 
do not have documented skilled nursing needs. You do not have documented skilled therapy needs. Your daily 
skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of 
your condition. Your care needs appear to be custodial and, as a practical matter, can 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 skilled nursing facility (SNF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient hospital visit (G0463) 
provided on September 9, 2021. 
 
You asked the Plan to waive the copayment for the outpatient hospital visit. You say that the services should be 
covered as you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied 
correctly based on the services provided. 
 
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 and Other Medical Services Provided at Hospital Outpatient Facilities and 
Ambulatory Surgical Centers.  
 
 
  You have been asked to pay a $128.58 copayment for an outpatient hospital visit, which is less than the 
standard $350. 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 outpatient hospital visit (G0463) 
provided on September 9, 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 IRF services are medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found given the current functional level of modified independence, the enrollee needs no 
inpatient rehabilitation at any level. Her rehab needs can be met with a home exercise 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 pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary. The Plan 
denied your request. The Plan says based on Medicare guidelines and the information we have about your 
condition; you don't meet the requirements. 
 
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 enrollees nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee was admitted for surgical management of an epidural hematoma. Medical problems are stable. There 
are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
While the enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for 
an intensive 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 IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the oral exam (D0150), bitewing x-rays (D0274), panoramic x-rays 
(D0330), and cleaning (D0110) provided on November 18, 2021. 
 
You asked the Plan to pay for the dental services. You say that this dentist is listed in the Plan's records as in-
network. You state that you asked about this and were told that the dentist was in-network at another office. 
You also state that you were told by the provider that the dentist never worked at that office. You feel this 
should be covered because you had no way of knowing this provider was out of network. The Plan denied your 
request. The Plan says that you did not contact the Plan to verify provider status. This is an out of network 
dentist, and the services cannot be covered. 
 
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. Plans are required to address the arguments made by enrollees in an appeal. You 
claim that this provider is listed as in-network and that you were told that this was because she was in-network 
at another office. You also state that the provider claims they did not work at any other office. The Plan made 
no reference to this to explain this discrepancy. Since the provider was listed as in-network, we find that you 
would have a reasonable belief that these services would be covered. We find that for this one visit, the Plan's 
denial is not substantiated. Therefore, we decided that the Plan has to pay for the oral exam (D0150), bitewing 
x-rays (D0274), panoramic x-rays (D0330), and cleaning (D0110) provided on November 18, 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. 
 
Please note also: The Plans payment will be made based on their network fee schedule. If the doctor does not 
accept this as payment in full, then you will be responsible for the difference. In addition, this decision applies 
only to this date of service as you have now been notified that this provider is out-of-network.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound of the scrotum (76870) and a 
complete ultrasound of the arterial and venous blood flow in the abdomen and pelvis (93975) provided on 
January 28, 2022.  
 
You asked the Plan to waive the copayment for a scrotal ultrasound and an ultrasound of the vascular system in 
the abdomen and pelvis. You say that you only had an ultrasound done and do not understand why you are 
being billed for two services. The Plan denied your request. The Plan says the cost-share was applied 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 each covered diagnostic procedure or test at a network outpatient facility.  
 You have been asked to pay a $359.64 copayment for a scrotal ultrasound (76870) and an ultrasound of the 
vascular system in the abdomen and pelvis (93975). The services at issue fall within the Outpatient Diagnostic 
Tests and Therapeutic Services and Supplies benefit category. See below for a breakdown of your cost-share. 
 
(76870) Allowed Amount $138.78 
(93975) Allowed Amount $220.86 
$138.78 + $220.86 = $359.64 
 
For both services, you have been asked to pay less than the required $250 copayment listed in your 2022 EOC.  
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost-
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for an ultrasound of the scrotum (76870) and a complete 
ultrasound of the arterial and venous blood flow in the abdomen and pelvis (93975) provided on January 28, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient hospital services provided on 
August 27, 2021, September 17, 2021, and October 26, 2021. 
 
You asked the Plan to waive the copayment for outpatient hospital services. You say that the procedure was not 
performed at a hospital but at a location associated with the hospital so you believe you should pay the 
ambulatory surgical copayment of $225. The Plan denied your request. The Plan says the copayment applied 
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 $350 for 
each in-network copayment for outpatient hospital services. 
 You have been asked to pay a total of $1,050 ($350 x 3 visits = $1,050). Outpatient hospital services fall within 
the Outpatient hospital 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 
outpatient hospital services provided on August 27, 2021, September 17, 2021, and October 26, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve unlisted dental procedure, dentoalveolar structures 
(41899) provided February 7, 2022. 
 
You asked the Plan to pre-approve the dental service. You say that your teeth are rotting, and you need to have 
knee replacement surgery. The orthopedic surgeon will not perform the knee replacement surgery until your 
teeth are fixed. The Plan denied your request. The Plan says this service is not covered under the Plan benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
unlisted dental procedure, dentoalveolar structures (41899) provided February 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for alginate or other fiber gelling dressing (A6197) provided on 
September 28, 2021. 
 
You asked the Plan to pay for alginate or other fiber gelling dressing. You say that the requested item was a 
medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not 
been met. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code A6197 has a status indicator of P on the Physician Fee Schedule. This means that CPT 
code A6197 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of alginate or other fiber gelling dressing have not been met. Therefore, we decided that the Plan does not have 
to pay for alginate or other fiber gelling dressing (A6197) provided on September 28, 2021.