Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a therapy visit on January 7, 2022. 
 
You asked the Plan to waive the copayment for a therapy visit. You say that you were told by a customer 
service representative from the Plan that your provider was currently in-network and would not have a 
copayment. The Plan denied your request. The Plan says there is a $55 copayment for out-of-network therapy 
visits. Your provider is currently out-of-network. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $55 
copayment for out-of-network outpatient mental health.  
 
You have been asked to pay a $55 copayment for a therapy visit. A therapy visit falls within the out-of-network 
outpatient mental health 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 therapy 
visit on January 7, 2022.  
 Your complaint about being told by a customer service representative from the Plan, that your provider was 
currently in-network, and would not have a copayment for outpatient visits is not a valid appeal for medical 
coverage 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter. 
 
You asked the Plan to pre-approve these services. You say that you need the scooter for use outside of your 
home. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a power scooter.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Iron Dextran. 
 
You asked the Plan to pre-approve Iron Dextran. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested drug is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
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 Iron Dextran. Our reviewer says that 
the documentation does not support that the requested drug is medically reasonable or necessary. Our physician 
reviewer found the enrollee has a past medical history of diabetes and sleep apnea with a diagnosis of other 
disorders of iron metabolism. Based on the medical records provided and the Medicare-approved major drug 
compendia there is no documentation that the requested Iron Dextran meets Medicare criteria for medically 
reasonable and necessary for the enrollee. Iron Dextran is indicated for treatment of iron deficiency due to 
blood loss and iron deficiency anemia. The provided records do not document the enrollee has iron deficiency 
due to blood loss or iron deficiency anemia. Therefore, the enrollee does not meet criteria for the requested 
drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Iron Dextran have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Iron Dextran.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a therapy visit on December 23, 2021. 
 
You asked the Plan to waive the copayment for a therapy visit. You say that you were told by a customer 
service representative from the Plan that your provider was currently in-network and would not have a 
copayment.. The Plan denied your request. The Plan says there is a $55 copayment for out-of-network therapy 
visits. Your provider is currently out-of-network. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $55 
copayment for outpatient mental health care, out-of-network provider.  
 
You have been asked to pay a $55 copayment for therapy visit. Therapy visit falls within the outpatient mental 
health care, out-of-network provider 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 
therapy visit on December 23, 2021.  Your complaint about being told by a customer service representative from the Plan, that your provider was 
currently in-network, and would not have a copayment for outpatient visits 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair. 
 
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 the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that these services are being requested for use in a SNF. Therefore, we decided that the Plan 
does not have to pre-approve a power wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 7 acupuncture visits. 
 
You asked the Plan to pre-approve the acupuncture visits. You say that this service is medically necessary. The 
Plan denied your request. The Plan says rules for coverage are not met. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the record does not show a diagnosis of chronic lower 
back pain that meets coverage rules. Therefore, we decided that the Plan does not have to pre-approve 7 
acupuncture visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a Medicare-covered, primary care doctor in 
office visit on February 22, 2022. 
 
You asked the Plan to waive the copayment for in-network prime care office visit. You say that when you 
signed up for this plan, you thought the copay amounts would be less. You feel you should not have to pay for 
the $5 copay due to this. The Plan denied your request. The Plan says there is a $5 copayment for each 
Medicare covered, in network primary care doctor in-office visit. 
 
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 $5 
copayment for each Medicare-covered primary care doctor in office visit. 
 
You have been asked to pay $5 for in-network primary care office visit. In-network primary care office visit 
falls within the Medicare-covered primary care doctor in office visit 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 Medicare-covered, primary 
care doctor in office visit on February 22, 2022.  
 
Your complaint about the insurance representative giving misinformation 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Restasis (cyclosporine ophthalmic emulsion). 
 
You asked the Plan to pre-approve the Restasis eye drops. You say that the enrollee has failed other similar 
treatments. The Plan denied your request. The Plan says this is a self-administered medication that is not 
covered by 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 pre-approve Restasis (cyclosporine 
ophthalmic emulsion).  
 
Benefits for the Restasis eye drops 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 waive the coinsurance for the assistant surgeon services provided by 
an out of network provider on December 13, 2021. 
 
You asked the Plan to waive the coinsurance for the assistant surgeon services provided by an out of network 
provider. You say that you disagree with the amount owed. The Plan denied your request. The Plan says the 
claim has been processed correctly per the enrollee's plan benefits. 
 
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 $750 deductible which applies to services that are received before the 
Plan will pay their share for the enrollees covered medical services.  
 
 The item or service you asked the Plan to waive the coinsurance for falls within the deducible benefit category. 
The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible which 
applies to services that are received before the Plan will pay their share for the enrollees covered medical 
services. This cost sharing is a contractual obligation that had not been met at the time the assistant surgeon 
services provided by an out of network provider was received on December 13, 2021. Therefore, we decided 
that the Plan does not have to waive the coinsurance for the assistant surgeon services provided by an out of 
network provider on December 13, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to change the copayment for Medicare-covered outpatient surgery 
visits on February 10, 2022, through February 28, 2022. 
 
You asked the Plan to change the copayment for Medicare-covered outpatient surgery. You say that you 
received routine treatment of a diabetic ulcer. You say that you are being charged the wrong copayment 
amounts. You state you should only have a $30 copayment for each of these visits, not the $310 and $271.95. 
The Plan denied your request. The Plan says you pay $310 for each Medicare-covered outpatient admission to 
an ambulatory surgical center. The facility you have been seen at is considered an ambulatory surgical center. 
 
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 $310 for 
Medicare-covered outpatient admissions. You have been asked to pay $271.95, which is less than the $310 for 
Medicare-covered outpatient surgery 
 
You have been asked to pay $310 for Medicare-covered outpatient surgery. Medicare-covered outpatient 
surgery falls within the Medicare-covered outpatient admission 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 change the copayment for Medicare-covered outpatient 
surgery visits on February 10, 2022, through February 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cone beam computed tomography (CT) capture and 
interpretation (D0366) provided on February 10, 2022. 
 
You asked the Plan to pay for the cone beam CT capture and interpretation. You say that you have 
supplemental dental coverage with the Plan, and there is no contract exclusion for this service. You also say 
that this service was related to valid endodontic treatment. The Plan denied your request. The Plan says this 
procedure is not a contract benefit. 
 
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 pay for the cone 
beam computed tomography (CT) capture and interpretation (D0366) provided on February 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on 
January 20, 2022. 
 
You asked the Plan to pay for the comprehensive oral evaluation. You say that you would like to appeal this 
service. The Plan denied your request. The Plan says this procedure exceeds the frequency limitations under 
your plan. 
 
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, comprehensive oral exam is covered 
once every 36 months. The record shows that you received a comprehensive oral evaluation (D0150) on 
November 9, 2021 and your comprehensive oral exam benefit has been exhausted. Therefore, we decided that 
the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on January 20, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance response and treatment, no transport (code 
A0998) provided on February 7, 2022. 
 
You asked the Plan to pay for ambulance response and treatment, no transport. You say that the services were 
an emergency and you were administered intravenous fluids and the EMS left after twenty minutes. The Plan 
denied your request. The Plan says your Plan covers ambulance transportation only when you are actually 
transported by ambulance. 
 
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 February 7, 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 ambulance response and treatment, no transport 
(code A0998) provided on February 7, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the incision and drainage of hematoma (10140) and 
debridement (11044) provided on November 23, 2021. 
 
You asked the Plan to pay for the incision and drainage of hematoma (10140) and debridement (11044). You 
say that there is no relationship between CPT code 11044 and CPT code 21390 and both codes are eligible for 
reimbursement. You say that the operative report supports the services billed and payment should be submitted 
in a timely manner. The Plan denied your request. The Plan says procedure code 10140 is not supported by the 
medical records submitted and procedure code 11044 is considered inclusive to procedure code 21390. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
 
  In this case, the CPT Code Manual definition of code 10140 is incision and drainage of hematoma, seroma or 
fluid collection. The CPT Code Manual definition of code 11044 is debridement, bone (includes epidermis, 
dermis, subcutaneous tissue, muscle and/or fascia, if performed); first 20 sq cm or less. 
 
We asked our coder 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 incision and drainage of hematoma (10140) and 
debridement (11044). Our reviewer says that the documentation submitted was reviewed and does not meet the 
criteria for coverage. Our reviewer found the operative report describes an irrigation of hematoma in left 
maxillary sinus. Therefore, incision and drainage of hematoma cannot be verified. In addition, the operative 
report describes debridement was performed with fracture treatment. In this case, procedures performed for the 
treatment of the fracture would be inclusive to the primary procedure code.   
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the incision and drainage of hematoma (10140) and debridement (11044) have 
not been met. Therefore, we decided that the Plan does not have to pay for the incision and drainage of 
hematoma (10140) and debridement (11044) provided on November 23, 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 you are appealing the denial of IRF. The Plan denied 
your request. The Plan says the enrollee does not meet the requirements for approval. 
 
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 enrollee has a past medical history of Parkinson's disease who was evaluated in 
the emergency department on June 30, 2022 for dizziness and discharged home.  Our physician reviewer found there are no complex nursing or rehabilitation needs. While the enrollee has a 
need for physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve LTACH services. You say that LTACH admission is medically necessary. 
The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient care at the current 
hospital and can remain there until ready for discharge to a lower level of care. 
 
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 that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where she is currently receiving 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 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: 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 skilled nursing facility (SNF) services. You say that you cannot walk. The 
Plan denied your request. The Plan says you do not meet criteria for continued SNF stay. 
 
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 skilled nursing facility (SNF) services. 
Our reviewer says that there are no identifiable skilled therapy service needs. Our physician reviewer found 
you do not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a 
skilled professional nurse. You do not have daily skilled therapy needs that require the specialized skill, 
knowledge, and judgment of a skilled professional therapist. Our reviewer also found that you do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (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 skilled nursing facility (SNF) services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.