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

 
We decided that the Plan does not have to pre-approve an additional thirty-eight routine transportation trips. 
 
You asked the Plan to pre-approve an additional thirty-eight routine transportation trips. You say that you need 
transportation to dialysis. The Plan denied your request. The Plan says you have utilized twenty-two of the 
twenty-four allowed trips. An additional thirty-eight trips exceed the benefit limit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 trips per year.  
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve an additional thirty-eight routine transportation trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the placement of implant body (D6010), custom 
fabricated abutment (D6057), and abutment supported crown (D6058) for tooth #30. 
 
You asked the Plan to pre-approve the dental services. You say that you had 2 molars removed and these dental 
services are necessary. The Plan denied your request. The Plan says the denial of authorization for these 
services is correct, because the placement of implant body, custom fabricated abutment, and abutment 
supported crown are not covered by the 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, 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 the 
placement of implant body (D6010), custom fabricated abutment (D6057), and abutment supported crown 
(D6058) for tooth #30.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay from June 1, 
2022, to June 10, 2022. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you were transferred to 
a hospital in the same network, not discharged. 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 $375 
copayment for days 1 to 5 of inpatient hospital care for each admission.  
 
In this case, you were transferred and admitted to a different hospital. This constitutes a new admission. You 
have therefore been asked to pay $1,875, or a $375 copayment for each day of days 1 to 5 of a 10-day inpatient 
hospital stay. This item/service 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 hospital stay from June 1, 2022, to June 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for infusions provided on June 2, 2022. 
 
You asked the Plan to waive the coinsurance for infusions. You say that you feel this is extremely expensive 
for a few infusions. 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 prescription drugs ($2491 x 20% = $498.20).  
 
You have been asked to pay a $498.20 coinsurance for infusions. 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 coinsurance for infusions 
provided on June 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical placement of implant (D6010), and semi-
precision abutment placement (D6191). 
 
You asked the Plan to pre-approve surgical placement of implant, and semi-precision abutment placement. You 
say that the services are necessary. The Plan denied your request. The Plan says the services at issue are not a 
covered 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 pre-approve 
surgical placement of implant (D6010), and semi-precision abutment placement (D6191).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service May 12, 
2021. 
 
You asked the Plan to pay for procedure code 99100. You say that you disagree with the denial. The Plan 
denied your request. The Plan says procedure code 99100 is considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service May 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental cleaning (D1110) rendered by the out-of-network 
(OON) provider on August 17, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not payable as it was rendered 
by an out-of-network provider. 
 
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 in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. 
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the dental cleaning (D1110) rendered by the out-of-network (OON) provider on 
August 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cytopathology provided on June 7, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for a cytopathology. You say that this provider regularly complies with all 
administrative requirements for payments. The Plan denied your request. The Plan says the services were 
billed, rendered, and referred by non-participating providers. The Plan also says that these services were not 
approved in advance. 
 
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 a cytopathology provided on June 7, 2022, by an 
out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services (90837) provided on December 14, 
2021. 
 
You asked the Plan to pay for the psychotherapy services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the documentation was insufficient to support the billed services. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient information in the record to determine if Medicare rules for coverage of the psychotherapy services have been 
met. No clinical records were submitted to support the billed services. Therefore, we decided that the Plan does 
not have to pay for psychotherapy services (90837) provided on December 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for three crowns (D2740) provided by a participating provider 
on April 27, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were told that these services would be 
covered. The Plan denied your request. The Plan says your benefit for the requested item or service has already 
been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service April 27, 2022. 
Therefore, we decided that the Plan does not have to pay for three crowns (D2740) provided by a participating 
provider on April 27, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from September 12, 2020, to 
September 14, 2020. 
 
You asked the Plan to pay for the acute inpatient hospital care. You say that you would like this claim to be 
reprocessed. The Plan denied your request. The Plan says that the information now received does not support 
that criteria were met for inpatient hospitalization. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our 
physician reviewer found at the time of inpatient admission the admitting physician reasonably expected that 
the enrollee's necessary hospital care (including earlier emergency department and/or observation care) would 
span two midnights. 
 
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 acute inpatient hospital care have been met. Therefore, we decided that the 
Plan has to pay for the acute inpatient hospital care provided from September 12, 2020, to September 14, 2020.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist visit with a test provided on 
January 12, 2022. 
 
You asked the Plan to waive the copayment for a specialist visit with a test. You say that you saw a PA and not 
the actual doctor. You do not understand why these charges still apply if this is the case. 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 physician/provider services including office visits,  and a $20 copayment for other outpatient 
diagnostic tests - non-radiological diagnostic services. You have been asked to pay the allowed amount of 
$14.37 which is less than the $20 copayment for a heart test ($40 + $14.37 = $55.37). 
 You have been asked to pay a $55.37 copayment for a specialist visit with a test. This item/service falls within 
the physician/provider services including office visits, and other outpatient diagnostic tests - non-radiological 
diagnostic 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 a specialist visit with 
a test provided on January 12, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services provided on November 12, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the claim processed as in-
network because the services were medically necessary. The Plan denied your request. The Plan says that the 
rendering provider is an OON provider and there was no referral from an in-network provider or an approved 
authorization. Also, the service rendered was not urgent or emergent. 
 
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. The proper Evidence of Coverage (EOC) was not sent with the case file. 
Therefore, we decided that the Plan has to pay for the laboratory services provided on November 12, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oxygen equipment you purchased and shipping fees for date 
of service June 17, 2022. 
 
You asked the Plan to pay for the oxygen equipment and shipping fees. You say that the cost of the rental was 
$410 per month and you felt as though purchased a newer, quieter machine would be a savings. The Plan 
denied your request. The Plan says purchased oxygen equipment and shipping fees are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that that only rented oxygen equipment is eligible for 
coverage. Purchased oxygen equipment is statutorily non-covered. In addition, Medicare does not cover items 
and services not directly related to the treatment of an illness or injury or to improve the functioning of a 
malformed body member. Since you purchased this oxygen system, it is non-covered.  Medicare does not cover 
purchased oxygen equipment. Also, the shipping fees are not directly related to the treatment of an illness or 
injury, so that cost is not covered either. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the oxygen equipment and shipping fees have not been met. Therefore, we decided that the Plan 
does not have to pay for oxygen equipment you purchased and shipping fees for date of service June 17, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a surgical sling operation to correct 
urinary incontinence, the removal and replacement of an inflatable penile prosthesis, a self-administered drug, 
and medical/surgical supplies provided on July 25, 2022. 
 
You asked the Plan to waive the coinsurance for surgical services. You say that you should not have to pay for 
the additional out-of-network fees because the provider was able to resolve your issues and give you back your 
quality of life, which the in-network providers were unable to do. The Plan denied your request. The Plan says 
this cost sharing was charged correctly. The Plan says there are no records indicating you contacted the Plan 
prior to the date of service to confirm benefits and coverage rules.  
 
 
 The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 50% 
coinsurance for out-of-network outpatient surgery, including services provided at hospital outpatient facilities 
and ambulatory surgical centers.  
 
You have been asked to pay a 50% coinsurance for surgical services. The services at issue fall within the 
outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 
benefit category. You received services from an out-of-network provider. 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 coinsurance for a surgical sling operation to correct urinary incontinence, the removal and replacement of 
an inflatable penile prosthesis, a self-administered drug, and medical/surgical supplies provided on July 25, 
2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional physical therapy sessions. 
 
You asked the Plan to pre-approve physical therapy. You say that additional PT is medically necessary. The 
Plan denied your request. The Plan says these services have been correctly denied. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 physical therapy. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the enrollee can transition to an independent home exercise program 
with the approved therapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of physical therapy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve additional physical therapy sessions.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the foot orthotics (L3020) provided on March 21, 2022. 
 
You asked the Plan to pay for these items. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says these items are not a covered benefit under your 
contractual policy or by Medicare for your condition. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Additionally, Medicare rules say that with the exception of the situations described above, 
orthopedic footwear billed using code L3020 will be denied as non-covered. Therefore, we decided that the 
Plan does not have to pay for the foot orthotics (L3020) provided on March 21, 2022.