Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on April 25, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for office visit. You say that you are appealing the claim payment denial. The Plan 
denied your request. The Plan says the services were provided out-of-network and were not approved in 
advanced. 
 
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 office visit provided on April 25, 2022, by an out-
of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an autogenous connective tissue graft procedure on 
tooth #22 and 27 (D4273). 
 
You asked the Plan to pre-approve the graft procedures. The Plan denied your request. The Plan says an 
autogenous connective tissue graft procedure (D4273) is not covered by your routine dental 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 an 
autogenous connective tissue graft procedure on tooth #22 and 27 (D4273).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation provided on June 
6, 2022. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that you were 
unconscious and unable to provide consent for the trip. The Plan denied your request. The Plan says you have 
been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200 
copayment for each ground ambulance service.  
 
You have been asked to pay a $200 copayment for the ambulance transportation. The ambulance transportation 
falls within the Ambulance 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 
ambulance transportation provided on June 6, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically 
necessary. 
 
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 the enrollee appears to be unstable and requires additional short term acute care 
services that can be safely administered at the current facility until more stable and appropriate for 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 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99221 billed for date of service December 9, 
2021. 
  You asked the Plan to pay for procedure code 99221. You say that medical records are attached for review of 
code 99221. The Plan denied your request. The Plan says payment for code 99221 is bundled into payment for 
code 77290. 
 
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, we have confirmed that code 99221 
is a column II code to column I code 77290. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 99221 billed for date of service December 9, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed (E0265). 
 
You asked the Plan to pre-approve a total electric hospital bed. You say that you are a tetraplegic which means 
you only have full use of one arm therefore, you have to be hoisted in and out of bed and a wheelchair. The 
Plan denied your request. The Plan says the requested hospital bed is not covered due to the height adjustment 
feature. The Plan also says you were approved for a semi-electric bed, but you refused. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed (E0265).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and related services provided on May 12, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit and related services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says no prior authorization was obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
office visit and related services. We found no exception that would require the Plan to pay for the office visit 
and related services. The records provided for review do not show that the office visit and related services were 
urgent or emergent. Therefore, we decided that the Plan does not have to pay for the office visit and related 
services provided on May 12, 2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically 
necessary. 
 
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 the enrollee appears to be improving but is somewhat unstable and requires 
additional short term acute care services that can be safely administered at the current facility until more stable 
and appropriate for 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 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that this copayment is too 
high, and that you cannot afford it. The Plan denied your request. The Plan says you were charged this cost 
sharing 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 $310 
copayment for each ambulance trip. You had 1 ambulance trip(s). The Plan charged you $310 for these 
services. 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 the ambulance services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the omalizumab injection provided on May 
10, 2022. 
 
You asked the Plan to waive the copayment for the omalizumab injection. You say that you should not be 
charged a copay for an allergy injection. The Plan denied your request. The Plan says you have been charged 
the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for Part B drugs.  
 
You have been asked to pay a 20% coinsurance for Part B drugs for the omalizumab injection for a total of 
$447.24. The omalizumab injection 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 the omalizumab injection provided on May 10, 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 from 
September 24, 2021, to September 26, 2021. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that this bill came 9 months 
after this incident, and you feel the Plan should take care of it. The Plan denied your request. The Plan says the 
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 $350 
copayment per day(s) 1-5 for inpatient hospital care.  
 
You have been asked to pay the allowed amount of $300, which is less than the $350 for an inpatient hospital 
stay. An inpatient hospital stay falls within the Inpatient Hospital Care benefit category. This means that you 
have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for an inpatient hospital stay provided from September 24, 2021, to 
September 26, 2021.  Your complaint about receiving an untimely bill 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation provided on 
February 24, 2022. 
 
You asked the Plan to waive the copayment for ambulance transportation. You say that you should not be 
responsible for this because you were admitted to the hospital. 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 $270 
copayment for each one-way Medicare-covered ground trip ambulance transportation.  
 
You have been asked to pay $270 for ambulance transportation. Ambulance transportation falls within the 
Ambulance 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 ambulance 
transportation provided on February 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a semi-precision attachment (D6192) for teeth #22 & 
#27 provided by a participating provider. 
 
You asked the Plan to pre-approve a semi-precision attachment. You say that you would like the Plan to pay 
for this. The Plan denied your request. The Plan says the requested service is 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 a 
semi-precision attachment (D6192) for teeth #22 & #27 provided by a participating provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Cologuard test, an oncology (colorectal) screening, 
quantitative real-time target and signal amplification of 10 DNA markers and fecal hemoglobin, utilizing stool, 
algorithm reported as a positive or negative result (81528). 
 
You asked the Plan to pre-approve a Cologuard test. You say that the test was ordered by your provider and is 
required to be done. The Plan denied your request. The Plan says you do not meet criteria for coverage of this 
test. The Plan also says the Cologuard test is only a covered benefit for patients who are between the ages of 
50-85. 
 
The Plan must follow Medicare rules. Medicare rules say the Cologuard test is covered once every three years 
for Medicare beneficiaries that meet all of the criteria.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a Cologuard test have not been met. Specifically, the Cologuard test is covered for patients who are 
between the ages of 50-85, are asymptomatic and at average risk of developing colorectal cancer. The records 
show the procedure was ordered as a routine colorectal cancer screening test. Therefore, we decided that the 
Plan does not have to pre-approve a Cologuard test, an oncology (colorectal) screening, quantitative real-time 
target and signal amplification of 10 DNA markers and fecal hemoglobin, utilizing stool, algorithm reported as 
a positive or negative result (81528).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) care provided 
from January 14, 2022, to February 7, 2022. 
 
You asked the Plan to waive the copayment for the SNF care. You say that you were not aware of the 60 day 
timeframe between benefit periods. The Plan denied your request. The Plan says you have been charged the 
correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $0 per 
day for days 1-20 and $188 per day for days 21-100 for each benefit period. 
 
 
 
 
 
 Dates of Service Benefit Days Copayment 
November 19, 2021, to December 3, 2022 1-14 $0/day 
December 15, 2021  December 20, 2021 15-20 $0/day 
December 21, 2021, to December 27, 2021 21-26 $188/day 
*January 14, 2022  February 7, 2022* 27-41 $188/day 
Total:  $4,512 
 
The file shows that you were in the nursing facility from January 14, 2022, to February 7, 2022. Since 60 days 
had not passed since your last nursing facility stay or hospitalization, this stay is part of the same benefit 
period. Therefore, you have been asked to pay $188 per day for days 27-41 for SNF care, for a total of $4,512. 
The SNF care falls within the Skilled Nursing Facility (SNF) 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 skilled nursing facility (SNF) care provided from January 14, 2022, to February 7, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an echocardiogram provided on April 18, 
2022. 
 
You asked the Plan to waive the deductible for an echocardiogram. You say that you did not know there would 
be such a large charge for this test. No one warned you about it, and you cannot afford it. The Plan denied your 
request. The Plan says the deductible applied was correct. 
 
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 outpatient diagnostic tests.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category Outpatient 
Diagnostic Tests. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 
deductible which applies to outpatient diagnostic tests. This cost sharing is a contractual obligation that had not 
been met at the time an echocardiogram was received on April 18, 2022. Therefore, we decided that the Plan 
does not have to waive the $495.96 deductible for an echocardiogram provided on April 18, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says that the requested 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 found to be medically reasonable and necessary. Our physician reviewer found the 
documentation shows that you have multiple active health conditions and would benefit from close medical 
supervision. You have functional impairments involving more than one discipline of therapy and evaluating 
therapies state that you require and would tolerate intense 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 IRF care have been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gingival irrigation (D4921) provided on April 7, 2022. 
 
You asked the Plan to pay for the gingival irrigation (D4921). You say that you did not know you would be 
charged, and you cannot afford it. The Plan denied your request. The Plan says gingival irrigation (D4921) is 
not covered under your supplemental 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 
gingival irrigation (D4921) provided on April 7, 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 May 
2, 2022. 
 
You asked the Plan to pay for the dental services. You say that you had to go to a new dentist and were 
informed that you could only have the procedure done every three years. 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 July 8, 2021. Therefore, 
we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on May 
2, 2022.