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

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
November 9, 2022, to November 12, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you should not have to 
pay for room and board. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $275 
copayment per day for days 1-6 of each inpatient hospital stay. 
 You have been asked to pay a $275 copayment per day for days 1-3 of the inpatient hospital stay. You have not 
been charged for the day you were discharged. You have been asked to pay a total of $825 for the inpatient 
hospital stay ($275 copayment per day x 3 days = $825). 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 the inpatient hospital stay 
provided from November 9, 2022, to November 12, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the x-ray provided on January 11, 2023. 
 
You asked the Plan to waive the deductible for the x-ray. You say that you should not be held responsible for 
the deductible. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $750 deductible which applies to outpatient diagnostic tests and 
therapeutic services and supplies.  
 
The item or service you asked the Plan to waive the deductible for falls within the outpatient diagnostic tests 
and therapeutic services and supplies benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $750 deductible which applies to outpatient diagnostic tests and 
therapeutic services and supplies. This cost sharing is a contractual obligation that had not been met at the time the x-ray was received on January 11, 2023. Therefore, we decided that the Plan does not have to waive the 
deductible for the x-ray provided on January 11, 2023.
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 enrollee would benefit from an IRF admission to 
regain maximum function and strength. The Plan denied your request. The Plan says the IRF services requested 
are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. 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. Medically necessary care can 
be provided in a different 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation, intraoral x-ray, and crown (D0220, 
D0140, D2740) provided on March 3, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the dental services were received from an out-of-
network provider and are not covered by your supplemental 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. 
 
 
  The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a limited oral evaluation, intraoral x-ray, and crown (D0220, D0140, D2740) provided on March 3, 
2022.
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 member meets the criteria for and would benefit 
from an IRF admission. The Plan denied your request. The Plan says the member does not meet the criteria for 
an IRF admission. 
 
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 does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. 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. Medically necessary care can 
be provided in a different 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 pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that an LTACH can improve the enrollee's 
condition and avoid hospital readmission. The Plan denied your request. The Plan says an LTACH admission is 
not medically necessary, and the enrollee's needs can be met in the current hospital setting. 
 
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 the enrollee is currently receiving care. The health plan has approved ongoing care in 
the current acute care 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental cleaning (D1110), periodic oral evaluation 
(D0120), and the intraoral-complete series of radiographic images (D0210) provided on December 12, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says your benefit for the dental cleaning and 
periodic oral evaluation provided has already been exhausted. Additionally, an intraoral-complete series of 
radiographic images is not covered. 
 
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 dental cleaning and the periodic oral evaluation was exhausted on date of service 
June 8, 2022. Specifically, the Plan contract provides coverage of a dental cleaning and a periodic oral 
evaluation once per calendar year. You previously received these services on June 8, 2022, which were paid for 
by the Plan. Therefore, you have exhausted the allowable benefit for these services. Additionally, an intraoral-
complete series of radiographic images is not a covered benefit. Therefore, we decided that the Plan does not 
have to pay for the dental cleaning (D1110), periodic oral evaluation (D0120), and the intraoral-complete series 
of radiographic images (D0210) provided on December 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an implant/abutment supported removable denture and a 
semi-precision attachment (D6110, D6192) provided on June 29, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your 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 pay for an 
implant/abutment supported removable denture and a semi-precision attachment (D6110, D6192) provided on 
June 29, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacroiliac (SI) joint radiofrequency ablation (RFA). 
 
You asked the Plan to pre-approve an SI joint RFA. You say that the services are necessary. The Plan denied 
your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that sacroiliac joint injections (SIJI) will be considered 
medically reasonable and necessary when specific criteria are met. 
 
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 an SI joint RFA. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found there is no documentation of a 
diagnostic intercostal nerve block which is a prerequisite before performing intercostal neurolysis. Therefore, 
the request is deemed not medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an SI joint RFA have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a sacroiliac (SI) joint radiofrequency ablation (RFA).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the wheelchair provided from May 8, 2022, 
to January 8, 2023. 
 
You asked the Plan to waive the cost share for the wheelchair. You say that you returned this wheelchair. The 
Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan clearly says that enrollees must pay 20% coinsurance for in-network durable medical 
equipment. Your contract with the Plan also says that there is a $525 deductible which applies to in-network 
durable medical equipment.  You have been asked to pay 20% coinsurance of the allowed amount each month for the wheelchair. This 
item/service falls within the durable medical equipment 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. 
 
You have also been asked to pay $35.96 towards your 2023 deductible for the wheelchair. The Plan has 
followed Medicare rules by clearly disclosing in the contract that there is a $525 deductible which applies to in-
network durable medical equipment. This cost sharing is a contractual obligation that had not been met at the 
time the wheelchair was provided on January 8, 2023. Therefore, we decided that the Plan does not have to 
waive the cost share for the wheelchair provided from May 8, 2022, to January 8, 2023.
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says 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 not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee is medically stable and does not need physician's supervision 3 times a 
week in an IRF. At the current level of function, the enrollee does not need intensive therapies consisting of at 
least 3 hours of therapy per day at least 5 days per week with a multidisciplinary approach in an IRF. While the 
enrollee may benefit from continued physical therapy, and occupational therapy, the enrollees rehabilitation 
needs can be safely provided in a lower intensity and alternate 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 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for the onabotulinumtoxina injections 
provided on November 7, 2022. 
 
You asked the Plan to reduce the coinsurance for the injections. You say that the injection cost has increased. 
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 20% 
coinsurance for each Medicare-covered Part B drug obtained in an outpatient setting.  
 
You have been asked to pay $392.78 coinsurance, which is 20% of the allowed amount for the injection 
($1,961.39 x 20% = $392.78). You have also been asked to pay $99.66 coinsurance, which is 20% of the 
allowed amount for the injection ($490.35 x 20% = $99.66). These items/services fall 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 reduce the coinsurance for the 
onabotulinumtoxina injections provided on November 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance (D4910) provided on January 6, 
2023. 
 
You asked the Plan to pay for the dental services. You say that you did not know you had to wait 94 days in 
between the two different types of cleanings in order for this to 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. This benefit includes an 
annual maximum of $1,500. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows the Plan paid $1,416 on date of service January 11, 2023, and paid $84 on date of service January 6, 
2023 ($1,416 + $84 = $1,500). Therefore, your benefit was exhausted on date of service January 6, 2023. 
Therefore, we decided that the Plan does not have to pay for periodontal maintenance (D4910) provided on 
January 6, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown and core build up provided on January 18, 2023. 
 
You asked the Plan to pay for the dental services. You say that without these services you would not be able to 
chew on that side of your mouth. The Plan denied your request. The Plan says these services are not covered by 
the Plan's 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 pay for the crown 
and core build up provided on January 18, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for medication assisted treatment, methadone; weekly bundle including 
dispensing and/or administration, substance use counseling, individual and group (code G2067) provided on 
December 26, 2022. 
 
You asked the Plan to pay for medication assisted treatment, methadone; weekly bundle including dispensing 
and/or administration, substance use counseling, individual and group. You say that you have been enrolled in 
the Medicare program to provide Opioid Treatment Program (OTP) services since January 1, 2020. The Plan 
denied your request. The Plan says that the claim for these drugs was billed by the physician, not the opioid 
treatment program (OTP) facility. The rules say that only an entity enrolled with Medicare as an OTP can bill 
these codes. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the OTP is the billing provider and is Substance Abuse and Mental 
Health Services Administration (SAMHSA) certified. The rules cited by the Plan do not provide a valid reason to deny this claim given that the OTP meets the Medicare coverage criteria. This provider continues to use the 
professional claim, which is allowed under Medicare rules. Therefore, we decided that the Plan has to pay for 
medication assisted treatment, methadone; weekly bundle including dispensing and/or administration, 
substance use counseling, individual and group (code G2067) provided on December 26, 2022.   
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist office visit provided on 
January 20, 2023. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that you only received bone 
mass measurement services and should have no copayment. 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 $0 copayment for bone mass measurements. Your contract with the Plan also clearly says that you must pay a $50 
copayment for specialist office visits. 
 
The record shows you received a trabecular bone score (code 77089) during this visit. According to Medicare 
this is not a preventative service, and as such the specialist office visit copayment applies. You have been asked 
to pay $39.76, which is less than the standard $50 copayment for the specialist office visit. This item/service 
falls within the physician/practitioner 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 the specialist office visit provided on January 20, 2023.