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

 
We decided that the Plan has to pay for ambulance service, basic life support, emergency transport provided on 
March 19, 2022. 
 
You asked the Plan to pay for the ambulance service, basic life support, emergency transport. You say that you 
are requesting a reconsideration for the cost share applied to your claims from March 19, 2022. The Plan 
denied your request. The Plan says that this claim does not meet criteria for the ambulance transport. 
 
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 Plan has not provided us with any medical records or evidence 
of having made reasonable attempts to obtain medical records. Without this necessary information we are 
unable to make a determination regarding the medical necessity of the non-emergent transport services in 
dispute. The Plan has not substantiated their denial reason Therefore, we decided that the Plan has to pay for 
ambulance service, basic life support, emergency transport (bls) provided on March 19, 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from February 26, 2022, 
to March 27, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the NOA was submitted timely. 
The Plan denied your request. The Plan says the claim has not been billed with the correct admission date. 
 
 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from February 26, 2022, to 
March 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on June 
27, 2022. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that your maximum out-of-
pocket had been met. 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 a specialist office visit.  
 
You have been asked to pay $40 for a specialist office visit. This item/service falls within the specialist office 
visit benefit category. At the time this claim was processed your out-of-pocket maximum had not been met. 
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 office visit provided on June 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve catheter placement in coronary artery(s) for coronary 
angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and 
interpretation; with left heart catheterization including intraprocedural injection(s) for left ventriculography 
(93458). 
 
You asked the Plan to pre-approve cardiac catheterization. You say that you disagree with the denial. The Plan 
denied your request. The Plan says cardiac catheterization is medically needed if the enrollee has high risk 
findings on their stress test or if the enrollee is about to undergo a high-risk surgical procedure. The enrollee 
had a prior normal stress test and is not going to have high risk surgery. Therefore, the procedure is denied. 
There are other tests that she can have to evaluate her heart arteries that are safer. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 cardiac catheterization. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has had no chest pains and a radionuclide stress test in the past was 
negative for ischemia. Medical therapy has not been optimized, with BP recorded as 158mmHg. 
Documentation does not support the rationale for this invasive imaging study. Guidelines do not support a need 
for cardiac catheterization in this setting. As a result, at this time cardiac catheterization would not be 
considered medically appropriate and necessary in this enrollee's clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of cardiac catheterization have not been met. Therefore, we decided that the Plan 
does not have to pre-approve catheter placement in coronary artery(s) for coronary angiography, including 
intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with left heart 
catheterization including intraprocedural injection(s) for left ventriculography (93458).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intracept procedure (64628). 
 
You asked the Plan to pre-approve the intracept procedure. You say that the service is medically necessary. The 
Plan denied your request. The Plan says this service is considered experimental. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 the intracept procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found documentation was/is lacking regarding reasonably detailed and/or evidenced 
findings supportive of the spinal vertebral bodies as being the overwhelming primary generators of the 
enrollees chronic persistent pain. Documentation does not support actual formal surgical ablation of pre-
designated basivertebral nerves as being medically necessary and/or reasonable at this time. There is no 
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. 
 
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 intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the intracept procedure (64628).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are appealing this denial. The Plan denied your 
request. The Plan says you do not meet Medicare criteria for admission to an IRF 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you do not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While you may need physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. 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 an IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of a ventilator. 
 
You asked the Plan to pre-approve ventilator. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says a ventilator is not covered for the requested purpose. 
 
The Plan must follow Medicare rules. Medicare rules say that ventilator products used to provide continuous or 
bilevel positive airway pressure (CPAP or BiPAP) therapy, regardless of the underlying medical condition, 
shall not be covered.  
 
We looked at the file and Medicare rules. A ventilator is not covered by Medicare for the requested purpose. 
The Plan says that they would consider approval of a BiPAP device with average volume assured pressure 
support (AVAPS) mode if requested. Please contact the Plan for more information about the enrollees options. 
Based on this information, we decided that Medicare rules for coverage of ventilator have not been met. 
Therefore, we decided that the Plan does not have to pre-approve use of a ventilator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal scaling and root planing services (D4341) 
provided on October 17, 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 
periodontal scaling and root planing services (D4341) provided on October 17, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve the electrical stimulator supplies (A4595), provided on July 1, 
2022. 
 
You asked the Plan to pre-approve the electrical stimulator supplies. You say that the items were medically 
necessary. The Plan denied your request. The Plan says that the member states they have not received the item. 
 
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 Plan did not include any documentation of the phone call to the enrollee 
outside of the summary, and the submitted documentation includes an itemized delivery ticket with the 
carriers tracking number and the proof of delivery confirming it was delivered. The Plan hasnt provided 
enough information about why this documentation is not sufficient. Therefore, we decided that the Plan has to 
pre-approve the electrical stimulator supplies (A4595), provided on July 1, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance and deductible for a crown (D2740) and core 
buildup (D2950) provided by an out-of-network provider on August 10, 2022. 
  You asked the Plan to waive the coinsurance and deductible for the dental services. You say that you did not 
understand the benefit and the difference of getting services from an out-of-network provider. The Plan denied 
your request. The Plan says this cost sharing was charged correctly. Also, you are responsible for any charged 
amount above the Plans cost-sharing amount when your services are received from an out-of-network 
provider. 
 
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% 
coinsurance for out-of-network covered prosthodontic and prosthodontic maintenance services and a $100 
deductible per calendar year for in and out-of-network dental services. The total amount billed for the crown 
was $1,208 and the total amount allowed was $1,014.25 leaving the difference of $193.75 ($1,208 billed - 
$1,014.25 allowed). The total coinsurance amount charged was $502.84 which is less than a 55% coinsurance 
charge of $557.83 ($1,014.25 allowed x 55% coinsurance). The yearly deductible of $100 was also charged. 
The total liability amount for the crown was $796.59 ($193.75 difference + $502.84 coinsurance + $100 
deductible). The total amount billed for the core buildup was $260 and the total amount allowed was $159 
leaving a difference of $101. The total coinsurance amount was $87.45 ($159 allowed amount x 55% 
coinsurance). The total liability amount for the core buildup was $188.45 ($101 difference + $87.45 
coinsurance). The total liability for the dental services was $985.04 ($796.59 crown + $188.45 core buildup). 
 
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. 
 
You have been asked to pay $985.04 for the dental services. This item/service falls within the supplemental 
dental benefits 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 and deductible for a crown (D2740) 
and core buildup (D2950) provided by an out-of-network provider on August 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided from March 9, 
2022, to March 29, 2022. 
 
You asked the Plan to pay for the billed services. You say that compression therapy aids in treatment of post-
operative lymphedema. The Plan denied your request. The Plan says the billed code is not eligible for 
reimbursement. The Plan must follow Medicare rules. Medicare rules say that pneumatic compression devices are only covered 
under certain medical indications.   
 
We looked at the file and Medicare rules. Items that are used for a preventative service or function are excluded 
from coverage under the Medicare DME benefit. Based on this information, we decided that Medicare rules for 
coverage of the billed services have not been met. Therefore, we decided that the Plan does not have to pay for 
the pneumatic compression device provided from March 9, 2022, to March 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the device is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the request for a home mechanical ventilator set in 
AVAPS mode with Auto-EPAP (AE) that could be delivered by BiPAP is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 
 
 
 
 
 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 a home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has severe obesity and 
obesity-hypoventilation syndrome. ABGs are consistent with chronic CO2 retention. The enrollee is currently 
using a home ventilator in a nursing facility. There is no diagnosis of COPD, thoracic restrictive disease, or 
neuromuscular disease. Medicare does not cover a home ventilator when used as BiPAP, or for the treatment of 
OHS. BiPAP during sleep has not been tried and shown to fail as an outpatient. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for ambulance transport provided on September 
14, 2022. 
 
You asked the Plan to waive the cost share for ambulance transport. You say that this should be covered. 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 $400 deductible which applies to Ambulance services.  
 
The item or service you asked the Plan to waive the cost share for falls within the Ambulance services benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $400 
deductible which applies to Ambulance services. This cost sharing is a contractual obligation that had not been 
met at the time ambulance transport was received on September 14, 2022. Therefore, $400 has been applied to 
meet the deductible. 
 Since the $400 deductible was met, you have also been asked to pay 2% coinsurance for ambulance transport. 
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 the 
Plan does not have to waive the cost for ambulance transport provided on September 14, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient hospital service provided on 
November 11, 2021. 
 
You asked the Plan to waive the copayment for outpatient hospital service. You say that you disagree with the 
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 $395 
copayment for outpatient hospital service.  
 
You have been asked to pay a $395 copayment for outpatient hospital service. This item/service falls within the 
outpatient hospital service benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for outpatient 
hospital service provided on November 11, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services provided on October 
17, 2022. 
 
You asked the Plan to waive the copayment for laboratory services. You say that this should be covered as part 
of your annual physical. 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 $35 
copayment for laboratory services provided in an outpatient hospital setting.  
 You have been asked to pay $32.91 for laboratory services. This is less than the standard $35 copayment. This 
item/service falls within the outpatient hospital services benefit category. This means that you have been asked 
to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation 
you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive 
the copayment for laboratory services provided on October 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodic oral evaluation - established patient (D0120). 
 
You asked the Plan to pay for the dental services. You say that the evaluation in June was a different situation; 
therefore, you say this evaluation should 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. Medicare rules. The contract 
says that the Plan covers certain dental services as a supplemental (extra) benefit. This benefit includes the 
requested periodic oral evaluation - established patient (D0120) but is limited to two visits per year. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. You 
previously received covered periodic oral evaluation - established patient (D0120) on April 5, 2022 and limited 
oral evaluation  problem focused (D0140) on June 29, 2022. Although these are two different services, they 
fall within the same category in your Evidence of Coverage and are subject to the same frequency limitations. 
Therefore, these benefits were exhausted as of June 29, 2022. Therefore, we decided that the Plan does not 
have to pay for periodic oral evaluation - established patient (D0120).