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

 
We decided that the Plan does not have to waive the copayment for a diagnostic mammogram provided on 
December 1, 2021. 
 
You asked the Plan to waive the copayment for the mammogram. You say that you were informed that this test 
was also preventive and you should not be charged. 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 no 
coinsurance, copayment, or deductible for screening mammograms. Only one screening is covered every 12 
months. 
 
Your contract with the Plan also clearly says that you must pay a $75 copayment for diagnostic procedures and 
tests, including ultrasounds. 
 
The file shows that your covered screening mammogram was received on October 25, 2021. Since this test was 
done within 12 months, the diagnostic test copayment applies. Therefore, you have been asked to pay a $75 
copayment for the mammogram. The mammogram falls within the Outpatient Diagnostic Tests and 
Therapeutic Services and Supplies 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 
diagnostic mammogram provided on December 1, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the acute inpatient hospital care provided from February 
20, 2022, through February 21, 2022. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that these services were medically 
necessary. The Plan denied your request. The Plan says that records show the enrollee does not have any signs 
of severe, persistent low oxygen, rapid breathing, or need for mechanical ventilation. 
 
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 pre-approve acute inpatient hospital care. 
 Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this 
case. The enrollee has a history of chronic hypoxic respiratory failure due to heart failure. She is maintained on 
1-2 liters of oxygen at home. She presented to the emergency department (ED) with a 1 week history of cough 
and increased oxygen requirements. Her vital signs were stable. A computed tomography of the chest did not 
show pulmonary embolism and showed evidence of viral pneumonia. There was no evidence of heart failure. 
She was put intravenous antibiotics and intravenous fluids. Testing was negative for COVID, viruses, and 
bacteria in the blood. By the next day, her symptoms had resolved, her oxygen needs were back to baseline, 
and she was discharged home with outpatient follow-up. The record did not show that at the time of inpatient 
admission the admitting physician reasonably expected that the patient's necessary hospital care (including 
earlier ED and/or observation care) would span two midnights. Our physician reviewer found that the enrollee's 
condition does not meet criteria for acute inpatient hospital 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 acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the acute inpatient hospital care provided from February 20, 2022, through 
February 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the removal of a tunneled central venous 
catheter provided on December 13, 2021. 
 
You asked the Plan to waive the coinsurance for a catheter removal. 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 20% 
coinsurance per visit for outpatient surgery.  
 
 You have been asked to pay $108.19, which is 20% of the allowed amount for a catheter removal ($540.97 
allowed amount x 20% coinsurance = $108.19). A catheter removal falls within the Outpatient Surgery, 
Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 the removal of a tunneled central venous 
catheter provided on December 13, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan of the 
abdomen and pelvis provided on December 8, 2021. 
 
You asked the Plan to waive the copayment for a CT scan. 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 $275 
copayment for diagnostic imaging services, including CT scans.  You have been asked to pay the allowed amount of $229.85, which is less than the $275 copayment for a CT 
scan. A CT scan falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies 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 computed tomography (CT) scan of the 
abdomen and pelvis provided on December 8, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation provided on 
November 16, 2021. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that you would like 
assistance with the copayment. The Plan denied your request. The Plan says the proper copayment was applied 
for this service. 
 
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 $225 
copayment for In-Network each Medicare-covered trip.  
 
  You have been asked to pay a $225 copayment for the ambulance transportation. The ambulance transportation 
falls within 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 November 16, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on October 12, 2020. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the codes are 
not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the testing services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for the lab services provided on October 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99203) rendered by the out-of-network 
(OON) provider on November 12, 2021. 
 
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 the service was rendered by an out of network 
provider, without prior authorization. 
 
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 office visit (99203) rendered by the out-of-network (OON) provider on  
November 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit (99213) provided on  
July 14, 2021. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
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 $45 
copayment for services obtained from a specialist.  
 
You have been asked to pay a $45 copayment for the specialist office visit provided. 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 office visit (99213) provided on July 14, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), bitewing x-rays 
(D0274), and prophylaxis (D1110) provided on November 22, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the periodic oral evaluation, bitewing x-rays, and prophylaxis. You say that you 
did not realize the dentist that you have been seeing for 20 years was not in the Plan's network. You also say 
that you are on a fixed income and cannot afford to pay for these services. The Plan denied your request. The 
Plan says services performed by an OON provider are not covered because your healthcare plan does not have 
OON benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, you are responsible for 100% of the 
cost for dental services rendered by an OON provider. Therefore, we decided that the Plan does not have to pay 
for the periodic oral evaluation (D0120), bitewing x-rays (D0274), and prophylaxis (D1110) provided on 
November 22, 2021 by an out-of-network (OON) provider.
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 this is medically necessary. The Plan denied your 
request. The Plan says this request 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 complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for peripheral vascular disease and had a below the knee amputation. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. 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 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. 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. 
 
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: Favorable

 
We decided that the Plan has to pre-approve a maxillary partial denture - resin base (including, 
retentive/clasping materials, rests, and teeth) (D5211) and mandibular partial denture - resin base (including, 
retentive/clasping materials, rests, and teeth) (D5212). 
 
You asked the Plan to pre-approve an upper and lower partial denture. You say that you cannot afford the full 
cost of the dentures. The Plan denied your request. The Plan says that these services are not covered under your 
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 Plan covers an upper and 
lower partial denture once every 84 months. 
 
We looked at the file and Medicare rules. The Plans 2022 Evidence of Coverage shows that partial dentures 
are a covered service under your dental benefits. The Plan has not provided any documentation showing that 
these dentures are excluded from coverage or that you have exceeded the frequency limit for this service. 
Based on this information, we decided that the Plan's rules for coverage of an upper and lower partial denture 
have been met. Therefore, we decided that the Plan has to pre-approve a maxillary partial denture - resin base 
(including, retentive/clasping materials, rests, and teeth) (D5211) and mandibular partial denture - resin base 
(including, retentive/clasping materials, rests, and teeth) (D5212).  
 
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 an additional amount for the surgical extractions (D7210 x 4), 
simple extractions (D7140 x 2), and excision of benign tumor (D7340) provided from October 7, 2021, to 
November 11, 2021. 
 
You asked the Plan to pay an additional amount for the dental services. You say that this bill was a hardship for 
the enrollee. You say that the dentist advised the enrollee that the services were necessary. You also say that 
you were under the impression that the services were covered. The Plan denied your request. The Plan says the 
deductible and coinsurance were applied correctly. 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage and extractions are listed as covered, 
there is a $50 deductible that must be met before payment can be applied. The record shows that the deductible 
was satisfied with 1 surgical extraction. The record shows there is a 20% coinsurance that applies to extractions 
performed by an in network provider. This is a contractual obligation you agreed to when you enrolled in the 
Plan's dental coverage. Additionally, excision of benign tumor is not among those covered under this benefit. 
Therefore, we decided that the Plan does not have to pay an additional amount for the surgical extractions 
(D7210 x 4), simple extractions (D7140 x 2), and excision of benign tumor (D7340) provided from October 7, 
2021, to November 11, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found you ambulated 150 feet and 100 feet with dual 
tasking. You were functioning below your baseline due to poor balance, insight/safety awareness, word-finding 
difficulties, and cognition. It is not medically reasonable and necessary to provide skilled therapy services on a 
daily basis, on an inpatient basis, in a skilled nursing facility 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation provided on 
October 15, 2021. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that the hospital chose 
to transport you to another hospital so you should not be held liable. The Plan denied your request. The Plan 
says the proper copayment was applied for the service rendered. 
 
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 $265 
copayment for each covered, one-way ambulance trip by ground or water.  
 
  You have been asked to pay a $265 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 October 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established 
patient (D0150) provided November 4, 2021. 
 
You asked the Plan to pay for the comprehensive oral exam. You say that this service should be covered. The 
Plan denied your request. The Plan says you have exceeded the frequency limit for this service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the 
comprehensive oral exam once every three years.  
 
We looked at the file and Medicare rules. The Plan provided documentation showing that a comprehensive 
exam was previously covered on September 18, 2021. Based on this information, we decided that the Plan's 
frequency limit for coverage of the comprehensive oral exam has been exceeded. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established patient (D0150) provided November 4, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient therapies provided from 
October 1, 2021, to October 14, 2021. 
 
You asked the Plan to waive the copayment for the outpatient therapies. You say that you should not have to 
pay more than $40 per day. The Plan denied your request. The Plan says the copayments applied are 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 $40 
copay per day, per therapy received for Outpatient rehabilitation services.  
 
 
 You have been asked to pay $560 for the outpatient therapies ($40 per therapy x 14 therapies received). The 
outpatient therapies fall within the Outpatient rehabilitation 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 outpatient therapies provided from October 1, 2021, to October 
14, 2021.