Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve periodontal scaling and root planing (D4341) in 4 quadrants. 
 
You asked the Plan to pre-approve the dental services. You say that the enrollee needs these dental procedures 
to manage and maintain their periodontal disease. The Plan denied your request. The Plan says that the x-rays 
taken did not show the enrollee had gum disease and bone loss; therefore, the denial of authorization for the 
dental services is denied. 
 
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 the dental 
services when the services are medically necessary and reasonable. 
 
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 dental services. Our reviewer says 
that the documentation provided meets the criteria for coverage for periodontal scaling and root planing 
(D4341) in 4 quadrants. Our physician reviewer found that review of the documentation indicates the presence 
of 4-5mm periodontal pockets in all quadrants, the presence of moderate to heavy calculus and bleeding. 
Periodontal scaling and root planing is medically reasonable and necessary to treat the patient's periodontal 
disease. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental services have been met. Therefore, we decided that the Plan has to 
pre-approve periodontal scaling and root planing (D4341) in 4 quadrants.  
 
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: 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 you need IRF care. The Plan denied your request. 
The Plan says based on Medicare guidelines, the requested IRF services do not meet the requirements for 
approval. 
 
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 you are functioning at a level care often managed with home-based rehabilitation. You do not require intensive rehabilitation and do not require frequent physiatry oversight. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on May 13, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the evaluation and management service. You say that the enrollee is an 
established patient. You also say that you were not aware that a referral was needed. The Plan denied your 
request. The Plan says prior authorization was not 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 provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 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 the office visit provided on May 13, 2022, by an out-of-network 
(OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve resting transthoracic echocardiography and carotid 
vertebrobasila. 
 
You asked the Plan to pre-approve resting transthoracic echocardiography and carotid vertebrobasila. You say 
that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been 
established. Therefore, coverage criteria have not been met. 
 
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 resting transthoracic echocardiography 
and carotid vertebrobasila. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found clinical guidelines do not support carrying 
out a transthoracic echocardiogram (TTE) to assess for the presence of heart disease in such an enrollee. In 
summary, there is no supportive evidence for the medical necessity of a TTE in this 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 resting transthoracic echocardiography and carotid vertebrobasila have not been met. Therefore, we decided that the Plan does not have to pre-approve resting transthoracic echocardiography 
and carotid vertebrobasila.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician or allowed practitioner certification for 
Medicare-covered home health services under a home health plan of care (G0180) provided on May 13, 2022 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the physician or allowed practitioner certification for Medicare-covered home 
health services. The Plan denied your request. The Plan says the services were not rendered by a network 
provider, nor were they referred by a network provider or rendered in a participating facility. The Plan also 
says that these services were not urgent or emergent, nor were they approved in advance. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan 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 the physician or allowed practitioner certification 
for Medicare-covered home health services under a home health plan of care (G0180) provided on May 13, 
2022 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87634 billed for date of service August 15, 
2021. 
 You asked the Plan to pay for procedure code 87634. You say that you would like this claim reprocessed based 
on the medical records. The Plan denied your request. The Plan says payment for code 87634 is bundled into 
payment for code 87631. 
 
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 87634 
is a column II code to column I code 87631. 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 87634 billed for date of service August 15, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for surgery provided on July 20, 2022. 
 
You asked the Plan to waive the copayment for surgery. You say that you were told you would only be charged 
$270 so thats how much you want to pay. 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 $370 
copayment for Surgery in an outpatient hospital. 
 
You have been asked to pay a $370 copayment for surgery. This item/service falls within the Surgery in an 
outpatient hospital 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 surgery provided on 
July 20, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need rehabilitation at least for a week to help 
regain your strength. The Plan denied your request. The Plan says the Medicare guidelines were not met, and 
the enrollee can receive the services they need in a skilled nursing facility. 
 
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 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 surgical management of an abdominal tumor. 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 IRF admission and services.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a computed tomography (CT) scan of the chest with contrast 
(71260). 
 
You asked the Plan to pre-approve a CT scan of the chest with contrast. You say that the service is medically 
necessary. The Plan denied your request. The Plan says that the service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
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 CT scan of the chest with contrast. 
Our reviewer says that the service is reasonable and medically necessary. Our physician reviewer found you are 
a past smoker and had a chest CT for lung cancer screening on August 26, 2022. This showed a new 6 mm 
nodule in the trachea, with a laryngeal abnormality, raising concern for upper airway malignancy with spread 
to the trachea. Lung imaging reporting and data system classification was 4a, suspicious. The 3-month follow-
up chest CT is indicated, along with the neck CT that has been approved.  
 
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 CT scan of the chest with contrast have been met. Therefore, we decided that 
the Plan has to pre-approve a computed tomography (CT) scan of the chest with contrast (71260).  
 
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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician discharge services provided on February 14, 2022. 
 
You asked the Plan to pay for the physician services. The Plan denied your request. The Plan says they are not 
responsible for payment because you were enrolled in hospice at the time services were provided. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
You were under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we 
decided that the Plan does not have to pay for physician discharge services provided on February 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical pathology procedures provided on May 31, 2022 by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for surgical pathology procedures. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the enrollee must receive care from a network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The 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 surgical pathology procedures provided on May 
31, 2022 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for hospital observation provided on December 
03, 2021. 
 
You asked the Plan to waive the copayment for hospital observation. You say that this was just an emergency 
room visit so it shouldnt cost this much. 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 
$274.12 copayment for Outpatient hospital observation. 
 
You have been asked to pay a $274.12 copayment for hospital observation. This item/service falls within the 
Outpatient hospital observation 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 been asked to pay $274.12 which is less than the standard $300 
copayment for the hospital stay. Therefore, we decided that the Plan does not have to waive the copayment for 
hospital observation provided on December 03, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on June 25, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you denied 
ambulance transportation and initialed a paper saying you did not want to be transported. You also say that you 
cannot afford to pay this bill. The Plan denied your request. The Plan says since you were not transported, the 
services are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on June 25, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport (A0998) provided on June 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physician/practitioner service provided on 
June 16, 2022. 
 
You asked the Plan to waive the copayment for primary care physician's office visit. You say that you weren't 
expecting a 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 $10 
copayment for Provider and Professional Services.  
 
You have been asked to pay $10 copayment for primary care physician's office visit. This item/service falls 
within the Provider and Professional 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 physician/practitioner service provided on June 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an inpatient hospital stay provided from March 1, 2022, to 
March 3, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an inpatient hospital stay. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the enrollee must receive care from a network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The 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 an inpatient hospital stay provided from March 1, 
2022, to March 3, 2022 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a memory foam cervical pillow 
 
You asked the Plan to pre-approve the pillow. The Plan denied your request. The Plan says you were already 
provided one pillow. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have memory foam cervical pillow. This pillow serves the same purpose as the 
requested pillow. Therefore, we decided that the Plan does not have to pre-approve a memory foam cervical 
pillow
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for CT scan provided on June 08, 2022. 
 
You asked the Plan to waive the copayment for CT scan. 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $350 
copayment for Diagnostic radiology services. 
 
You have been asked to pay a $350 copayment for CT scan. This item/service falls within the Diagnostic 
radiology 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 CT scan provided 
on June 08, 2022.