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

 
We decided that the Plan does not have to waive the copayment for a duplex scan (93923, 93926) provided on 
January 31, 2022. 
 
You asked the Plan to waive the copayment for the duplex scan. You say that the services should be covered as 
you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied correctly 
based on the services 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 $175 
copayment for Outpatient Diagnostic Tests and Therapeutic Services and Supplies.  
 
 
  You have been asked to pay a $175 copayment for a duplex scan. Duplex scans fall 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 duplex scan (93923, 93926) provided on January 31, 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 are requesting services for the enrollee to stay at 
an acute rehabilitation stay for a full recovery following a left foot amputation and acute osteomyelitis 
infection. The Plan denied your request. The Plan says denied services because the service can be provided 
safely in other settings like a skilled nursing facility, home health, or home outpatient therapy. 
 
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 was admitted to an acute hospital with Osteomyelitis of left foot, s/p 
TMA, and debridement. On IV antibiotics which will continue for several weeks. NWB on LLE. Stable 
medically and comorbid conditions are all stable. PMH: HLD, HTN, Atrial fibrillation, COPD, DM, 
Neuropathy, CLL, h/o TIA, Anemia, Vitamin B12 and D deficiency, BPH, Gout. PMR, Obesity, Anemia, 
Anxiety, and depression. Therapy notes reviewed. Needed mod to max A of 2 for ADLs and mobility on the 
day of referral to IRF. 
 
On review of the available records, the enrollee with medical history as described above, does not meet CMS 
coverage criteria for IRF admission. The enrollee is medically stable and does not need PM&R physician's 
supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations 
of chronic medical conditions. 
 
At the current functional (mod to max A of 2) mobility level, the enrollee does not need intensive therapies, 
(Speech, PT and OT) consisting of at least 3 hours of therapy per day at least 5 days per week with 
multidisciplinary approach in an IRF. The enrollee is unlikely to make a significant functional progress in the 
predicted 7-10 days in an IRF. IRF admission is not medically necessary based on lack of medical complexity, 
and current functional level. The enrollee's rehab needs can be safely provided in a lower intensity and alternate 
setting such as in an SNF. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on December 2, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 office visit 
provided on December 2, 2021 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 a diagnostic eye exam provided on 
November 9, 2021. 
 
You asked the Plan to waive the copayment for a diagnostic eye exam. You say that this was a routine eye 
exam, and you should not have a $45 copayment. 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 $45 
copayment for Medicare-covered benefits, including diagnosis and treatment for diseases and conditions of the 
eye.  
 
The record shows you previously utilized your vision benefit for 2021. You have been asked to pay a $45 
copayment for a diagnostic eye exam. A diagnostic eye exam falls within the Vision 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 a diagnostic eye exam provided on November 9, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a disc tissue allograft. 
 
You asked the Plan to pre-approve a disc tissue allograft. You say that the requested procedure is medically 
necessary for functional improvement and pain management. The Plan denied your request. The Plan says 
review of the current medical literature does not consider the requested service to be standard medical 
treatment for the enrollee's condition. 
 
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 a disc tissue allograft. Our reviewer 
says that a disc tissue allograft is not considered medically reasonable and necessary in this case. Our physician 
reviewer found this an experimental/investigational treatment. 
 
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 disc tissue allograft have not been met.  
 
  
Therefore, we decided that the Plan does not have to pre-approve a disc tissue allograft.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture provided on July 21, 2021. 
 
You asked the Plan to pay for acupuncture. You say that you were seeing no results from the previous provider 
so you switched to a different provider. The Plan denied your request. The Plan says a licensed acupuncturist is 
a non-covered provider type. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, a licensed acupuncturist is a non-covered provider 
type. Therefore, we decided that the Plan does not have to pay for acupuncture provided on July 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visits provided on January 
27, 2022, and February 24, 2022. 
 
You asked the Plan to waive the copayment for the specialist office visits. You say that the services should be 
covered as you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied 
correctly based on the services 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 $35 
copayment for Physician/Practitioner services, including doctors office visits.  
 
 
  You have been asked to pay a $70 copayment for two specialist office visits. Specialist office visits fall within 
the Physician/Practitioner services, including doctors office visits 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 specialist office visits provided on January 27, 2022, and February 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture provided on November 19, 2021. 
 
You asked the Plan to pay for acupuncture. You say that acupuncture is a covered service. The Plan denied 
your request. The Plan says a licensed acupuncturist is a non-covered provider type and the provider is not 
supervised by any physician, physician assistant, nurse practitioner or a clinical nurse specialist. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, a licensed acupuncturist is a non-covered provider 
type and the provider is not supervised by any physician, physician assistant, nurse practitioner or a clinical 
nurse specialist. Therefore, we decided that the Plan does not have to pay for acupuncture provided on 
November 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and drug testing provided on March 30, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an office visit and drug testing. You say that this was your pain management and 
should have been paid, and you have to change pain management because they do not take this insurance. The 
Plan denied your request. The Plan says this provider is not a network provider with the Plan, and they have 
also determined that these services are 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 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 office visit and drug testing provided on March 
30, 2022, by an out-of-network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital admission provided from June 24, 
2020, to July 2, 2020. 
 
You asked the Plan to pay for the inpatient hospital admission. You say that the services provided were 
medically necessary and should be covered. The Plan denied your request. The Plan says original Medicare is 
responsible for payment. 
 
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.   The enrollee was 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 the inpatient hospital admission provided from June 24, 2020, 
to July 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740) for tooth #15. 
 
You asked the Plan to pre-approve the crown. You say that the enrollee has a problem due to open contact due 
to a huge filling giving away. You also say that you must provide a crown to close the contact. The Plan denied 
your request. The Plan says the Plan does not cover crowns for cosmetic reasons or for closing gaps. The Plan 
also says that the treatment requested is solely for purpose of closing an open space per the narrative that was 
submitted. 
 
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 Plan does not cover crowns for 
closing gaps. Therefore, we decided that the Plan does not have to pre-approve a crown (D2740) for tooth #15.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a pelvic ultrasound provided on February 
10, 2022. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you were told your cancer 
screenings would be fully covered. 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 $110 
copayment for out-of-network basic radiological services, including ultrasounds at an outpatient hospital.  
 
The records show this claim was approved, and you have a cost sharing amount. You have been asked to pay a 
$110 copayment for an ultrasound. An ultrasound 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 pelvic 
ultrasound provided on February 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the TMJ treatment you received on December 21, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a covered 
benefit. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for the TMJ treatment you received 
on December 21, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital discharge services provided on January 8, 2022. 
 
You asked the Plan to pay for hospital discharge services. You say that you are billing for the discharge prior to 
the enrollee going into hospice. The Plan denied your request. The Plan says original Medicare is responsible 
for payment. 
 
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.  
 The enrollee was 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 hospital discharge services provided on January 8, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy provided by a participating provider. 
You asked the Plan to pre-approve physical therapy. You say that additional physical therapy sessions are 
medically necessary. The Plan denied your request. The Plan says additional PT is not needed. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 physical therapy. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the enrollee has had prior therapy and the documentation does not 
reveal that the enrollee's requires the unique skills of a professional therapist to safely and effectively provide 
treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of physical therapy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve physical therapy provided by a participating provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a battery-operated portable oxygen concentrator. 
 
You asked the Plan to pre-approve a battery-operated portable oxygen concentrator. You say that the member 
would prefer this item. The Plan denied your request. The Plan says the member's oxygen needs are being met. 
 
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 the enrollee has a home oxygen concentrator and portable oxygen system. These items 
serve the same purpose as a battery-operated portable oxygen concentrator. Therefore, we decided that the Plan 
does not have to pre-approve a battery-operated portable oxygen concentrator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Virtual visit (Telehealth) on January 12, 
2022. 
 
You asked the Plan to waive the copayment for Telehealth visit. You say that these charges are unjust, that she 
wasted an hour of our time and did not provide service. The Plan denied your request. The Plan says the cost-
sharing amount the enrollee is being charged is 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $5 copay per covered telehealth visit.  
 
The enrollee has been asked to pay a $5 copayment for Telehealth visit. Telehealth visits fall within the 
Physician/Practitioner Services, Including Doctors Office Visits benefit category. The billed amount was 
$150.00. The allowed amount was $58.46. The plan paid $53.43. Per the enrollee benefits, the enrollee is 
responsible for a $5 copayment per Telehealth visit. This means that the enrollee has been asked to pay the 
correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee 
agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for Virtual visit (Telehealth) on 
January 12, 2022.
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 December 14, 2021. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that your 
benefit package states ambulance service is a covered benefit. You also say that you declined being transported 
to the hospital by ambulance. The Plan denied your request. The Plan says the ambulance benefit is a 
transportation benefit. The Plan also says if you are not transported, no covered service has been provided. 
 
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 December 14, 2021. 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 December 14, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional mileage for routine transportation beyond the 
Plan's 75-mile limit. 
 
You asked the Plan to pre-approve additional mileage for routine transportation. You say that you had a good 
experience with this provider in the past and would like to continue to see him. The Plan denied your request. 
The Plan says this trip will exceed the Plan's mileage limit for routine transportation. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation up to 75 miles of driving distance for each one-way trip.  
 We looked at your request, the records in the case file, and the rules. We verified that the requested trip will 
exceed the Plans 75-mile limit. Based on this information, we decided that the Plans rules for coverage of 
routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve 
additional mileage for routine transportation beyond the Plan's 75-mile limit.