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

 
We decided that the Plan has to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee has had extensive physical, 
occupational, and speech therapy along with intensive nursing care, but still has significant cognitive deficits 
and would be unsafe to be at home alone. The Plan denied your request. The Plan says that based on Medicare 
guidelines, the IRF services requested 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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the clinical documentation shows that the enrollee has complex functional impairments and active 
medical issues. The enrollee would be expected to require continued inpatient hospitalization with an 
interdisciplinary approach to rehabilitation care and close medical monitoring. The enrollee is documented as 
ambulating 150 feet but still requires physical assistance and cognitive cueing. Evaluating physical, 
occupational and speech therapists all recommend intensive therapy in an IRF setting thus IRF criteria met. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute IRF admission and services.  
 
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 the MRI provided on August 7, 2021. 
 
You asked the Plan to pay for the MRI. You say that enrollee was discharged from hospice on August 2, 2021, 
and did not go back into hospice until November 15, 2021. The Plan denied your request. The Plan says 
Medicare is responsible for payment. 
 
 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on August 2, 2021. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the MRI provided on 
August 7, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on May 15, 2022. 
 
You asked the Plan to pay for ambulance services. You say that the claim was previously paid, however, the 
payment was taken back. You also say you are following Medicare guidelines. The Plan denied your request. 
The Plan says Original Medicare is responsible for this 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 ambulance services provided on May 15, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repair of the shoulder rotator cuff. 
 
 
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your 
request. The Plan says the type of surgery requested is not supported by the research and is not covered. 
 
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 surgery. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there is a lack of large volume, long-term peer-reviewed outcome studies to support the use of 
superior capsular release as an effective treatment. The magnetic resonance imaging (MRI) did not corroborate 
a massive irreparable supraspinatus and/or infraspinatus tear. There are limited large-scale, long-term 
references showing the safety and efficacy of the requested surgery in this clinical setting. There was no 
evidence of any extenuating circumstances in this patient's specific case either. Therefore, the requested rotator 
cuff repair (superior capsular reconstruction), in this case, is not medically reasonable or necessary. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve repair of the shoulder rotator cuff.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on September 23, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental 
services on September 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a periodic oral evaluation (D0120), bitewings (D0274), 
and a cleaning (D1110) provided on July 20, 2022. 
 
You asked the Plan to pay more for the dental services. You say that the dentist is an in-network provider. The 
Plan denied your request. The Plan says you are responsible for any charged amount above the Plans cost-
sharing amount when your services are received from an out-of-network provider. Also, during the date of 
service the provider was an out-of-network provider. 
 
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 the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for a periodic oral evaluation (D0120), 
bitewings (D0274), and a cleaning (D1110) provided on July 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for a specialist office visit provided on August 
31, 2022. 
 
You asked the Plan to waive the cost share for a specialist office visit. You say that you disagree with the cost 
share. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $600 deductible which applies to physician/practitioner 
services/specialist's Office. You are being asked to pay $119.25 towards your $600 deductible. 
 
The item or service you asked the Plan to waive the cost share for falls within the physician/practitioner 
services/specialist's Office benefit category. The Plan has followed Medicare rules by clearly disclosing in the 
contract that there is a $600 deductible which applies to physician/practitioner services/specialist's Office. This 
cost sharing is a contractual obligation that had not been met at the time a specialist office visit was received on 
August 31, 2022. Therefore, we decided that the Plan does not have to waive the cost share for a specialist 
office visit provided on August 31, 2022.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pre-approve physical therapy services to be provided by an OON provider. 
 
You asked the Plan to pre-approve therapy services. You say that the therapy services are medically necessary. 
The Plan denied your request. The Plan says that the requested services are available in-network. 
 
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 provide the correct Evidence of Coverage (EOC). Without the 
correct EOC we are unable to determine if the Plan covers the requested services with an OON provider. 
Therefore, we decided that the Plan has to pre-approve physical therapy services to be provided by an OON 
provider.  
 
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: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for magnetic resonance imaging (MRI, code 77049) provided on June 20, 
2022. 
 
You asked the Plan to pay for MRI. You say that medical records support the service rendered. The Plan denied 
your request. The Plan says that this claim is a duplicate that has already been considered for payment. 
 
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 denied payment for this claim on the basis that it is a duplicate claim. 
However, the Plan did not submit any evidence of an original claim that was paid. Therefore, the Plan has not 
shown that this is a duplicate claim and has offered no other rationale or evidence to support a denial. The Plan 
has not shown that its decision to deny payment is correct or justified. Therefore, we decided that the Plan has 
to pay for magnetic resonance imaging (MRI, code 77049) provided on June 20, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an inpatient consultation visit provided on July 7, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for an inpatient consultation visit. You say that it was the responsibility of the 
facility to obtain authorization for the services. The Plan denied your request. The Plan says there is no 
authorization on file for the services provided. 
 
 
 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 consultation visit provided on July 7, 
2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the implant venous access device services 
performed by your primary care physician on March 23, 2022, April 6, 2022, and May 4, 2022. 
 
You asked the Plan to waive the copayment for the implant venous access device services. You say that this 
service 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 $15 
copayment for each Medicare-covered primary care doctor visit (including telehealth services and urgently 
needed services) furnished in a physicians office, certified ambulatory surgical center, hospital outpatient 
department, or any other location. 
 
 
 
 You have been asked to pay a $45 copayment for three implant venous access device services ($15 x 3 = $45).  
These items/services 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 the implant venous access device services 
performed by your primary care physician on March 23, 2022, April 6, 2022, and May 4, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the take-home supply of methadone (G2078) provided on September 
12, 2022. 
 
You asked the Plan to pay for the outpatient service. You say that the facility is enrolled in the Medicare 
program to provider opioid treatment program services. You also say this should be covered. The Plan denied 
your request. The Plan says that the provider in this case is not a Substance Abuse and Mental Health Services 
Administration (SAMHSA) certified provider. 
 
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 file does not support the Plan's denial that the provider is not 
certified. Therefore, we decided that the Plan has to pay for the take-home supply of methadone (G2078) 
provided on September 12, 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided on June 
27, 2022, to June 29, 2022. 
 
You asked the Plan to waive the copayment for an emergency room visit. 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 $100 
copayment for emergency care.  
 
You have been asked to pay a $100 copayment for an emergency room visit. This item/service falls within the 
emergency 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 an emergency room visit 
provided on June 27, 2022, to June 29, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay from August 7, 
2022, to August 10, 2022. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you do not feel you 
should have to pay this copayment because you were admitted to the hospital because your doctor did not take 
your concerns seriously. 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 $325 
copayment for inpatient hospital care.  
 
 You have been asked to pay $975 ($325/day x 3 days =$975) for an inpatient hospital stay. This item/service 
falls within the inpatient hospital care benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
an inpatient hospital stay from August 7, 2022, to August 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99212) and destruction of premalignant 
lesions (17000) provided on September 8, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the physician services. You say that the enrollee was referred by their primary 
care physician (PCP). 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. 
 
You are not a network provider with the Plan. There is no evidence that the enrollee was referred by a plan provider for the services. 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 office visit (99212) and destruction of premalignant lesions (17000) provided on September 8, 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 use of a ventilator. 
 
You asked the Plan to pre-approve ventilator. You say that the enrollee is in a life-threatening situation and 
needs this ventilator. The Plan denied your request. The Plan says a ventilator is not covered by Medicare for 
this 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 this purpose. The Plan 
says that they would consider coverage of a BiPAP device with average volume-assured pressure support 
(AVAPS) mode if requested. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a telehealth visit provided on October 6, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for a telehealth visit. You say that it was not possible to obtain authorization prior to 
the services that were provided. The Plan denied your request. The Plan says there is no authorization on file 
for the services rendered. 
 
 
 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 a telehealth visit provided on October 6, 2022, by 
an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on August 1, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the services are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental 
services on August 1, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care  provided on September 4, 2022. 
 
You asked the Plan to pay for subsequent hospital care  subsequent hospital care. You say that the enrollee was 
not enrolled on hospice on the date of service and would like the payment to be reprocessed. 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. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on September 2, 2022. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for subsequent hospital 
care  provided on September 4, 2022.