Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the facility fee for the specialist office visit provided on 
October 3, 2022. 
 
You asked the Plan to waive the facility fee for the specialist office visit. You say that you have already paid 
the copayment for a specialist office visit. 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 $45 
copayment for each specialist office visit. The Plan contract also says that you may be charged the facility fee 
in addition to your office visit cost share, and that your out-of-pocket cost for the facility fee is the same cost as 
your specialist copayment. 
 
 You have been asked to pay a $45 copayment for a facility fee for a specialist office visit. This item/service 
falls within the specialist office visit 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 facility fee for 
the specialist visit provided on October 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical placement of implant body: endosteal implant 
tooth #'s 3 and 5 (D6010). 
 
You asked the Plan to pre-approve the surgical placement of implant body: endosteal implant tooth #'s 3 and 5. 
You say that you are in pain and cannot wait till next year to receive care. The Plan denied your request. The 
Plan says this service is not covered under the benefit package. 
 
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 pre-approve 
surgical placement of implant body: endosteal implant tooth #'s 3 and 5 (D6010).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the provision of INR test materials 
provided from January 26, 2022, to July 31, 2022. 
 
You asked the Plan to waive the copayments for the provision of INR test materials. You say that the tests were 
done in your home, and no doctor visits were made. The Plan denied your request. The Plan says this cost 
sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a $35 
copayment for physician/practitioner services, including doctor's office visits (specialist).  
 
 
  Please note that these tests require analysis and interpretation by a specialist. Therefore, you have been asked to 
pay a $35 copayment for each provision of INR test materials. There were a total of 7 tests for a total of $245. 
This item/service falls within the physician/practitioner services, including doctor's office visits (specialist) 
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 copayments for the provision of INR test 
materials provided from January 26, 2022, to July 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on August 31, 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 your benefit for the requested item or service has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service August 31, 2022. 
Therefore, we decided that the Plan does not have to pay for the dental services on August 31, 2022.
Appeal type: Outpatient Therapies
Decision: Partially Favorable

 
We decided that the Plan has to reduce the copayments for the PT services. We also decided that the Plan does 
not have to reduce the copayments for the ECG recordings.  
 You asked the Plan to reduce the copayments for physical therapy (PT) services and electrocardiographic 
(ECG) recordings provided from July 13, 2022, to August 3, 2022.. You say that your copayments are in excess 
of Plan document requirements. The Plan says that this cost sharing was charged correctly. 
 
We decided that the Plan has to reduce the copayments for the PT services.  
 
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 Plan says that you must pay a 50% coinsurance for the PT 
services. Based on the Plan contract, however, you cannot be asked to pay more than a $30 copayment for the 
PT services. Therefore, we decided that the Plan has to reduce the copayments for the PT services to $30.  
 
We also decided that the Plan does not have to reduce the copayments for the ECG recordings. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as 
copayments, deductibles, and coinsurance). You have been asked to pay $57.89 for each of the ECG 
recordings, which is less than the $200 copayment per the EOC. This item/service falls within the outpatient 
diagnostic procedures and tests in a hospital setting benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to reduce the copayments for 
the ECG recordings. 
 
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 initial hospital care (99221) provided on June 30, 2022. 
 
You asked the Plan to pay for the hospital care. You say that the enrollee was not in an active hospice episode 
on this date. The Plan denied your request. The Plan says the enrollees claim would be covered under Original 
Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of 
the month in which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage before rendering services and to know proper billing procedures for a Medicare Advantage 
member on hospice. 
 
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 June 29, 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 the initial hospital care 
(99221) provided on June 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two dimensional oral x-rays (D0350), diagnostic casts 
(D0470), oral hygiene instructions (D1330) and an occlusion analysis (D9950). 
 
You asked the Plan to pre-approve two dimensional oral x-rays (D0350), diagnostic casts (D0470), oral 
hygiene instructions (D1330) and an occlusion analysis (D9950). You say that you want the Plan to consider 
the submitted records for payment of services provided. The Plan denied your request. The Plan says these 
services are not covered under your benefit package. 
 
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 pre-approve two 
dimensional oral x-rays (D0350), diagnostic casts (D0470), oral hygiene instructions (D1330) and an occlusion 
analysis (D9950).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for the radiation therapy services provided on 
May 28, 2021, to May 31, 2021. 
 
You asked the Plan to reduce the coinsurance for the radiation therapy services. You say that you did not know 
the provider was out-of-network. 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 20% 
coinsurance for outpatient diagnostic tests and therapeutic services and supplies (therapeutic radiology). 
 
You have been asked to pay 20% coinsurance for the radiation therapy services. This item/service falls within 
the outpatient diagnostic tests and therapeutic services and supplies (therapeutic radiology) 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. Please note that while the 
provider was listed as out-of-network, the claim was processed with the in-network cost share of 20%. Therefore, we decided that the Plan does not have to reduce the coinsurance for the radiation therapy services 
provided on May 28, 2021, to May 31, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung 
cancer screening (71271). 
 
You asked the Plan to pre-approve the requested LDCT scan. You say that you are requesting a reconsideration 
of the Plan's denial. The Plan denied your request. The Plan says you do not meet criteria for coverage of the 
requested service. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung 
cancer screening for enrollees who meet all the criteria described in the Medicare rules section of this letter.  
 
 We reviewed the file and the Medicare rules. We find that you do not meet criteria for coverage of the 
requested service. Specifically, the record indicates that you do not have a tobacco smoking history of at least 
30 pack-years. Therefore, we decided that the Plan does not have to pre-approve a low dose computed 
tomography (LDCT) scan for lung cancer screening (71271).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the parenteral nutrition (B4189, B4220, B4224), provided on 
March 5, 2022. 
 
You asked the Plan to pay for the parenteral nutrition. You say that the items are medically necessary. The Plan 
denied your request. The Plan says there is no proof of delivery for these items. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. There was no 
packing slip or delivery slip submitted with this case. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay 
for the parenteral nutrition (B4189, B4220, B4224), provided on March 5, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided on May 24, 2022, June 22, 
2022, June 28, 2022, July 5, 2022, and August 16, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the home health services. You say that you were unaware that an authorization 
was needed and would like the claims considered for payment. The Plan denied your request. The Plan says the 
rendering provider is an OON provider and there was no approved authorization. Also, the services rendered 
were not urgent or emergent. 
 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 the home health services provided on May 24, 
2022, June 22, 2022, June 28, 2022, July 5, 2022, and August 16, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on August 05, 2022. 
 
You asked the Plan to pay for the office visit. You say that the records provided support medical necessity. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the office visit provided 
on August 05, 2022.
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 are an amputee and received a prosthetic foot 
but was not taught how to use it and you're afraid you won't be able to regain your maximum function. The 
Plan denied your request. The Plan says your records show that it is not reasonable to expect that you will be 
able to safely participate in, or fully benefit from, the intensity of services of an IRF. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care may be provided safely in a 
different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
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. The Plan denied your request. The Plan says the enrollee's records 
do not show the need for complex rehabilitation requiring frequent evaluation by a rehabilitation doctor. The 
services needed may safely be provided in other settings, 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 there is not a reasonable expectation that the 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a TENS device and related supplies to be provided by 
an OON provider. 
 
You asked the Plan to pre-approve a TENS device and related supplies. You say that you are appealing with 
supporting records. The Plan denied your request. The Plan says this service is not covered out-of-network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a TENS device and related supplies to be provided by an OON provider.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for ambulance service, advanced life support, non-emergency transport 
provided on January 31, 2022. 
 
You asked the Plan to pay for the ambulance service, advanced life support, non-emergency transport. You say 
that the service was a medical  necessity and feel it should be paid. The Plan denied your request. The Plan says 
the details we received from your doctor dont meet Medicare guidelines that show a medical reason that the 
enrollee needed non-emergency ambulance transportation and ground mileage. 
 
Medicare pays for ambulance services only when an emergency exists or when other means of transport would 
endanger the patients health. The Plan follows the same rules.  
 
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 pay for the ambulance service, advanced life 
support, non-emergency transport. Our reviewer says that the service was medically necessary. Our physician 
reviewer found the record indicates the enrollee was transported from an emergency room facility to a hospital. 
The enrollee was evaluated for a femur fracture and possible pulmonary embolism and required a higher level 
of care. The enrollee was receiving a heparin drip. The record is sufficient to indicate that the enrollee's clinical 
condition is such that other methods of transport, such as stretcher, are contraindicated and that the expertise, 
services and lifesaving and life sustaining equipment that only a fully equipped ambulance can provide was 
required. 
 
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 ambulance service, advanced life support, non-emergency transport have 
been met. Therefore, we decided that the Plan has to pay for ambulance service, advanced life support, non-
emergency transport provided on January 31, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on September 14, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
September 14, 2022.