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

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from December 31, 2022, 
forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from December 31, 2022, forward. You say that 
the services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue 
are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 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 inpatient psychiatric care from 
December 31, 2022, forward. Our reviewer says that the services are not medically necessary. Our physician 
reviewer found based upon review the records provided, this enrollee does not meet the criteria for treatment in 
an acute inpatient mental health treatment beyond the date in question of December 31, 2022, forward and 
could have been treated in a lesser restrictive setting as the enrollee was not showing any suicidal or homicidal 
ideation, auditory or visual hallucinations, delusions and was not showing any behaviors or aggression being 
cooperative and compliant while not showing any acute threats to safety as the enrollee awaited placement. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care from December 31, 2022, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from December 31, 
2022, forward.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral radiographic images (D0230), cone beam 
computerized tomography (D0364), sealant repair (D0460), core buildup (D2950), root canals (D3320 and 
D3330), treatment of root canal (D3331), gingivectomy (D4211), and a consultation (D9310) for tooth #29 and 
#31 provided on July 18, 2022. 
 
You asked the Plan to pay for the dental services. You say that you should not owe any extra money for the 
dental services that were provided. The Plan denied your request. The Plan says your annual dental benefit for 
the year 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 annual dental benefit for the year was exhausted on date of service July 18, 2022. On April 5, 2022, 
the Plan paid $181 for the dental services. On July 14, 2022, the Plan paid $70 for the dental services. On July 
18, 2022, the Plan paid $1,249 for the dental services. For the year of 2022, the Plan paid a total of $1,500 
($181 paid + $70 paid + $1,249 paid) for dental services. Therefore, we decided that the Plan does not have to 
pay for intraoral radiographic images (D0230), cone beam computerized tomography (D0364), sealant repair 
(D0460), core buildup (D2950), root canals (D3320 and D3330), treatment of root canal (D3331), 
gingivectomy (D4211), and a consultation (D9310) for tooth #29 and #31 provided on July 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on September 14, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that the records attached support the services provided. 
The Plan denied your request. The Plan says there is no prior 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 office visit provided on September 14, 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 (99212) provided on September 15, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit by the 
Plan or by Medicare. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit (99212) provided on September 15, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for CT scan and outpatient services on 
February 28, 2022. 
 
You asked the Plan to waive the copayments for CT scan and outpatient services. You say that you want to 
appeal the amount being charged. 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 $150 
copayment for CT, MRI, MRA, and SPECT scans. Covered services include but are not limited to advanced 
radiology services (CT, MRI, MRA, SPECT, PET). You must pay a $225 copayment for outpatient observation 
services. Observation services are hospital outpatient services given to determine if you need to be admitted as 
an inpatient or can be discharged. $150 + $225 = $375. Therefore, results in the total cost sharing amount of 
$375.  You have been asked to pay a $150 copayment for CT scan and a $225 copayment for outpatient services. This 
item/service falls within the Outpatient diagnostic tests and therapeutic service 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 copayments for CT scan and outpatient services on February 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the remote lab testing services provided 
on May 5, 2021. 
 
You asked the Plan to waive the cost sharing for remote lab testing. You say that you were not notified that 
your provider was going 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 50% of 
the Medicare-allowed amount in all settings out-of-network for diagnostic procedures and tests.  
 
You have been asked to pay $27.94 for remote lab testing ($55.87 x .50). This item/service falls within the 
diagnostic procedures and tests 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 cost sharing for 
the remote lab testing services provided on May 5, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the best thing for the enrollee would be 
to be treated under the oversight of a medical doctor coupled with acute care level clinical interventions and 
interdisciplinary treatment team driven rehabilitation, cardiology, and infectious disease intervention. The Plan 
denied your request. The Plan says the enrollee does not require complex medical management such as high-
risk medicine adjustments that can only be given in a hospital setting. The required skilled rehabilitation, 
wound care and skilled nursing services can be provided appropriately at a lower level of care such as a skilled 
nursing facility (SNF) 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to be improving and more stable and should only require short-
term additional acute care hospital services that can safely be provided at the current facility until more 
appropriate for a lower level of care. The enrollee does not require services at the LTACH that are not already 
available at the current facility.   
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit provided on September 26, 
2022. 
 
You asked the Plan to waive the copayment for the office visit. You say that you were informed that there was 
no copayment due. 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 doctors office visits (specialist). 
 
You have been asked to pay a $35 copayment for the office visit. This item/service falls within the 
physician/practitioner services, including doctors 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 copayment for the office visit provided on September 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the remote physiologic monitoring provided on August 31, 
2022. 
 
You asked the Plan to pay for the remote physiologic monitoring. You say that the assisted living facility is 
responsible for obtaining authorization. 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 remote physiologic 
monitoring provided on August 31, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a cervical spine x-ray provided on 
September 7, 2022. 
 
You asked the Plan to waive the copayment for a cervical spine x-ray provided on September 7, 2022. You say 
that you say you are being billed $42.05. 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 x-rays at an in-network specialist's office.  
 
 
 
 
 
  
You have been asked to pay $42.05 for a cervical spine x-ray. This amount is less than the standard copayment. 
This item/service falls within the cervical spine x-rays 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 cervical spine x-ray provided on September 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dentures (D5751) provided on November 19, 2021 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the charges. The Plan denied your request. The Plan says your $1,000 dental benefit maximum 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 6/25/2021. Therefore, we 
decided that the Plan does not have to pay for dentures (D5751) provided on November 19, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided from May 28, 2022 to June 6, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your $1,000 dental benefit maximum for the 
requested items or services 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 June 6, 2022. Therefore, 
we decided that the Plan does not have to pay for dental services provided from May 28, 2022 to June 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visit provided on June 02, 2022. 
 
You asked the Plan to waive the copayment for office visit. You say that you do not think you should have a 
copayment, your visit was a wellness 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 $30 
copayment for Physician/Practitioner services, including doctors office visits. 
 
You have been asked to pay a $30 copayment for office visit. This item/service falls 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 office visit provided on June 02, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve routine transportation services. 
 
You asked the Plan to pre-approve the routine transportation services. You say that you have an appointment 
scheduled with pain and spine consultants and that the requested transportation services are needed. The Plan 
denied your request. The Plan says the services being requested do not meet the criteria for coverage of 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 Plan's coverage rules apply in this 
case. The Plan covers routine transportation when each one-way trip does not exceed 50 miles of driving distance.  
 
We looked at your request, the records in the case file, and the rules. The records show that you are requesting 
coverage for routine transportation services to a location that is 82 miles away from your home. This exceeds 
the Plan's benefit limitation of 50 miles per one-way trip. Based on this information, we decided that the Plan's 
rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not 
have to pre-approve routine transportation 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. You say that the enrollee needs IRF care. The Plan denied your 
request. The Plan says Medicare criteria are not met, and the enrollee's needs can be met at a lower level of 
care. 
 
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 enrollees nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does 
support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-
disciplinary rehabilitation program. 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay provided on 
September 16, 2022, to September 18, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. 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 Inpatient hospital care. 
 
You have been asked to pay a $350 copayment for 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. You have been asked to pay $700 ($350 x 2 nights) copayment for your inpatient stay. 
Therefore, we decided that the Plan does not have to waive the copayment for inpatient hospital stay provided 
on September 16, 2022, to September 18, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for testing provided on September 20, 2022. 
 
You asked the Plan to waive the copayment for testing. You say that you cannot afford this charge. 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 Outpatient procedures and services. 
 
You have been asked to pay a $370 copayment for testing. This item/service falls within the Outpatient 
procedures and 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 testing 
provided on September 20, 2022.