Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy provided on August 16,
2021.

You asked the Plan to waive the copayment for physical therapy. You say that you were never charged a
copayment prior to this visit. The Plan denied your request. The Plan says the copayment was 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). Your contract with the Plan clearly says that you must pay a $10
copayment for Medicare covered Physical Therapy (in-person or virtual) visits.

You have been asked to pay a $10 copayment for physical therapy. Physical therapy falls within the Outpatient
Rehabilitation 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 physical
therapy provided on August 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the targeted case management provided on September 27,
2021 by an out-of-network (OON) provider.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services were rendered by an out-of-network provider without prior authorization.

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 targeted case management provided on
September 27, 2021 by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic exercises (97110) provided on July 20, 2021,
by an OON provider.
You asked the Plan to pay for the therapeutic exercises. You say that there are no in-network providers in the
area. You also say that you would like this claim to be reprocessed based on medical necessity. The Plan
denied your request. The Plan says the rendering and referring providers are non-participating providers. The
Plan also says that these services were not authorized.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the therapeutic exercises (97110) provided on July
20, 2021, by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient mental health care, for the enrollee.
You asked the Plan to pre-approve inpatient mental health care. You say that the admission is necessary for
mood stabilization and safe discharge. The Plan denied your request. The Plan says the stay is 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 mental health care.
Our physician reviewer found based upon review the records provided for the admission of this enrollee does
not meet criteria for acute inpatient mental health treatment as this enrollee was not shown to be a danger to
themselves or others, no auditory or visual hallucinations. The enrollee is noted to be cooperative and
compliant with treatment while not showing any aggressive behaviors.
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 mental health care have not been met. Therefore, we decided that the
Plan does not have to pre-approve inpatient mental health care, for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental extractions provided on June 7, 2021.
You asked the Plan to pay for the dental extractions. You say that the service should be covered. The Plan
denied your request. The Plan says prior authorization was required for this service.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's 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
extractions provided on June 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the debridement services provided on September 1, 2021 by
an out-of-network (OON) provider.

You asked the Plan to pay for the debridement services. You say that you would like the plan to reconsider
their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.

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 debridement services provided on September
1, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for wound debridement (11043) provided on August 25, 2021,
by an out-of-network (OON) provider.
You asked the Plan to pay for wound debridement. You say that the treatment rendered to the patient was
medically necessary per the physician that provided the services. You also say that you have provided
supporting records. The Plan denied your request. The Plan says no authorization was obtained prior to
rendering the services.
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 wound debridement (11043) provided on August
25, 2021, 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 visit (99215) provided on August 20, 2021.

You asked the Plan to pay for the visit. The Plan denied your request. The Plan says this service is included in 
the global surgical payment.

The Plan must follow Medicare rules. Medicare rules say that payment for the listed services is included in 
global surgical payment. 

We looked at the file and Medicare rules. In this case, payment for the requested office visit is included in 
global surgical payment for the surgery (44140) provided on May 28, 2021. This procedure has a global 
surgical period of 90 days. Based on this information, we decided that Medicare rules for coverage of the visit 
have not been met. Therefore, we decided that the Plan does not have to pay for the visit (99215) provided on 
August 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit (99336) rendered by the out-of-network (OON) provider on March 19, 2021.
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 the service was rendered by an out of network provider, without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue.
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the domiciliary or rest home visit (99336) rendered by the out-of-network (OON) provider on March 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the acupuncture (97810) provided on September 
13, 2021.

You asked the Plan to reimburse you for the acupuncture. You say that you still have some money left. You 
also say that you wish you could afford this more often. The Plan denied your request. The Plan says the 
maximum $150 wellness benefit has been exceeded. The Plan says you received $115 for services received on 
June 14, 2021. The Plan says you received $35 for services received on September 13, 2021. The Plan also says 
that you are responsible for any amount over the $150 wellness benefit.

The Plan must follow Medicare rules. Medicare rules say that plans must pay for a medical service or item if 
regular Medicare would pay for it in this case.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the acupuncture have not been met. Specifically, the $50 wellness benefit has been exhausted.
Therefore, we decided that the Plan does not have to reimburse you for the acupuncture (97810) provided on 
September 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the cardiologist office visit on June 9, 2021.
You asked the Plan to waive the copayment for the cardiologist office visit. You say that you received inadequate care during your visit to the cardiologist. The Plan denied your request. The Plan says the copayment was 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). Your contract with the Plan clearly says that you must pay a $20 copayment for each Medicare covered specialist visit. You have been asked to pay a $20 copayment for cardiologist office visit. The cardiologist office visit falls within the Physician/Practitioner Services, including doctor's 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 cardiologist office visit on June 9, 2021.
Your complaint about your experience with this provider is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periapical x-ray (D0220) provided on August 18, 2021.
You asked the Plan to pay for the dental service. You say that the x-ray was taken during a routine dental consultation to confirm the existence of a dental infection. The Plan denied your request. The Plan says periapical x-ray is not listed as a covered service.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the periapical x-ray is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the periapical x-ray (D0220) provided on August 18, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve replacement of an implantable loop recorder (ILR) for 
the enrollee.

You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not medically necessary.
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 the enrollee has a history of stroke in 2018, at which time atrial fibrillation was diagnosed. He was 
placed on anti-coagulation. There is no documentation provided to suggest a history of unexplained syncope, 
cryptogenic stroke or any other apparent indication for an ILR. In summary, there is insufficient documentation 
to support the medical necessity for insertion of an ILR in this enrollee's clinical management.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve replacement of an implantable loop recorder (ILR) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete series of intraoral x-rays (D0210) provided on October 6, 2021.
You asked the Plan to pay for the complete series of intraoral x-rays. You say that you gave the provider your insurance information and assumed they would contact the Plan to verify your benefits. You also say that the provider proceeded with the dental services without verifying your coverage. The Plan denied your request. The Plan says this service exceeds the maximum allowed per period.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, complete series of intraoral x-rays (D0210) is limited to one procedure every three plan years. The record shows that you received a complete series of intraoral x-rays (D0210) on January 14, 2020 and your complete series of intraoral x-rays (D0210) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the complete series of intraoral x-rays (D0210) provided on October 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a complete lower
denture (D5120) to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve a complete upper denture and a complete lower denture. You say that you
are losing your teeth due to malnutrition. You are not able to eat correctly and will most likely lose all of your
remaining teeth because you do not have teeth or dentures. You also say you have a speech impediment. You
are asking for an expedited appeal as you have wasted valuable time and need to start getting help as soon as
possible. The Plan denied your request. The Plan says the requested services are not listed as a covered benefit
with your Plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's 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. The EOC confirms that you must receive services from a participating
provider. Therefore, we decided that the Plan does not have to pre-approve a complete upper denture (D5110)
and a complete lower denture (D5120) to be provided by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient rehabilitation services provided
by a participating provider on August 25, 2021.
You asked the Plan to waive the copayment for outpatient rehabilitation services. You say that you do not agree
with this copayment. The Plan denied your request. The Plan says the correct copayment has been applied.
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 $10
copayment for outpatient rehabilitation services.
You have been asked to pay a $10 copayment for outpatient rehabilitation services. The correct copayment has
been applied to the outpatient therapy services that were provided. Outpatient rehabilitation services falls
within the outpatient rehabilitation 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 outpatient rehabilitation services provided on August 25, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultrasound coded 76705 provided on August 11, 2021.
You asked the Plan to pay for the ultrasound. You say that you would like the plan to reconsider their denial.
The Plan denied your request. The Plan says the services billed are not separately payable.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 76705
is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we
decided that the Plan does not have to pay for the ultrasound coded 76705 provided on August 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the outpatient hospital clinic visits and 
wound care provided on June 18, 2021, and June 25, 2021.

You asked the Plan to waive the copayments for the outpatient hospital clinic visits and the wound care. You 
say that you were billed as a surgical procedure. You say you did not have surgery of any kind. The Plan 
denied your request. The Plan says you have been asked to pay 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 $345 
copayment at an in-network outpatient hospital. 

You have been asked to pay a $408.93 copayment for the outpatient hospital clinic visits and the wound care. 
The outpatient hospital clinic visits and the wound care fall within the "Outpatient surgery, including services 
provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows 
the outpatient hospital clinic visits are considered services provided at a hospital outpatient facility. The wound 
care is considered a surgical service. See chart below.

      Date of Service          Service             Allowed Amount           Copayment            Member Liability
        June 18, 2021        Clinic visit                 $110.93                       $345                      $100.15

        June 18, 2021       Wound care               $197.85                      $345                       $197.85
                                     (application of 
                                        paste boot)
                                                                   
       June 25, 2021          Clinic visit                $110.93                       $345                       $110.93

               Total                                                                                                                    $408.93


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 outpatient hospital clinic visits and wound care 
provided on June 18, 2021, and June 25, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Injectafer for the enrollee.

You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says the information submitted doesn't meet the plan's medical necessity guidelines for 
coverage.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications.

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 drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found the case file does not 
contain documentation of trial and failure of Infed (iron dextran) and Venofer (iron sucrose). The 
documentation does not support that Infed (iron dextran) and Venofer (iron sucrose) would likely be less 
effective, and/or would likely have adverse effects for the enrollee in this case.

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 drug have not been met. Therefore, we decided that the Plan does not have
to pre-approve Injectafer for the enrollee.