Persius/hicric huggingface dataset:
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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically necessary.
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 complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 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. 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the debridement of nail services provided 
from January 7, 2020 to April 29, 2021. 
 
You asked the Plan to waive the copayments for the debridement of nail services. You say that you feel the 
enrollee should not be responsible for the cost share amount and you would like the Plan to reconsider your 
request. The Plan denied your request. The Plan says the enrollee received debridement of nail services on the 
dates of service at issue in this appeal. Debridement is not the same service as nail trimming. The Plan says that 
the correct copayments have applied per the enrollee's contract with the Plan. 
 
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 enrollee's contract with the Plan clearly says that enrollees 
must pay a $35 copayment for Podiatry services.  
We looked at the file, the Plan's contract and Medicare rules. The file shows that the enrollee received 
debridement of nail services from January 7, 2020 to April 29, 2021. The enrollee has been asked to pay a $35 
copayment for each of the debridement of nail services. The debridement of nail services fall within the 
Podiatry services benefit category. This means that the enrollee has been asked to pay the correct amount based 
on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon 
enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for the 
debridement of nail services provided from January 7, 2020 to April 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for office services provided by a non-Medicare participating 
provider from June 9, 2020, to October 27, 2020. You asked the Plan to pay for office services. You say that you were advised that you would be reimbursed for 
all out-of-pocket expenses and are unable to pay these monthly bills. The Plan denied your request. The Plan 
says the cost-sharing amount you are being charged is correct, and you are responsible for any amount above 
what the Plan covered because this provider does not participate in Medicare. 
 
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 rules say that if a provider does not participate in the Medicare 
program, the Plan pays the provider the difference between cost-sharing and the Original Medicare limiting 
charge for covered services. Your contract with the Plan clearly says that you must pay 30% coinsurance for 
out-of-network specialist visits. Although all of the visits were covered by the Plan, the Plan is only asking you 
to pay cost-sharing for the visit on October 27, 2020. The allowed amount of this visit is $110.31, resulting in a 
coinsurance amount of $22.06 which is less than 30% coinsurance. 
 
You have been asked to pay less than 30% coinsurance for office services. Office services fall 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. In addition, the Plan does not pay any amount for 
these claims above the Medicare allowed amount for the services. Therefore, we decided that the Plan does not 
have to pay for office services provided by a non-Medicare participating provider from June 9, 2020, to 
October 27, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve inpatient psychiatric treatment. 
 
You asked the Plan to pre-approve inpatient psychiatric treatment. You say that the services are necessary. The 
Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not 
been met. 
 
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 treatment. Our 
reviewer says that the services are medically necessary. Our physician reviewer found based upon review of the 
records provided, you do meet the criteria for continued acute inpatient mental health treatment for the dates in 
question of September 7, 2021 forward as you were shown to be a danger to yourself and others. You were 
being noncompliant with medication. You were not showing any auditory or visual hallucinations with acute 
threats the safety. 
 
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 treatment have been met. Therefore, we decided that the 
Plan has to pre-approve inpatient psychiatric treatment.  
 
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial hospital care represented by code 99223 provided 
on February 10, 2021. 
 
You asked the Plan to pay for code 99223. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the medical records do not support the billing of code 
99223. 
 
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, the CPT Code Manual definition of code 99223 is Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit. 
 
We find that CPT code 99223 is not supported in the medical record. Specifically, the medical records provided 
substantiate a detailed history only. Based on this information, we decided that Medicare rules for coverage of 
code 99223 have not been met. Therefore, we decided that the Plan does not have to pay for the initial hospital 
care represented by code 99223 provided on February 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete maxillary denture or pay more for the
mandibular partial denture provided on May 6, 2021.
You asked the Plan to pay for the complete maxillary denture and to pay more for the mandibular partial
denture. You say that you would like to appeal this claim. The Plan denied your request. The Plan says your
annual maximum dental benefit has been exhausted for the benefit year.
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 Plan offers a $500 annual dental
benefit maximum. The record shows that you met the annual maximum benefit while processing this claim for
the May 6, 2021 date of service and your annual maximum benefit has been exhausted. Therefore, we decided
that the Plan does not have to pay for the complete maxillary denture or pay more for the mandibular partial
denture provided on May 6, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit you had on 
April 28, 2021. 
 
You asked the Plan to waive the copayment for the ER visit. You say that you should not have to pay this 
copayment because there was a long wait to be seen and the service was poor. The Plan denied your request. 
The Plan says you were charged this copayment 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 $90 
copayment for emergency room visits. You have been asked to pay a $90 copayment for the ER visit. This copayment applies regardless of wait time 
or your satisfaction with the services. 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 emergency room 
(ER) visit you had on April 28, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the EKG provided on March 16, 2021.
You asked the Plan to waive the copayment for the EKG. You say that your physician has performed the EKG
in the past as a part of your annual wellness visit and did not have a copayment. 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 $30
copayment for Medicare-covered non-radiological diagnostic services. For this date of service, you have been
asked to pay the allowed amount of the claim because this amount is less than the standard $30 copayment for
the EKG.
You have been asked to pay a $15.73 copayment for the EKG. The EKG falls within the "Outpatient diagnostic
tests and therapeutic services and supplies" benefit category. The record shows the EKG is considered a nonradiological
service that is considered separate from the annual physical exam. 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 EKG provided on March 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown and resin-based composite provided on January 
20, 2021. 
 
You asked the Plan to pay for the crown and resin-based composite. You say that you paid $820 out-of-pocket 
and you didn't get reimbursement. You say that you were not told they were no longer in-network. The Plan 
denied your request. The Plan says payment cannot be issued for services performed by providers who have 
opted out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the crown 
and resin-based composite provided on January 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services provided on October 14, 2020, by an
OON provider.
You asked the Plan to pay for the anesthesia services. You say that the enrollee was unaware prior
authorization was needed. The Plan denied your request. The Plan says no prior authorization was 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.
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. The
records provided for review do not show that the services at issue were urgent or emergent. Therefore, we
decided that the Plan does not have to pay for anesthesia services provided on October 14, 2020, by an OON
provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the neurobehavioral services provided on March 23, 2021, to 
May 4, 2021, by an OON provider. 
 
You asked the Plan to pay for the neurobehavioral services. You say that you were told the provider is in-
network and the services would be covered. The Plan denied your request. The Plan says no prior authorization 
was 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. 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 neurobehavioral services provided on March 
23, 2021, to May 4, 2021, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the preventive procedure (D1999), crown (D2740), and 
mandibular partial denture (D5214) provided on November 18, 2020, and December 14, 2020. 
 
You asked the Plan to pay for the preventive procedure, crown, and mandibular partial denture. You say that 
you were told that these claims would be covered by your insurance. You also say that you are receiving bills 
for these services and you are unable to pay them. The Plan denied your request. The Plan says the preventive 
procedure is not covered. The Plan also says that your annual maximum dental allowance has been met. 
 
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 Plan offers a $3,000 combined 
allowance for supplemental preventive and comprehensive services every year. The contract says that you are 
responsible for any amount over and above the allowance amount. The record shows that you met the annual 
maximum benefit while processing the claim for December 14, 2020, and your annual maximum benefit has 
been exhausted. Therefore, we decided that the Plan does not have to pay for the preventive procedure 
(D1999), crown (D2740), and mandibular partial denture (D5214) provided on November 18, 2020, and 
December 14, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the interspinous stabilization device provided on May 4, 2021.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the clinical effectiveness for severe lumbar stenosis has not been demonstrated in peer-reviewed literature.
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 pay for the services provided. Our physician reviewer found that the enrollee received an interspinous stabilization device. The device is considered experimental. More research is needed to show safety and efficacy of the device. Therefore, the device is not considered medically reasonable and 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 services provided have not been met. Therefore, we decided that the Plan does not have to pay for the interspinous stabilization device provided on May 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the crown for tooth #27 and #28 provided on February 23, 
2021. 
 
You asked the Plan to pay for the crowns. You say that the provider told you not to worry about the denied pre-
treatment estimate and the crowns would be covered. The Plan denied your request. The Plan says crowns are 
only covered once every 5 years. 
 
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, you also have a maximum benefit o f 
one crown per tooth every 5 years. The Plan paid for a crown for tooth #27 and #28 provided on August 31, 
2017, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the crown for 
tooth #27 and #28 provided on February 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye refraction provided on April 29, 2021.

You asked the Plan to pay for the eye refraction. You say that you believe the claim denied due to a coding issue. The Plan denied your request. The Plan says an eye refraction is not a covered benefit since it was performed for punctate keratitis, which is considered a medical reason.

Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state of the eyes. Refractive procedures are not covered even when done in connection with otherwise covered diagnosis or treatment of illness or injury.

We looked at the file and the Medicare rules. The file shows that you received an eye exam for a Medicare-covered eye condition and not a routine eye exam. The file shows that part of this exam was for a refraction. Medicare does not cover refractive procedures even when done in connection with otherwise covered diagnosis or treatment of illness or injury. Therefore, we decided that the Plan does not have to pay for an eye refraction provided on April 29, 2021.
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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically necessary.

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 complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 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. 

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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex superion device.

You asked the Plan to pre-approve a Vertiflex superion device. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a Vertiflex superion device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the vertiflex device is experimental. More research is needed to show safety and efficacy. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Vertiflex superion device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex superion device.