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

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs to be transferred to an 
LTACH versus staying in the short term acute care hospital or discharging to a lower level of care. The 
enrollee's condition has stabilized and will require a multi-disciplinary approach for an extended period of time. 
The Plan denied your request. The Plan says based on Medicare guidelines and the information we have about 
the enrollee's condition they do not meet all the requirements. 
 
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 is an 80 year old female admitted to acute hospital on 07/12/2022 for a 
perforated gastric antrum ulcer and underwent laparoscopic repair as well as an acute kidney injury and acute 
respiratory failure.  The enrollee was intubated post operatively and extubated on July 14, 2022. The enrollee 
was also reintubated on July 15, 2022, and extubated on July 19, 2022, and parenteral nutrition was stopped.  
 On July 20, 2022, her tube feeds were changed to Nepro. Currently, as of August 3, 2022, it is noted that the 
enrollee is stable and awaiting placement. The enrollee is to continue proton pump inhibitor, carafate, and is 
tolerating an oral diet. The oxygen saturation is 94 percent on room air. The enrollee is receiving hemodialysis 
now on Mondays, Wednesdays, and Friday. The enrollee has not required prolonged mechanical ventilation. 
The enrollee is receiving appropriate care at the present setting. The enrollee does not require services at the 
LTACH that are not available at the acute care hospital where they are currently receiving 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 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on November 12, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab 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 provided on November 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical access of roots on tooth #5 and 20 (D3421), a 
filling placed during root surgery on tooth #5 and 20 (D3430), and sedation (D9239, D9243). 
 
You asked the Plan to pre-approve the dental services. You say that you disagree with the denial of dental 
services. The Plan denied your request. The Plan says surgical access of roots (D3421), a filling placed during 
root surgery (D3430), and sedation (D9239, D9243) are not covered by your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
 
 
 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
surgical access of roots on tooth #5 and 20 (D3421), a filling placed during root surgery on tooth #5 and 20 
(D3430), and sedation (D9239, D9243).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for inpatient hospital stay provided from 
February 9, 2022, to February 11, 2022. 
 
You asked the Plan to waive the coinsurance for inpatient hospital stay. You say that this charge should be 
covered. The Plan denied your request. The Plan says the coinsurance applied is 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 10% 
coinsurance per admission.  
 
You have been asked to pay $966.76 which is less than the standard 10% of the allowed amount for inpatient 
hospital stay.  The allowed amount is $10, 126.02 (10% x $10,126.02 = $1,012.60). Inpatient hospital stay falls 
within the Inpatient Hospital Care benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for 
inpatient hospital stay provided from February 9, 2022, to February 11, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for ambulance transportation and an 
emergency room (ER) visit provided on March 7, 2022. 
 
You asked the Plan to waive the copayments for the ambulance transportation and ER visit. You say that the 
doctor informed you to go to the ER without being seen. The Plan denied your request. The Plan says you have 
been charged 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 $275 
copayment for each one-way ambulance trip. 
 
Your contract with the Plan also clearly says that you must pay a $90 copayment for each emergency room 
visit. You have been asked to pay a $275 copayment for the ambulance transportation. The ambulance transportation 
falls within the Ambulance Services benefit category. You have also been asked to pay a $90 copayment for 
the ER visit. The ER visit falls within the Emergency Care benefit category. The total for the services is $365. 
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 ambulance transportation and an emergency room (ER) 
visit provided on March 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99202), ultrasound therapy (97035), hot or 
cold packs therapy (97010), and the mechanical traction therapy (97012) provided from February 9, 2022, 
through March 1, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services are not covered under your 
contractual policy 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 services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the office visit (99202), ultrasound therapy (97035), hot or cold packs 
therapy (97010), and the mechanical traction therapy (97012) provided from February 9, 2022, through  
March 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a primary care provider office visit 
provided on April 23, 2022. 
 
You asked the Plan to waive the copayment for a primary care provider office visit. You say that you should 
not have to pay this copayment. The Plan denied your request. The Plan says the copayment applied 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 Physician/Practitioner services.  
 
You have been asked to pay a $10 copayment for a primary care provider office visit. A primary care provider 
office visit 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 a primary care provider office visit provided on April 23, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional supplies, materials, and clinical staff time 
rendered on November 5, 2020. 
 
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 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. 
 
 
 We find that CPT code 99072 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99072 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of these services have not been met. Therefore, we decided that the Plan does not have to pay for the additional 
supplies, materials, and clinical staff time rendered on November 5, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dexamethason. 
 
You asked the Plan to pre-approve Dexamethason. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested drug is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Dexamethason.  
 
Benefits for Dexamethason may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for computerized ophthalmic diagnostic 
imaging provided on May 16, 2022. 
 
You asked the Plan to waive the copayment for computerized ophthalmic diagnostic imaging. You say that you 
were not expecting this additional cost. The Plan denied your request. The Plan says the copayment applied is 
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 $10 
copayment for x-rays, laboratory, and other diagnostic tests you pay a $10 copayment for each category per 
service date.  
 
 
 You have been asked to pay $10 copayment for computerized ophthalmic diagnostic imaging. Computerized 
ophthalmic diagnostic imaging falls within the Outpatient Diagnostic Tests and Therapeutic Services 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 copayment for computerized ophthalmic 
diagnostic imaging provided on May 16, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Part B drugs provided on February 15, 
2022. 
 
You asked the Plan to waive the coinsurance for Part B drugs. You say that you cannot afford to pay this bill. 
The Plan denied your request. The Plan says the coinsurance applied is 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 20% 
coinsurance for Medicare covered Part B drugs.  
 
You have been asked to pay $5,182.32 which is 20% of the allowed amount for Part B drugs. The allowed 
amount is $25,911.60 (20% x $25,911.60= $5,182.32). Part B drugs falls within the Medicare Part B 
Prescription Drugs 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 coinsurance for Part B drugs 
provided on February 15, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
February 5, 2022. 
 
You asked the Plan to waive the copayment for the ER visit. You say that the enrollee feel at the skilled 
nursing facility and they should be responsible for the costs. The Plan denied your request. The Plan says the 
enrollee has been charged 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $90 copayment for each emergency room visit.  
 
The enrollee has been asked to pay a $90 copayment for the ER visit. The ER visit falls within the Emergency 
Care 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 copayment for an emergency room 
(ER) visit provided on February 5, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 19, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab 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 provided on January 19, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ilumya. 
 
You asked the Plan to pre-approve Ilumya. You say that you would like the plan to reconsider their denial. The 
Plan denied your request. The Plan says the requested drug is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Ilumya.  
 
Benefits for Ilumya may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital services provided from October 18, 2021, to 
October 22, 2021. 
 
You asked the Plan to pay for the hospital services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the provider is not enrolled in the Medicare 
program. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the hospital services provided from 
October 18, 2021, to October 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for oxygen equipment and supplies provided 
on February 23, 2022. 
 
You asked the Plan to waive the coinsurance for oxygen equipment and supplies. You say that since you were 
notified of the charges you shouldn't have to pay it. The Plan denied your request. The Plan says the 
coinsurance applied is 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 20% 
coinsurance for Medicare-covered items.  
 
 
 You have been asked to pay $29.21 which is 20% of the allowed amount for oxygen equipment and supplies. 
The allowed amount is $146.05 (20% x $146.05= $29.21). Oxygen equipment and supplies falls within the 
Durable Medical Equipment (DME) and Related 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 coinsurance for oxygen equipment and supplies provided on February 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the liver transplant evaluation to be provided by an out-
of-network (OON) provider. 
 
You asked the Plan to pre-approve the liver transplant evaluation. You say that you have already had testing 
done with this provider and have established good rapport with the provider. The Plan denied your request. The 
Plan says the provider is 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 liver transplant evaluation. We found no exception that would require the Plan to 
pre-approve the liver transplant evaluation. Therefore, we decided that the Plan does not have to pre-approve 
the liver transplant evaluation to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Intravenous infusion, for therapy, 
prophylaxis, or diagnosis (specify substance or drug) (96365) provided January 6, 2022 to January 12, 2022. 
 
You asked the Plan to waive the copayment for the infusion services. You say that because of a persistent 
infection your doctor ordered antibiotics delivered as an infusion. From 01/06/2022 to 01/12/2022 you went to 
the hospital for these infusions. You are being billed as if you had surgery every day for 7 days. The Plan 
denied your request. The Plan says the claim was processed with the correct cost share applied per the 
Evidence of Coverage. 
 
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 $375 for 
Medicare covered surgery or other services provided at an ambulatory surgical center, including but not limited 
to hospital or other facility charges and physician or surgical charges.  
 You have been asked to pay $2625 ($375 x 7 days) for the infusion services. The infusion services fall within 
the Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory 
Surgical Centers 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 Intravenous infusion, 
for therapy, prophylaxis, or diagnosis (specify substance or drug) (96365) provided January 6, 2022 to January 
12, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing and home health aide services. 
 
You asked the Plan to pre-approve skilled nursing and home health aide services. You say that the services are 
medically necessary. The Plan denied your request. The Plan says the enrollee does not have skilled nursing 
needs. 
  The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 skilled nursing and home health aide 
services. Our reviewer says that you do not have documented skilled nursing needs. As such, skilled nursing 
services and associated home health aide services are not medically necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of skilled nursing and home health aide services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve skilled nursing and home health aide services.