Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic laryngoscopy provided on 
January 10, 2022. 
 
You asked the Plan to waive the copayment for a diagnostic laryngoscopy. You say that you disagree with the 
additional $50 copayment. 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 $50 
copayment for outpatient diagnostic tests. The contract also says that if you receive services in addition to 
outpatient diagnostic tests a separate cost-sharing may apply. 
 You have been asked to pay a $50 copayment for a diagnostic laryngoscopy. A diagnostic laryngoscopy 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 a diagnostic laryngoscopy provided on January 10, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 you are medically stable and do not need a PMR physician's close supervision 3 
times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic 
medical conditions. At the current functional level, you do not need IRF therapies consisting of 3 hours a day, 5 
days a week with interdisciplinary management. Your rehab needs can be safely met in an alternate and low 
intensity setting such as in a skilled nursing facility (SNF). Since you live alone and needs min A, you would 
benefit from SNF rehab. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular radiofrequency ablation procedure (64624). 
 
You asked the Plan to pre-approve the procedure. You say that given that the enrollee continues to suffer from 
chronic left knee pain, you believe she would be a good candidate for a genicular nerve radiofrequency ablation 
The Plan denied your request. The Plan says this service is considered unproven and experimental as peripheral 
nerve block is not a standard treatment for unilateral primary osteoarthritis, left knee. There is not enough 
medical proof that shows the safety and/or success of peripheral nerve block when used for this reason. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve 
genicular radiofrequency ablation procedure (64624).
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 records provided support the need for IRF care. 
The Plan denied your request. The Plan says it is not medically necessary for the enrollee to be in an IRF at this 
time. The Plan says that the enrollee's needs can be safely 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 the enrollee is medically stable and does not need physical medicine and rehabilitation physician close supervision 3 times per week (at a minimum) for the ongoing management of any 
active or acute exacerbations of chronic medical conditions. There are no rehabilitation nursing needs identified 
or documented in the record. An uncomplicated fracture patient does not need IRF stay. She needs physical 
therapy and occupational therapy in alternate and low intensity setting. The enrollee does not need 3 hours a 
day five days a week of IRF therapies with interdisciplinary management and the rehabilitation needs can be 
met in an alternate and lower setting such as in an assisted living facility (ALF) with therapies as needed. An 
IRF admission is not medically necessary based on medical stability, lack of medical complexity, and lack of 
rehabilitation nursing needs. Documentation does not support the necessity for admission to an IRF. The 
enrollee's rehab needs can be safely met in an alternate and low intensity setting such as in a skilled nursing 
facility (SNF.) 
 
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: Favorable

 
We decided that the Plan has to approve inpatient hospital care. 
 
You asked the Plan to approve these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says that the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 approve these services. Our reviewer says that the 
documentation supports that the criteria for inpatient services are met. Our physician reviewer found the 
enrollee presented to the emergency room (ER) on May 7, 2022 with chief complaints of four days of 
headache, abdominal pain, nausea, and vomiting. She stated the symptoms came on gradually and headache 
was generalized with no exacerbating or relieving factors. She was examined on May 10, 2022 and the 
abdominal pain, nausea, and vomiting had improved. The records support a reasonable expectation that the 
enrollee would require at least two midnights of inpatient hospital 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 these services have been met. Therefore, we decided that the Plan has to 
approve inpatient hospital care.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Jazzy Air Wheelchair. 
 
You asked the Plan to pre-approve a Jazzy Air Wheelchair. You say that the requested device is medically 
necessary. The Plan denied your request. The Plan says no new clinical information has been received despite 
being requested. There is no face-to-face evaluation or wheelchair specialist evaluation present in the records. 
The provider letter does not state which features are required that cannot be provided by a covered wheelchair 
or scooter. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
We looked at the file and Medicare rules. The records show that there is no face-to-face evaluation or 
wheelchair specialist evaluation present in the records. Based on this information, we decided that Medicare 
rules for coverage of the Jazzy Air wheelchair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Jazzy Air Wheelchair.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room visit on January 6, 2022. 
 
You asked the Plan to waive the copayment for emergency room visit. You say that you should not have to pay 
this bill because you were injured due to a fall at the hospital. The Plan denied your request. The Plan says 
copayment 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 $90 
copayment for emergency care visits.  
 
You have been asked to pay $90 copayment for the emergency room visit. The emergency room visit falls 
within the Emergency 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 copayment for emergency 
room visit on January 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator for the enrollee. 
 
You asked the Plan to pre-approve the ventilator. You say that this is medically necessary. The Plan denied 
your request. The Plan says the request for a home mechanical ventilator set in average volume-assured 
pressure support (AVAPS) mode with Auto-EPAP (AE) that could be delivered by bilateral positive airway 
pressure (BiPAP) is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our reviewer says that 
the requested ventilator is not medically reasonable or necessary. Our physician reviewer found the enrollee 
has chronic obstructive pulmonary disease (COPD), with a recent exacerbation requiring admission and bilateral positive airway pressure (BiPAP). The partial pressure of carbon dioxide (PaCO2) was 73 with a 
normal pH, suggesting chronic hypercarbic respiratory failure. The patient may benefit from BiPAP during 
sleep, with or without the AVAPS mode of support. But Medicare does not cover a home ventilator when used 
as BiPAP. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a portable ventilator for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy provided on December 20, 
2021. 
 
You asked the Plan to waive the copayment for physical therapy. You say that you did the things you were 
supposed to do and the plan paid for the service before. The Plan denied your request. The Plan says you have 
been charged the correct copayment amount. 
 
The rules say that a Cost plan must disclose in writing all benefits available under the Plan. The health plan 
contract says that enrollees must pay $40 copayment for Medicare covered physical therapy (in-person or 
virtual) visits. 
 
You have been asked to pay $40 copayment for the physical therapy visit. 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 December 20, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for psychotherapy services provided on April 
8, 2021. 
 
You asked the Plan to waive the copayment for the psychotherapy services. You say that you were not 
informed of any copayment at the time of service. 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 $35 
copayment for each in-person therapy visit.  
 
You have been asked to pay a $35 copayment for the psychotherapy services. The psychotherapy services fall 
within the Outpatient Mental Health 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 copayment 
for psychotherapy services provided on April 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Domiciliary services provided on October 25, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for Domiciliary services. You say that that it isn't your responsibility to obtain prior 
authorization. The Plan denied your request. The Plan says prior authorization is required for an out-of-network 
visit. 
 
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 Domiciliary services provided on October 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 electrical stimulation (unattended) other than wound care, a 
therapeutic, prophylactic, or diagnostic injection, a therapeutic procedure on 1 or more areas, a vasopneumatic 
device therapy, an unknown drug injection, a thiamine hcl 100 mg injection, a pyridoxine hcl 100 mg injection, 
and a levocarnitine injection provided on August 9, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for electrical stimulation (unattended) other than wound care, a therapeutic, 
prophylactic, or diagnostic injection, a therapeutic procedure on 1 or more areas, a vasopneumatic device 
therapy, an unknown drug injection, a thiamine hcl 100 mg injection, a pyridoxine hcl 100 mg injection, and a 
levocarnitine injection. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the services are not authorized because this provider is a non-network provider who does not 
work with the member's health plan, and the member self-directed for care. The Plan also says that the 
member's primary care provider did not refer for services, and no medical necessity for an out-of-network 
provider, such as an urgent or emergency situation, has been documented. The Plan also said that there is no 
referring provider listed on the claim. 
 
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 electrical stimulation (unattended) other than 
wound care, a therapeutic, prophylactic, or diagnostic injection, a therapeutic procedure on 1 or more areas, a 
vasopneumatic device therapy, an unknown drug injection, a thiamine hcl 100 mg injection, a pyridoxine hcl 
100 mg injection, and a levocarnitine injection provided on August 9, 2021, by an out-of-network (OON) 
provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140) and periapical imaging 
(D0230, D0140 and D0220) provided on January 11, 2022. 
 
You asked the Plan to pay for the limited oral evaluation and periapical imaging. You say that you would like 
reconsideration because this is the first dental service you have received and you did not exceed the frequency 
limitation. The Plan denied your request. The Plan says the frequency limitation has been exceeded. 
 
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 limited oral evaluation is 
not among those covered under this benefit. Additionally, the record shows that the Plan processed and paid for 
periapical imaging services that were provided on January 18, 2022. The record indicates that this claim was submitted and subsequently paid first. The frequency limitation for periapical imaging has been exceeded. 
Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) and periapical 
imaging (D0230, D0140 and D0220) provided on January 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost for the outpatient specialist visit and Part B 
prescription drugs provided on January 5, 2022. 
 
You asked the Plan to waive the cost for an outpatient specialist visit and Part B prescription drugs. You say 
that when you went to pay your $40 copay at the specialists office you were told it was not necessary and now 
you are receiving a bill. The Plan denied your request. The Plan says the cost share was applied 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 $40 for 
the outpatient specialist visit and 20% coinsurance for Part B prescription drugs. 
 
You have been asked to pay a total of $44.56 for the outpatient specialist visit and Part B prescription drugs. 
 
Service Allowed Amount Standard Cost Member Liability 
Specialist Visit $134.45 $40 Copayment $40 
Part B Prescription Drugs $22.80 20% Coinsurance $4.56 
TOTAL:   $44.56 
 
Outpatient specialist visits fall within the Physician/Practitioner services, including doctors office visits 
benefit category.  The Part B prescription 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 cost for the outpatient specialist visit and Part B prescription 
drugs provided on January 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete 
series of radiographic images (D0210) provided on January 13, 2022. 
 
You asked the Plan to pay for the comprehensive oral evaluation and complete series of radiographic images. 
You say that you would like reconsideration because there are no in-network providers available. The Plan 
denied your request. The Plan says these services are not covered out-of-network. 
 
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. Specifically, the Plan does not cover comprehensive oral evaluations and complete series of radiographic images when rendered by an out-of-network provider. The record indicates 
that this provider is out-of-network. Therefore, we decided that the Plan does not have to pay for the 
comprehensive oral evaluation (D0150) and complete series of radiographic images (D0210) provided on 
January 13, 2022.