Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the cardiac specialist office visit provided 
on September 30, 2022. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that you should not have to 
pay this since our met your out-of-pocket maximum. The Plan denied your request. The Plan says this cost 
sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 copayment for each specialist office visit.  
 
The records show that you had not met your out-of-pocket maximum prior to receiving the specialist office 
visit provided on September 30, 2022. You have been asked to pay a $45 copayment for the specialist office 
visit. This item/service falls within the physician/practitioner 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 the cardiac specialist office visit provided on September 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve extraction, erupted tooth requiring removal of bone 
and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210) Tooth #2, 3, 4 
and 5, deep sedation/general anesthesia first 15 minutes (D9222), deep sedation/general anesthesia  each 
subsequent 15-minute increment (D9223 x1), therapeutic parenteral drugs, two or more administrations, 
different medications (D9612), alveoloplasty in conjunction with extractions - four or more teeth or tooth 
spaces, per quadrant (D7310) and reduction of osseous tuberosity (D7485) both on oral cavity 10. 
 
You asked the Plan to pre-approve dental services. You say that you need the dental work, so you would like 
the requested services approved. The Plan denied your request. The Plan says these services are not covered 
under your Plan. 
 
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. Extraction, erupted tooth 
requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if 
indicated, deep sedation/general anesthesia first 15 minutes, deep sedation/general anesthesia  each 
subsequent 15-minute increment, therapeutic parenteral drugs, two or more administrations, different 
medications, alveoloplasty in conjunction with extractions - four or more teeth or tooth spaces, per quadrant 
and reduction of osseous tuberosity (D7485) are not covered under the Plans dental benefits. 
 
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 
extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of 
mucoperiosteal flap if indicated (D7210) Tooth #2, 3, 4 and 5 deep sedation/general anesthesia first 15 minutes 
(D9222), deep sedation/general anesthesia  each subsequent 15-minute increment (D9223 x1), therapeutic 
parenteral drugs, two or more administrations, different medications (D9612), alveoloplasty in conjunction 
with extractions - four or more teeth or tooth spaces, per quadrant (D7310) and reduction of osseous tuberosity 
(D7485) both on oral cavity 10.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildup, including any pins when required 
(D2950). 
 
You asked the Plan to pre-approve dental services. You say that you are requesting your insurance plan to 
authorize the dental procedure. The Plan denied your request. The Plan says this service is not covered under 
your Plan. 
 
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. Core buildup, including any 
pins when required (D2950) is not covered under the Plans dental benefits. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D2950 is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve core 
buildup, including any pins when required (D2950).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for SNF services provided from October 1, 
2022, and October 28, 2022. 
 
You asked the Plan to waive the copayment for SNF services. You say that the care received was not adequate 
and the member should not be held financially liable. The Plan denied your request. The Plan says this cost 
sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay $0 copayment per day for days 1 to 20 and a $188 copayment per day for days 21 to 100 for SNF 
care.  
 The enrollee has been asked to pay a $2,256 copayment for SNF services ($188 per day x 12 days = $2,256). 
This item/service falls within the SNF 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 SNF services provided from October 1, 2022, and October 28, 2022.  
 
Your complaint about the inadequate care provided by the skilled nursing facility 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the regadenoson injection and the 
technetium tc-99m sestamibi injection provided by an in-network provider on November 1, 2022. 
 
You asked the Plan to waive the cost sharing for the injections. You say that you do not agree with the cost 
sharing. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
 
 The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a 5% 
coinsurance for each in-network Medicare-covered Part B drug and non-chemotherapy drugs to treat cancer, 
and a 20% coinsurance for each in-network Medicare-covered medical supply. 
 
You have been asked to pay a $12.30 coinsurance for the regadenoson injection ($245.92 allowed amount x .05 
= $12.30 rounded up). This item/service falls within the Medicare Part B prescription drugs benefit category. 
You have also been asked to pay a $94.40 coinsurance for the technetium tc-99m sestamibi injection ($472 
allowed amount x .20 = $94.40). This item/service falls within the outpatient diagnostic tests and therapeutic 
services and supplies benefit category.  
 
You have been asked to pay a total cost share of $106.70 for the injections ($12.30 + $94.40 = $106.70). This 
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the cost sharing for the regadenoson injection and the technetium tc-99m 
sestamibi injection provided by an in-network provider on November 1, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CT scan. 
 
You asked the Plan to pre-approve a CT scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says this type of imaging is not medically necessary. It is not covered for individuals with 
known disease of the blood vessels supplying blood to the heart muscle (coronary artery disease). You have a 
diagnosis of coronary artery disease. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
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 CT scan. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found CT imaging of the heart without contrast 
material with quantitative evaluation of coronary calcium is considered experimental/investigational for the 
evaluation and management of this patient's medical condition. 
 
 
 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 CT scan. have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a CT scan.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99152 provided on October 17, 2022. 
 
You asked the Plan to pay for procedure code 99152. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the records do not support the billing of 
procedure code 99152. 
 
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 99152 is Moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older. 
 
We find that CPT code 99152 is not supported in the medical record. Specifically, the medical record does not 
contain evidence that moderate sedation was performed with the presence of an independent trained observer. 
Based on this information, we decided that Medicare rules for coverage of procedure code 99152 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 99152 provided on October 
17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on July 6, 2022. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the services that were provided are 
medically necessary. The Plan denied your request. The Plan says Original Medicare is responsible for 
payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for subsequent nursing facility care provided on July 6, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the emergency room visit, and inpatient 
hospital stay provided from November 21, 2022, to November 24, 2022. You asked the Plan to waive the copayments for the emergency room visit, and the inpatient hospital stay. You 
say that these services were the result of a previous surgery and should be covered. The Plan denied your 
request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 
copayment for each emergency room visit. Your contract with the Plan also clearly says that you must pay a 
$250 copayment per day for days 1-7 of each inpatient hospital stay. 
 
You have been asked to pay a $90 copayment for the emergency room visit. This item/service falls within the 
emergency care benefit category. You have also been asked to pay a $250 copayment per day for days 1-3 of 
the inpatient hospital stay. You have been asked to pay a total of $750 for the inpatient hospital stay ($250 
copayment per day x 3 days = $750). You have not been charged for the day you were discharged. These 
items/services fall within the inpatient hospital care benefit category. You have been asked to pay a total of 
$840 ($90 copayment + $750 copayment = $840). 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 emergency room visit, and inpatient hospital stay provided from November 21, 2022, to November 24, 
2022.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from May 4, 2022, through May 7, 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 that the acute inpatient hospital care provided was 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 pay for these services. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found that the enrollee was brought to the emergency department (ED) on May 4, 2022 with weakness, cough and shortness of breath. She was evaluated and the chest x-ray showed a small right plural effusion. She was treated with supplemental oxygen, intravenous fluids, steroids, and Ceftriaxone/Azithromycin antibiotics, as well as intravenous Protonix. She was admitted and treated for community acquired pneumonia. Her condition stabilized and improved and she was discharged on May 7, 2022. The review indicates that the record showed that at the time of the inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or observation care) would span two midnights.

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 pay for the acute inpatient hospital care provided from May 4, 2022, through May 7, 2022.

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 pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee has had a decline in functional levels 
and would benefit from inpatient rehabilitation to improve functional levels. The Plan denied your request. The 
Plan says the IRF care is not medically necessary, and the enrollee's needs can be met at a lower level such as a 
skilled nursing facility, outpatient setting, or home health 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 at home receiving home care services with lumbar radiculopathy. 
Currently, the enrollee is stable medically, and no other acute illness or admission to a hospital was 
documented. The record does not support necessity for admission to an IRF due to lack of acute medical 
illness, nursing needs, and medical complexity. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive drug testing of 1-7 classes (G0480) provided 
on September 13, 2021. 
 
You asked the Plan to pay for the definitive drug testing of 1-7 classes. You say that the claim was not filed 
timely due to staffing issues. The Plan denied your request. The Plan says this claim was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the definitive drug testing of 1-7 classes was not filed until October 21, 2022. 
This means that more than one calendar year from the date of service had passed before a claim was filed. 
Therefore, we decided that the Plan does not have to pay for the definitive drug testing of 1-7 classes (G0480) 
provided on September 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the water circulating heat pad with pump (E0217) provided 
from June 27, 2022, to July 20, 2022. 
 
You asked the Plan to pay for the water circulating heat pad with pump. You say that this item is medically 
necessary for the enrollee. You also say that it is approved by the Food and Drug Administration (FDA). The 
Plan denied your request. The Plan says this item is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if a moist electric heating pad or water 
circulating heat pad with pump is provided it will be denied as not reasonable and necessary.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the water circulating heat pad with pump have not been met. Therefore, we decided that the Plan 
does not have to pay for the water circulating heat pad with pump (E0217) provided from June 27, 2022, to 
July 20, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the single-photon emission computerized 
tomography (SPECT) scan, the regadenoson injection, and the technetium tc 99m tetrofosmin injection 
provided by an in-network provider on March 18, 2022. You asked the Plan to waive the cost sharing for the single-photon emission computerized tomography 
(SPECT) scan and the injections. You say that you do not agree with the cost sharing. The Plan denied your 
request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a $150 
copayment for in-network Medicare-covered diagnostic radiology services, which includes single-photon 
emission computerized tomography (SPECT) scans, performed in a provider's office or freestanding facility, a 
20% coinsurance for in-network Medicare-covered medical supplies, and a 20% coinsurance for other in-
network Medicare-covered Part B drugs. 
 
You have been asked to pay a $150 copayment for the single-photon emission computerized tomography 
(SPECT) scan. You have also been asked to pay a $22.80 coinsurance for the technetium tc 99m tetrofosmin 
injection ($114 allowed amount x .20 = $22.80). These items/services fall within the outpatient diagnostic tests 
and therapeutic services and supplies benefit category. You have also been asked to pay a $47.98 coinsurance 
for the regadenoson injection ($239.92 allowed amount x .20 = $47.98). This item/service falls within the 
Medicare Part B prescription drugs benefit category.  
 
You have been asked to pay a total cost share of $220.78 for the single-photon emission computerized 
tomography (SPECT) scan and the injections ($150 + $22.80 + $47.98 = $220.78). This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the cost sharing for the single-photon emission computerized tomography (SPECT) scan, the 
regadenoson injection, and the technetium tc 99m tetrofosmin injection provided by an in-network provider on 
March 18, 2022.