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

 
We decided that the Plan does not have to waive the copayment for office visit on May 11, 2022. 
 
You asked the Plan to waive the copayment for office visit. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says the cost sharing you are being charged 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 a $25 
copayment per visit to a specialist. Covered services include medically necessary medical care or surgery 
services furnished in a physicians office, certified ambulatory surgical center, hospital outpatient department, 
or any other location. Consultation, diagnosis, and treatment by a specialist. The provider billed in the amount 
of $54 and the allowed is $21.06. This is less than the copayment amount. Therefore, results in the total cost 
sharing amount of $21.06. 
 
 
 
 
 You have been asked to pay a $21.06 copayment, which is less than the copayment amount for office visit. 
Office visits 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. Therefore, we decided that 
the Plan does not have to waive the copayment for office visit on May 11, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that you are appealing the denial of SNF admission. The 
Plan denied your request. The Plan says the enrollee exceeds mobility criteria for SNF admission. The enrollee 
would be equally well served in an alternative level of care, such as discharge to home with health and home 
care services and family assistance as needed. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee received physical and occupational therapy. The enrollee was at an 
independent level for bed mobility and transfers. The enrollee could ambulate 200 feet with stand by assist to 
contact guard assist, and required varying assist with activities of daily living skills. The enrollee does not have 
daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional 
nurse. The enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and 
judgment of a skilled professional therapist. Our reviewer also found the enrollee does not require daily skilled 
nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a procedure provided from October 26, 
2021, to December 28, 2021. 
 
You asked the Plan to waive the copayment for a procedure. You say that you do not consider what you had 
done to be a procedure, especially because you had to have this treatment done nearly every week. 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 $320 
copayment for hospital outpatient facilities and ambulatory surgical centers. These allowed amounts of these 
copayments were all less than the $320 copayments due each time. $222.40 x 6 visits = $1334.40 + $318.93 x 5 
visits = $1594.65. This gives you a total of $1334.40 + $1594.65 = $2929.05.  
 You have been asked to pay a $2929.05 copayment for a series of procedures. A procedure falls within the 
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 a procedure provided from October 26, 2021, to December 28, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and transport, no treatment, (A0998) 
provided on September 8, 2021. 
 
You asked the Plan to pay for the ambulance service. You say that your vision began to change, and you ended 
up passing out. You say that you hit your head when you went unconscious. You say that the ambulance came 
and checked your vitals. You also say that this should be covered. The Plan denied your request. The Plan says 
since no transport was provided, there is no payable service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on September 8, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and transport, no 
treatment, (A0998) provided on September 8, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy (PT) services provided on 
November 19, 2021. 
 
You asked the Plan to waive the copayment for the PT services. You say that you cannot afford all of the 
copayments. 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 physical therapy visit.  
 
You have been asked to pay a $35 copayment for the PT services. The PT services fall 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 (PT) services provided on November 19, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core buildup, including any pins (D2950) X2, pontic - 
porcelain/ceramic (D6245), and 3D photographic image (D0351) provided on March 15, 2022. 
 
You asked the Plan to pay for core buildup, pontic and 3D image. The Plan denied your request. The Plan says 
the services provided are not a covered benefit under your dental plan.  
  
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for core 
buildup, including any pins (D2950) X2, pontic - porcelain/ceramic (D6245), and 3D photographic image 
(D0351) provided on March 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit, computed tomography (CT) of the face, and 
upper jaw and facial prosthesis provided from March 30, 2022, to April 27, 2022, by an out-of-network (OON) 
provider. 
 
You asked the Plan to pay for the physician services. You say that you are aware of the non-coverage for 
temporomandibular joint (TMJ) services. You say that treatment of TMJ has nothing to do with the care of 
your teeth. You also say that you would like this non-coverage to be reconsidered. The Plan denied your 
request. The Plan says services that you receive out-of-network are not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan 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 office visit, computed tomography (CT) of the face, and upper jaw and facial prosthesis provided from March 30, 2022, to April 27, 2022, 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 comprehensive oral evaluation (D0150) and the intraoral-
complete series of radiographic images (D0210) provided on March 9, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says your benefit for the services provided 
has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the services provided was exhausted on date of service June 2, 2021. Specifically, the 
Plan contract states that one comprehensive oral evaluation is covered every three calendar years.  
 Additionally, one intraoral-complete series of radiographic images or panoramic radiographic image is covered 
every five calendar years. You previously received a comprehensive oral evaluation and a panoramic 
radiographic image on June 2, 2021, which were paid for by the Plan. Therefore, you have exhausted the 
allowable benefit for the services provided in this case. Therefore, we decided that the Plan does not have to 
pay for the comprehensive oral evaluation (D0150) and the intraoral-complete series of radiographic images 
(D0210) provided on March 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visit on August 31, 2021. 
 
You asked the Plan to waive the copayment for office visit. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says the cost sharing you are being charged 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 a $40 
copayment for physician specialist services (including surgery second opinion, telehealth, and urgently needed 
services). Covered services include medically necessary medical care or surgery services furnished in a 
physicians office, certified ambulatory surgical center, hospital outpatient department, or any other location. 
Consultation, diagnosis, and treatment by a specialist.  
 
 
 
 
 You have been asked to pay a $40 copayment for office visit. Office visits 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. Therefore, we decided that the Plan does not have to waive the copayment 
for office visit on August 31, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied
your request. The Plan says the stay is not medically necessary based on IRF 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 there is not a reasonable expectation that this enrollee will be able to fully participate
in and benefit from the intensive rehabilitation therapy program provided in an IRF.
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 IRF admission and services.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency 
transport (A0428), and ground mileage (A0425) provided on February 28, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that the enrollee revoked their hospice benefit 
before the date of service. The Plan denied your request. The Plan says the enrollees claim would be covered 
under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until 
the last day of the month in which hospice is revoked. The Plan also says it is the providers responsibility to 
verify the enrollees coverage before rendering services and to know proper billing procedures for a Medicare 
Advantage member on hospice. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on February 6, 2022. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the ambulance 
service, basic life support, non-emergency transport (A0428), and ground mileage (A0425) provided on 
February 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit provided on April 20, 2022. 
 
You asked the Plan to waive the copayment for the office visit. You say that the provider could not do anything 
for you, and you should get your copay back. 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 $40 
copayment for a specialist visit.  
 
You have been asked to pay a $40 copayment for a visit with a specialist. The 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 the office visit provided on April 20, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting reconsideration of approval for 
IRF due to presence of coronary angioplasty implant. The Plan denied your request. The Plan says based on 
Medicare guidelines the inpatient rehabilitation facility services you are requesting do not meet the 
requirements for approval. 
 
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 were admitted to an acute hospital on August 24, 2022 with chest pain and 
right lower extremity pain and was found to have significant multivessel cardiac disease and non-ST-elevation 
myocardial infarction. You underwent a two-vessel bypass on August 30, 2022. You had hypokalemia, which 
was repleted with improvement, were hypoxemic and was provided with oxygen supplementation. You are 
medically stable with decreased function and debility. Comorbid conditions are all stable. While you would 
benefit from physical and occupational therapy your rehabilitation needs can be safely provided in an alternate 
and low intensity setting such as in-home with services or in a skilled nursing facility. 
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy provided on  
September 13, 2021. 
 
You asked the Plan to waive the copayment for physical therapy. You say that you should not be responsible 
for this cost share. 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 a $20 
copayment for Medicare-covered physical therapy visits.  
 
You have been asked to pay $20 for physical therapy. Physical therapy falls within the Outpatient 
Rehabilitation Services benefit category. This means that you have been asked to pay the correct amount based 
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for physical therapy provided on September 13, 
2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing and home health services provided from 
January 15, 2022, to February 13, 2022. 
 
You asked the Plan to pay for skilled nursing and home health services. 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 skilled nursing and home health services provided from 
January 15, 2022, to February 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and a complete 
series of intraoral x-rays (D0240) provided on April 26, 2022. 
 
You asked the Plan to pay for the dental services. You say that the dental receptionist confirmed with the Plan 
that the charges would all be paid in full through the Plan. The Plan denied your request. The Plan says your 
benefit for the requested item or service has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service July 3, 2020. Therefore, 
we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and a complete 
series of intraoral x-rays (D0240) provided on April 26, 2022.