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

 
We decided that the Plan does not have to pay for electromagnetic radiation imaging (X-ray) provided on 
October 19, 2022. 
 
You asked the Plan to pay for electromagnetic radiation imaging (X-ray).You say that the claim was billed 
correctly and should be paid. The Plan denied your request. The Plan says the services were billed with the 
wrong place of service code. 
 
 
The Plan must follow Medicare rules. Medicare rules say that many of the diagnostic services, including 
radiology services, provided by physicians/practitioners contain both a technical component (TC) and a 
professional component (PC). Often, the PC and TC of diagnostic services are furnished in different settings. 
As a general policy, the Place of Service (POS) code assigned by the physician/practitioner for the PC of a 
diagnostic service shall be the setting in which the beneficiary received the TC service. You can find this information in the Centers for Medicare and Medicaid Services, Internet-Only Manual, Publication 100-04, 
Medicare Claims Processing Manual, Section 150 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of electromagnetic radiation imaging (X-ray). 
 
 have not been met. Therefore, we decided that the Plan does not have to pay for electromagnetic radiation 
imaging (X-ray) provided on October 19, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for inpatient hospital stay on September 06, 
2022, to September 07, 2022. 
 
You asked the Plan to waive the coinsurance for inpatient hospital stay. You say that you want to appeal the 
amount being charged. 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 20% 
coinsurance for each Medicare-covered hospital stay each time you are admitted for inpatient hospital stay. 
Includes inpatient acute, inpatient rehabilitation, long-term care hospitals, and other types of inpatient hospital 
services. Inpatient hospital care starts the day you are formally admitted to the hospital with a doctors order. 
The day before you are discharged is your last inpatient day. The provider billed the amount of $45,415 and the 
allowed amount is $12,181.07. The enrollee should have been assessed a coinsurance of $2,436.21, however as 
the enrollee reached their out-of-pocket maximum, the enrollee was only assessed a coinsurance amount of 
$1,778. Therefore, results in the total cost sharing amount of $1,778. 
 
You have been asked to pay a $1,778 coinsurance for inpatient hospital stay. This item/service 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 on September 06, 2022, to September 07, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery services provided on 
August 1, 2022, to August 4, 2022. 
 
You asked the Plan to waive the copayment for outpatient surgery services. You say that you disagree with the 
copayment. 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 $300 
copayment per surgery for outpatient surgery/outpatient hospital.  
 
You have been asked to pay a $300 copayment per surgery for outpatient surgery services. The total amount 
you are being asked to pay $600 ($300 x 2 surgery = $600). 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 outpatient surgery services provided on August 1, 2022, to August 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for core buildup services, a crown, and intraoral x-ray 
(D2950, D2740, D0220) provided on October 20, 2022. 
 
You asked the Plan to pay more for the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says you are responsible for any charged 
amount above the Plans cost-sharing amount when your services are received from an out-of-network 
provider. 
 
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. 
 
 
  You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for core buildup services, a crown, and intraoral 
x-ray (D2950, D2740, D0220) provided on October 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 a ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found a home ventilator is not medically 
necessary. There is a diagnosis of chronic obstructive pulmonary disease (COPD), but there are no pulmonary 
function test to confirm the severity. If this enrollee has severe COPD and chronic carbon dioxide (CO2) 
retention, as documented on an arterial blood gas done while stable, may benefit from bilevel positive airway 
pressure (BiPAP) with average volume assured pressure support (AVAPS) during sleep. Medicare does not cover a home ventilator when used at settings that can be provided with 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 a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral x-ray (D0210) provided on December 5, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within 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 pay for an 
intraoral x-ray (D0210) provided on December 5, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for in home physical therapy provided on September 05, 2022, 
to September 29, 2022. 
 
You asked the Plan to pay for in home physical therapy. You say that you had to have physical therapy while 
out-of-area. The Plan denied your request. The Plan says that unauthorized, out-of-network care is 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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for in home physical 
therapy provided on September 05, 2022, to September 29, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve trans perineal spacer placement. 
 
You asked the Plan to pre-approve trans perineal spacer placement. You say that the services are necessary. 
The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not 
been met. 
 
The Plan follows Medicare rules. Medicare rules say that Polyethylene-glycol (PEG) hydrogel is covered when 
specific criteria are met. 
 
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 trans perineal spacer placement. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found you do not meet the 
coverage criteria. The records show that you have unfavorable intermediate prostate cancer, which excludes 
coverage of trans perineal rectal spacer. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of trans perineal spacer placement have not been met. Therefore, we decided that 
the Plan does not have to pre-approve trans perineal spacer placement.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 13 home health physical therapy visits. 
 
You asked the Plan to pre-approve home health services. You say that you would like to request 
reconsideration of the denied prior authorization. The Plan denied your request. The Plan says the services are 
not medically necessary. 
 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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found that after the 
physical therapy treatments already provided, the records do not support that the complexity of the enrollee's 
conditions are such that the skills of a professional therapist are required to achieve further improvement in the 
enrollee's symptoms or functional status. The records document the enrollee has been educated on a home 
exercise program. Further utilization of the home exercise program appears appropriate at this point. No 
medical notes from the enrollee's treating physician are provided documenting an order or need for additional 
skilled therapy services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 13 home health physical therapy visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral x-ray, fluoride application, a crown, and 
peridontal maintenance (D0220, D1206, D2740, D4910) provided on November 3, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your $2,000 dental maximum benefit allowance 
for the requested item or service has already been exhausted. The record also indicates that you already 
received an intraoral x-ray on January 12, 2022, these procedures can only be covered once per plan year. 
 
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 requested item or service was exhausted on date of service April 8, 2022. Therefore, 
we decided that the Plan does not have to pay for an intraoral x-ray, fluoride application, a crown, and 
peridontal maintenance (D0220, D1206, D2740, D4910) provided on November 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core build-up services (D2950) provided on October 25, 
2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within 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 pay for core 
build-up services (D2950) provided on October 25, 2022.
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 LTACH services are medically 
necessary. The Plan denied your request. The Plan says that the coverage criteria has not been met. 
 
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 that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. All medically necessary care is being provided in 
the current acute care setting. The requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only 
on an inpatient basis. 
 
 
 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 LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral x-ray (D0210) provided on October 19, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. 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 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 requested item or service was exhausted on date of service November 10, 2021. 
Therefore, we decided that the Plan does not have to pay for an intraoral x-ray (D0210) provided on October 
19, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ultrasound provided on September 14, 2022. 
 
You asked the Plan to pay for ultrasound. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says that unauthorized, out-of-network care is 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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for ultrasound provided on 
September 14, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for a mammogram provided on October 6, 
2022. 
 
You asked the Plan to waive the cost share for a mammogram. You say that you disagree with the cosh share. 
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. Your 
contract with the Plan says that there is a $150 deductible and a 5% coinsurance which applies to outpatient 
diagnostic tests/advanced imaging services.  
 
The item or service you asked the Plan to waive the cost share for falls within the outpatient diagnostic 
tests/advanced imaging services benefit category. The total amount you are being asked towards your 
deductible is $64.92. Also, you are being asked to pay the remaining .83 for your coinsurance. The total 
amount you are being asked to pay is $65.76 ($64.92 + .83 = $65.76). This cost sharing is a contractual 
obligation that had not been met at the time a mammogram was received on October 6, 2022. Therefore, we 
decided that the Plan does not have to waive the cost share for a mammogram provided on October 6, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient diagnostic test provided on 
October 28, 2022. 
 
You asked the Plan to waive the copayment for an outpatient diagnostic test. You say that you disagree with 
the copaymet. 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 $250 
copayment for outpatient diagnostic tests/For CT scans, MRIs, PET scans, and nuclear cardiac imaging tests. 
 
You have been asked to pay a $250 copayment for an outpatient diagnostic test. This item/service falls within 
the outpatient diagnostic tests/For CT scans, MRIs, PET scans, and nuclear cardiac imaging tests 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 an outpatient diagnostic test provided on 
October 28, 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 need physical therapy that a skilled nursing 
facility would not be able to provide like an inpatient rehabilitation facility would. The Plan denied your 
request. The Plan says that the admission to an IRF is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of your nursing, medical, and rehabilitation needs do not require 
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical status does not currently require intensive physician and nursing oversight in an IRF. While you may benefit from 
additional multiple therapies, including physical and occupational therapy, the documentation does not reveal 
that you require this therapy on an intensive IRF level. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the disposable drug delivery system (A4305) and infusion 
supplies not used with external infusion pump, per cassette or bag (list drugs separately) (A4223) provided 
August 23, 2022, to August 29, 2022. 
 
You asked the Plan to pay for the infusion supplies. You say that the home infusion therapies allow patients to 
continue medical treatment at a lower cost than if they were to remain in the hospital. The Plan denied your 
request. The Plan says this service is not covered by Medicare. 
 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 infusion supplies have not been met. Therefore, we decided that the Plan does not have to pay 
for the disposable drug delivery system (A4305) and infusion supplies not used with external infusion pump, 
per cassette or bag (list drugs separately) (A4223) provided August 23, 2022, to August 29, 2022.