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

 
We decided that the Plan does not have to pay for the continued acute inpatient psychiatric hospital care 
provided from May 27, 2023, through May 30, 2023.  
 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the acute inpatient psychiatric hospital care 
provided was not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 
acute inpatient psychiatric hospital care provided was not medically necessary. Our physician reviewer found 
that the enrollee was involuntarily admitted for acute inpatient psychiatric hospitalization on April 20, 2023 
with Schizoaffective Disorder Bipolar Type. Based upon the review of the records provided, it was not 
expected that this enrollee would improve in a reasonable period of time for the dates in question as she did not 
have suicidal or homicidal ideation, or auditory and visual hallucinations. The enrollee was compliant with 
treatment while not showing any acute threats to safety. It did not appear medically necessary and reasonable to 
have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the 
dates in question as she did not have dangerousness to self or others and was compliant with her treatment. The 
health plans denial of continued inpatient psychiatric services is appropriate. This enrollee did not appear to 
require inpatient mental health treatment beyond the date in question as she was not a danger to herself or 
others and did not have auditory or visual hallucinations. It did not appear that active treatment was taking 
place beyond the date in question. It did not appear that the services were reasonably expected to improve the 
enrollees condition or were for the purpose of a diagnosis beyond the date in question. It did appear that the 
records were supervised and evaluated by a physician. Based upon the review of the records provided, the 
enrollee does not meet the criteria for coverage of the acute inpatient psychiatric hospital care provided from 
May 27, 2023 forward as she was not shown to be a danger to herself or others, and did not have delusions, or 
auditory and visual hallucinations as noted. She was cooperative/compliant with treatment while not showing 
any threats to safety. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pay for the continued acute inpatient psychiatric hospital care provided from May 27, 2023, through 
May 30, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve mandibular partial denture - flexible base (D5226). 
 
You asked the Plan to pre-approve the dental services. You say that this is medically necessary. 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 March 6, 2023. 
Therefore, we decided that the Plan does not have to pre-approve mandibular partial denture - flexible base 
(D5226).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for crowns and core build up services (D2750, 
D2950) provided on June 28, 2023. 
 
You asked the Plan to waive the copayment for the dental services. You say that the services should be covered 
as you disagree with the charges. The Plan denied your request. The Plan says your benefit for the crowns and 
core build up services was exhausted on the appealed claim. Additionally, the set of codes that were paid 
applied a 50% coinsurance correctly. 
 
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 crown and core build up services was exhausted with the appealed claim on date of 
service June 28, 2023. 
 
You have been asked to pay a 50% for a crown and core buildup. This item/service falls within the Dental 
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 coinsurance for crowns and core build up 
services or pay for the additional crowns and core build up x2 (D2750, D2950) provided on June 28, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for advanced life support (Als), level 2 (A0433), ground mileage 
(A0425) and Als routine disposable supplies (A0398) provided on January 29, 2022. 
 
You asked the Plan to pay for advanced life support (Als), level 2 (A0433), ground mileage (A0425) and Als 
routine disposable supplies (A0398). You say that initially you filed to the incorrect Plan and were denied. The 
Plan denied your request. The Plan says claim denied as untimely. The Plan also says that the first claim was 
received after a year from date of service. 
 
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 advanced life support (Als), level 2 (A0433), ground mileage (A0425) and 
Als routine disposable supplies (A0398) was not filed until March 27, 2023. 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 advanced life support (Als), level 2 (A0433), ground mileage (A0425) and Als routine 
disposable supplies (A0398) provided on January 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each sclerotherapy provided on March 24, 
2023, to April 28, 2023. 
 
You asked the Plan to waive the copayment for each sclerotherapy. You say that you say that the providers 
office told you this would be covered under your $0 office visit copay and you feel that due to the provider 
giving you incorrect information, this should be waived. 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 $270 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
You have been asked to pay a $270 copayment for each sclerotherapy. This item/service falls within the 
outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. The 
total you owe is $540 ($270 copayment x 2 visits = $540). Therefore, we decided that the Plan does not have to 
waive the copayment for each sclerotherapy provided on March 24, 2023, to April 28, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance service provided on April 11, 
2023. 
 
You asked the Plan to waive the copayment for ambulance service. You say that you are requesting 
reconsideration stating you were not given a choice as to the type of transportation you used and were forced to 
go via ambulance to ER. 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 $290 
copayment for ambulance service. 
 
You have been asked to pay a $290 copayment for ambulance service. This item/service falls within the 
ambulance service 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 ambulance service 
provided on April 11, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 8 additional routine transportation trips. 
 
You asked the Plan to pre-approve the additional trips. The Plan denied your request. The Plan says the record 
shows you currently have two (2) trips remaining and you will have exceeded your benefit limit. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 36 trips per year.  
 
We looked at your request, the records in the case file, and the rules. You asked the Plan to pre-approve 8 
additional routine transportation trips. Based on this information, we decided that you have exhausted the Plan 
maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to 
pre-approve 8 additional routine transportation trips.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from October 21, 2022, 
through October 23, 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 evaluated in the emergency department (ED) on October 21, 2022 and was noted to 
have evidence of congestive heart failure and atrial fibrillation with a burst of ventricular tachycardia,  
premature ventricular contractions, and a rapid ventricular rate. He was admitted and placed on an Amidarone 
infusion, supplemental oxygen, and intravenous diuretics. His condition stabilized and improved and he was 
medically stable to be discharged home on October 23, 2022. The review has determined that the record 
showed that at the time of the inpatient admission it was reasonable for the admitting physician to expect that 
the enrollee's necessary hospital care (including earlier ED and/or observation care) would span two midnights 
with supporting documentation of the enrollee's history and comorbidities, signs and symptoms, current 
medical needs, and risk of an adverse event.  
 
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 October 21, 2022, through October 23, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing provided on July 12, 2023. 
 
You asked the Plan to pay for drug testing. You say that you have to see this provider all the time. 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 drug testing provided on 
July 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block (64454). 
 
You asked the Plan to pre-approve a genicular nerve block. 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 nerve blockade for treatment of chronic pain and 
neuropathy 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 a genicular nerve block. Our reviewer says that the services are not medically necessary. Our physician reviewer found genicular nerve block is 
experimental for knee pain. 
 
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 genicular nerve block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a genicular nerve block (64454).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder test (0013M) provided on July 7, 2023. 
 
You asked the Plan to pay for the Cxbladder test. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for Cxbladder are non-
covered. 
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the Cxbladder test have not been met. Therefore, we decided that 
the Plan does not have to pay for the Cxbladder test (0013M) provided on July 7, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed. 
 
You asked the Plan to pre-approve a total electric hospital bed. You say that the item is necessary. The Plan 
denied your request. The Plan says the item is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed (E0265, E0266, 
E0296, and E0297) is not covered; the height adjustment feature is a convenience feature. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a total electric hospital bed have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a total electric hospital bed.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a resin-based composite (D2335) and an application of 
desensitizing for cervical and/or root surface (D9911) provided on June 19, 2023. 
 
You asked the Plan to pay for a resin-based composite (D2335) and an application of desensitizing for cervical 
and/or root surface (D9911). You say that you are appealing with supporting records. The Plan denied your 
request. The Plan says these services are not a covered benefit. 
 
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 a resin-
based composite (D2335) and an application of desensitizing for cervical and/or root surface (D9911) provided 
on June 19, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for in-network echocardiography (EKG) test 
and other diagnostic testing provided from April 3, 2023, to April 11, 2023. 
 
You asked the Plan to waive the deductible for an echocardiography (EKG) test and other diagnostic testing. 
You say that you went from having a basic copayment to having these two tests done and now you owe over 
$800. You feel you should not have to pay this. 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 an $800 deductible which applies to diagnostic tests.  
 
The item or service you asked the Plan to waive the deductible for falls within the diagnostic tests benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is an $800 
deductible which applies to diagnostic tests.  
 This cost sharing is a contractual obligation that had not been met at the time an echocardiography (EKG) test 
and other diagnostic testing was received on April 3, 2023, to April 11, 2023. You have been asked to pay 
$807.67 towards this deductible. There is a 10% coinsurance on EKGs and other diagnostic tests, which is 
where the additional $7.67 is being cited. 
Therefore, we decided that the Plan does not have to waive the deductible for in-network echocardiography 
(EKG) test and other diagnostic testing provided from April 3, 2023, to April 11, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each ambulance service provided on April 
21, 2023, to April 25, 2023. 
 
You asked the Plan to waive the copayment for each ambulance service. You say that you are asking for an 
extra help for the copayment because you are unable to work due to your condition right now. 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 $225 
copayment for ambulance services. 
 
You have been asked to pay a $225 copayment for each ambulance service. This item/service falls within the 
ambulance 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. The total you owe is $450 ($225 copayment x 2 visits = $450). Therefore, we decided that the Plan 
does not have to waive the copayment for each ambulance service provided on April 21, 2023, to April 25, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone replacement graft for ridge preservation (D7953). 
 
You asked the Plan to pre-approve bone replacement graft for ridge preservation (D7953). You say that you 
need these services before getting dentures. The Plan denied your request. The Plan says this is not a covered 
benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve bone 
replacement graft for ridge preservation (D7953).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an in-network heated humidifier, used 
with positive airway pressure device provided on May 25, 2023. 
 
You asked the Plan to waive the coinsurance for an in-network heated humidifier, used with positive airway 
pressure device. You say that you were not aware you were going to be charged for this item. 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 20% 
coinsurance for durable medical equipment (DME) and related supplies. 
 
You have been asked to pay 20% coinsurance for an in-network heated humidifier, used with positive airway 
pressure device. This item/service falls within the durable medical equipment (DME) and related supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. The 
total you owe is $54.80 ($274 allowed amount x 20% = $54.80) Therefore, we decided that the Plan does not 
have to waive the coinsurance for an in-network heated humidifier, used with positive airway pressure device 
provided on May 25, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair.  
 
You asked the Plan to pre-approve a shower chair. You say that you the enrollee needs the shower chair to bath 
safely. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.