Persius/hicric huggingface dataset:
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 discharge to any lower level of care 
would likely result in recurrent hospitalization, morbidity, and potential mortality.  The Plan denied your 
request. The Plan says admission to an LTACH is not medically necessary.  
 
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 there is no documentation provided indicating medical necessity for admission to 
an LTACH. The enrollee does not require services at the LTACH that are not available at the acute care 
hospital where they are currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the Plan. 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: 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 meets the criteria for inpatient 
rehabilitation. The Plan denied your request. The Plan says the enrollee does not meet the criteria for 
admission. 
 
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 complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the drug administration provided on 
January 18, 2023. 
 
You asked the Plan to waive the copayment for the drug administration. You say that you did not receive an 
injection on this date. 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 $200 
copayment for in-network outpatient hospital services. 
 
You have been asked to pay a $200 copayment for the drug administration. This item/service falls within the 
in-network outpatient hospital 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 medical records show that drug administration services were provided 
on January 18, 2023. Therefore, we decided that the Plan does not have to waive the copayment for the drug 
administration provided on January 18, 2023.
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 cannot care for self independently and 
lives alone. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for 
admission to an Inpatient Rehabilitation Facility. 
 
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 complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing examination provided on December 15, 2022, by 
an OON provider.  
 
You asked the Plan to pay for the hearing exam. You say that you are requesting reconsideration of the denied 
claim. The Plan denied your request. The Plan says this service was not authorized. 
 
 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 Plan contract says the enrollees POS benefit only applies to 
covered routine dental services. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the item/service at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for the item/service. Therefore, 
we decided that the Plan does not have to pay for the hearing examination provided on December 15, 2022, by 
an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the Part B drug and the injection provided 
on January 23, 2023. 
 
You asked the Plan to waive the cost share for the Part B drug and the injection. You say that you are appealing 
this amount.  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 Medicare-covered Part B chemotherapy drugs and other Part B drugs and a $45 copayment for 
Medicare-covered exams to diagnose and treat diseases and conditions of the eye and all other Medicare-
covered vision services.  
 
You have been asked to pay $28.30 which is 20% of the allowed amount for the Part B drug. The allowed 
amount I s$141.50. ($141.50 x 20% = $28.30). The Part B drug falls within the Medicare Part B prescription 
drugs benefit category. You have been asked to pay a $45 copayment for the injection. The record shows the 
injection is considered a physician services. The injection falls within the vision 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 cost share for the Part B drug and the injection provided on January 23, 
2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance response and treatment, no transport provided on 
January 26, 2023. 
 
You asked the Plan to pay for ambulance response and treatment, no transport. You say that you had a total 
knee replacement on January 23, 2023 and you fell on January 26, 2023 and could not get up and you called the 
ambulance for help as your wife was not able to lift you off of the floor. You say that the fall did not cause any 
injury so you refused transport to the hospital. The Plan denied your request. The Plan says per Medicare, an 
ambulance service provided without transport is not covered by Medicare. 
 
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 January 26, 2023. 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 ambulance response and treatment, no transport 
provided on January 26, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 99348 billed for date of service January 10, 2023. 
 
You asked the Plan to pay for the billed services. You say that the services were billed correctly. The Plan 
denied your request. The Plan says that the claim was not billed with the correct modifier or place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99348 is supported. The rules say that this code is used to report services furnished in 
settings, including but not limited to, a custodial care facility. The claim shows that the services were provided 
in a custodial care facility (POS 33). The -AI modifier is not applicable in this case as this modifier is used for 
skilled nursing facilities and nursing facilities (POS 31 and 32 respectively). Based on this information, we 
decided that Medicare rules for coverage of the billed services have been met. Therefore, we decided that the 
Plan has to pay for procedure code 99348 billed for date of service January 10, 2023.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyewear provided on March 13, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the eyewear. You say that you were under the impression that the $250 
allowance was for an out-of-network and that you can request reimbursement. The Plan denied your request. 
The Plan says the provider was out-of-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
eyewear. We found no exception that would require the Plan to pay for the eyewear. Therefore, we decided that the Plan does not have to pay for the eyewear provided on March 13, 2023, by an out-of-network (OON) 
provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 29, 2021 
 
You asked the Plan to pay for the laboratory services. 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 laboratory services was not filed until January 31, 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 the laboratory services provided on January 29, 2021
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing provided on August 10, 2021. 
 
You asked the Plan to pay for the drug testing. 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 drug testing was not filed until February 12, 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 the drug testing provided on August 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gingivectomy or gingivoplasty, restorative procedure 
(D4212). 
 
You asked the Plan to pre-approve gingivectomy or gingivoplasty. You say that this should be covered. The 
Plan denied your request. The Plan says this is not a covered service. 
 
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 
gingivectomy or gingivoplasty, restorative procedure (D4212).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist office visit provided on 
February 17, 2023. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that this was only for a blood 
draw and you should not have a 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 $45 
copayment for specialist physician/practitioner services. 
 
You have been asked to pay a $45 copayment for the specialist office visit. This item/service falls within the 
specialist 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. However, since the allowed amount is less than the standard copayment, 
you only owe $30.36. Therefore, we decided that the Plan does not have to waive the copayment for the 
specialist office visit provided on February 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on October 6, 2021. 
 
You asked the Plan to pay for the laboratory services. 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 laboratory services was not filed until February 2, 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 the laboratory services provided on October 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve extractions, erupted tooth requiring removal of bone 
and/or sectioning of tooth (D7210) and guided tissue regeneration, natural teeth, resorbable barrier, per site 
(D4266). 
 
You asked the Plan to pre-approve the dental services. You say that this should be covered. The Plan denied 
your request. The Plan says your benefit for the extractions has already been exhausted and guided tissue 
regeneration is not a covered service. 
 
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. Therefore, we decided that the Plan does not have to pre-approve extractions, erupted tooth requiring removal of bone and/or sectioning of tooth 
(D7210) and guided tissue regeneration, natural teeth, resorbable barrier, per site (D4266).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography of the head or 
brain provided on January 1, 2023, and laboratory services provided from January 1, 2023 to January 4, 2023. 
 
You asked the Plan to waive the copayment for the computed tomography of the head and brain and laboratory 
services. You say that these services were provided in the emergency room. 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 advanced imaging services, outpatient hospital and pay a 20% coinsurance for lab services, 
outpatient hospital. You have been asked to pay a lesser amount of $101.72 for the computed tomography of the head and brain 
and $19.43 laboratory services. These services fall within the advanced imaging services, outpatient hospital 
benefit category and the lab services, outpatient hospital 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 computed tomography of the head or brain provided on January 1, 2023, and laboratory 
services provided from January 1, 2023 to January 4, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bitewings - four radiographic images (D0274) provided on 
December 30, 2022. 
 
You asked the Plan to pay for the bitewings - four radiographic images. You say that asdfasdf The Plan denied 
your request. The Plan says your benefit for the bitewings - four radiographic images 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 bitewings - four radiographic images was exhausted on date of service June 24, 
2022. Therefore, we decided that the Plan does not have to pay for bitewings - four radiographic images 
(D0274) provided on December 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the single vision lens and the polycarbonate lens provided on 
February 3, 2023. 
 
You asked the Plan to pay for the vision items. You say that you were unaware of the lens upgrade. You say 
that you informed the provider that you did not want to pay for any additional charges. The Plan denied your 
request. The Plan says the service is not a covered benefit. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when not covered. 
 
We looked at the file and the Plan's rules. Specifically, the polycarbonate lens is considered an upgrade and not 
covered. However, the record shows that the Plan paid the $20 allowed amount, and the provider originally 
billed $50 for the polycarbonate lens. ($50 - $20 - $30). Please note, the Plan fully paid for the single vision 
lens. Based on this information, we decided that the Plan's rules for coverage of the vision items have not been 
met. Therefore, we decided that the Plan does not have to pay for the single vision lens and the polycarbonate 
lens provided on February 3, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on October 25, 2021. 
 
You asked the Plan to pay for the laboratory services. 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 laboratory services was not filed until March 6, 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 the laboratory services provided on October 25, 2021.