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

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
April 1, 2023, to April 3, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you did not know you 
would be charged an additional copayment when being transferred to a new facility. 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 $450 
copayment per day for days 1-5 of each inpatient hospital stay. Your contract with the Plan also clearly says that you then pay a $0 copayment per day after day five. Your contract with the Plan also clearly says that a 
transfer to a separate facility type is considered a new admission. 
 
You have been asked to pay a $450 copayment per day for days 1-2 of the inpatient hospital stay. This 
item/service falls within the inpatient hospital care benefit category. You have not been charged after day two 
or for the day you were discharged. You have been asked to pay a $900 copayment for this inpatient hospital 
stay ($450 copayment per day x 2 days = $900). 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 inpatient hospital stay provided from April 1, 2023, to April 3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on March 21, 2023, by an OON 
provider.  
 
You asked the Plan to pay for the office visit. You say that the services were provided in good faith. The Plan 
denied your request. The Plan says the services were 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 items/services 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 these items/services. 
Therefore, we decided that the Plan does not have to pay for the office visit provided on March 21, 2023, by an 
OON provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the lumbar fusion and allograft. 
 
You asked the Plan to pre-approve the lumbar fusion and allograft . You say that the service is medically 
necessary. The Plan denied your request. The Plan says the lumbar fusion and allograft is not medically 
necessary. The Plan says there are missing MRI and CT reports, and there is no documentation of failing an 
adequate trial of conservative treatments. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 the lumbar fusion and allograft. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found there is no imaging documentation showing lumbar instability. There is no 
recent physical therapy for back 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 the lumbar fusion and allograft have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the lumbar fusion and allograft.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prefabricated abutment  includes modification and 
placement (D6056) and abutment supported porcelain/ceramic crown (D6058) Tooth #29 provided on March 
24, 2023. 
 You asked the Plan to pay for dental services. You say that the services should be covered because you did not 
know you needed a pre-authorization. The Plan denied your request. The Plan says a pre-authorization was not 
received or approved.  
 
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 services are covered but 
a pre-authorization is required in order to be covered. No pre-authorization was received prior to you receiving 
the requested services. Therefore, we decided that the Plan does not have to pay for the prefabricated abutment 
 includes modification and placement (D6056) and abutment supported porcelain/ceramic crown (D6058) 
Tooth #29 provided on March 24, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on January 11, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that the 
emergency medical service examined you and all you needed was a band aid to stop the bleeding. You also say 
that you did not call for an ambulance. The Plan denied your request. The Plan says these services are not a 
covered benefit.  
 
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 11, 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 the ambulance response and treatment with no 
transport provided on January 11, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc. 
 
You asked the Plan to pre-approve Synvisc. You say that the services are medically necessary. The Plan denied 
your request. The Plan says the records provided do not show that the enrollee has met the criteria. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Synvisc. Our reviewer says that the 
medication is not medically necessary. Our physician reviewer found the documentation does not support that 
the enrollee has tried and failed reasonable therapeutic alternatives. The documentation does not support that 
Synvisc is safe and effective for the enrollee. The request for Synvisc cannot be approved at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Synvisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Synvisc.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the replacement nasal pillows provided by 
an in-network provider on February 22, 2023. 
 
You asked the Plan to waive the cost sharing for the nasal pillows. You say that you do not feel you should 
have to pay 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. Your 
contract with the Plan says that there is a $800 deductible, and that you must pay a 10% coinsurance of the 
approved amount and the annual deductible applies for in-network durable medical equipment (DME) and 
related medical supplies. 
 
 
 
 You have been asked to pay a $3.04 coinsurance for the nasal pillows ($30.42 allowed amount x .10 = $3.04). 
You have also been asked to pay a $27.38 deductible for the nasal pillows. The items or services you asked the 
Plan to waive the cost sharing for fall within the durable medical equipment (DME) and related medical 
supplies benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there 
is a $800 deductible which applies to durable medical equipment (DME) and related medical supplies. This 
cost sharing is a contractual obligation that had not been met at the time the nasal pillows were provided on 
February 22, 2023. Therefore, we decided that the Plan does not have to waive the cost sharing for the 
replacement nasal pillows provided by an in-network provider on February 22, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are appealing this denial. The Plan denied your 
request. The Plan says you do not meet Medicare guidelines for services in an IRF. 
 
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 does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While you may have a need for physical therapy and/or occupational 
therapy, there is no documented need for intensive rehabilitation services.  
 
There is not a reasonable expectation that you 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 an IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are requesting an expedited appeal 
for the denial of an LTACH admission. The Plan denied your request. The Plan says the LTACH services 
requested do not meet the requirements for approval.  
 
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 the enrollee appears to be improving with current treatment and should only 
require short-term additional acute care services that can safely be provided at the current facility until more 
stable and appropriate for transfer to a lower level of care. There are no services at the LTACH that the enrollee 
requires that are not already available and covered at the current facility. Transfer to the LTACH would not be 
clinically advantageous at this time and completion of treatment at the current facility is recommended.  
 
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 long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical eye exam, and related services provided on May 
8, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the medical eye exam, and related services. You say that the provider was not 
responsible for obtaining authorization. The Plan denied your request. The Plan says enrollees must receive 
their care from a network provider. 
 
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 had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
items/services 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 medical eye exam, and related services 
provided on May 8, 2023, 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 inhalation of nitrous oxide/analgesia, anxiolysis (D9230) 
and the placement of intra-socket biological dressing to aid in hemostasis or clot stabilization (D7922) provided 
on April 18, 2023. 
 
You asked the Plan to pay for the inhalation of nitrous oxide/analgesia, anxiolysis (D9230) and the placement 
of intra-socket biological dressing to aid in hemostasis or clot stabilization (D7922). You say that this was an 
emergency extraction. You also say that as you have autoimmune diseases and are on a steroid, you did not 
have the option to choose another type of anesthesia. The Plan denied your request. The Plan says these 
services are not covered services under the Plan.  
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
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 the 
inhalation of nitrous oxide/analgesia, anxiolysis (D9230) and the placement of intra-socket biological dressing 
to aid in hemostasis or clot stabilization (D7922) provided on April 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical access to an implant body (D6011) provided on 
April 20, 2023. 
 
You asked the Plan to pay for surgical access to an implant body (D6011). You say that you firmly believe that 
this critical and necessary implant procedure is essential for your dental health and overall well-being. The Plan 
denied your request. The Plan says the claim is denied because this service is not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  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 surgical 
access to an implant body (D6011) provided on April 20, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are medically necessary for 
the enrollee's complex medical needs. The Plan denied your request. The Plan says the enrollee's medical needs 
are being met in the current setting. 
 
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 the enrollee appears to be improving with current treatment and should only require 
short-term additional acute care services that can safely be provided at the current facility until more stable and 
appropriate for transfer to a lower level of care soon. The enrollee does not require services at the LTACH that 
are not already available at the current 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 27, 2023, by an 
OON provider.  
 
You asked the Plan to pay for the laboratory services. You say that you are appealing the denial with 
supporting documentation. The Plan denied your request. The Plan says the 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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services 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 these items/services. 
Therefore, we decided that the Plan does not have to pay for the laboratory services provided on January 27, 
2023, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on April 8, 2022, billed with 
evaluation and management (EM) code 99203-25-CS, and procedure codes 87426-QW-CS and G2023-CS. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed codes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of codes 99203-25-CS, 87426-QW-CS, and G2023-CS is office 
or other outpatient visit for the evaluation and management of a new patient, which requires a medically 
appropriate history and/or examination and straightforward medical decision making.  When using time for 
code selection, 15-29 minutes of total time is spent on the date of encounter, severe acute respiratory syndrome 
coronavirus (eg, SARS-CoV, SARS-CoV-2(COVID-19), and specimen collection for covid 19.   
We asked our coder 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 the practitioner services provided. Our reviewer says that 
documentation does not support the billed code. Our reviewer found that CPT code 99203 is not supported. 
Procedure report supports minimal complexity; minimal data reviewed; and minimal risk. There is a more 
appropriate code to report for service provided. Use of modifier 25 is not supported as no additional evaluation 
and management report was submitted and therefore cannot be verified. Codes 87426 and G2023 are not 
supported as laboratory report does not include sufficient documentation to verify method of testing to confirm 
procedure codes billed.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on April 8, 2022, billed with evaluation and 
management (EM) code 99203-25-CS, and procedure codes 87426-QW-CS and G2023-CS.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that your provider is recommending IRF services. The 
Plan denied your request. The Plan says you do not meet Medicare guidelines for services in an IRF.  
 
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 does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While you may have a need for physical therapy and/or occupational 
therapy, there is no documented need for intensive rehabilitation services.  
 
There is not a reasonable expectation that you 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 an IRF admission and services.