Persius/hicric huggingface dataset:
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 services are medically necessary for the 
enrollee's complex medical needs. The Plan denied your request. The Plan says the enrollee's therapy needs are 
not those uniquely provided 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 the enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of 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: 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 
daily physician assessments and therapy services.  The Plan denied your request. The Plan says the enrollee can 
safely receive the services they need in the current hospital 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 somewhat unstable at this time and requires additional 
short-term acute care services that can safely be provided at the current facility until more stable and 
appropriate for a lower level of care. 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: Favorable

 
We decided that the Plan has to pay for procedure code G0483 provided on December 5, 2022. 
 
You asked the Plan to pay for procedure code G0483. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the records do not support the services 
billed. 
 
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 
code G0483 is Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs 
and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to 
gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, 
eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other 
universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and 
variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control 
material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all 
sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if 
performed. 
 
We find that CPT code G0483 is supported in the medical record. Specifically, the records show that more than 
22 drug classes were tested, including Alcohol biomarkers, Alkaloids-not otherwise specified, Amphetamines, 
Antidepressants-serotonergic class, Antidepressants-tricyclic and other cyclicals, Antidepressants-not otherwise 
specified, Antiepileptics-not otherwise specified, Antipsychotics-not otherwise specified, Barbiturates, 
Benzodiazepines, Buprenorphine, Cannabinoids-natural, Cannabinoids-synthetic, Cocaine, Fentanyls, 
Gabapentin-non-blood, Ketamine and Norketamine, Methadone, Methylenedioxyamphetamines, Opiates, 
Opioids and opiate analogs, Oxycodone, Phencyclidine, Pregabalin, Propoxyphene, Sedative Hypnotics (non-
benzodiazepines), Skeletal muscle relaxants, Stimulants-synthetic, Tapentadol, and Tramadol. Based on this 
information, we decided that Medicare rules for coverage of procedure code G0483 have been met. Therefore, 
we decided that the Plan has to pay for procedure code G0483 provided on December 5, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unspecified removable prosthodontic procedures (D5899) 
provided on January 17, 2023. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to approve the dental 
services. The Plan denied your request. The Plan says the denial of payment for these services is correct, 
because the unspecified removable prosthodontic procedures are 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 the 
unspecified removable prosthodontic procedures (D5899) provided on January 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an OON provider on April 6, 
2022. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says the dental services were received from an out-of-network provider and are not covered 
by your supplemental 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. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for dental services provided by an OON provider on April 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the portable oxygen system and the 
oxygen concentrator provided from February 12, 2022, to March 12, 2023. 
 
You asked the Plan to waive the coinsurance for the portable oxygen system and the oxygen concentrator. You 
say that you are being charged twice for the oxygen rental. 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 15% 
coinsurance for durable medical equipment and related supplies.  You have been asked to pay 15% coinsurance for the portable oxygen system and the oxygen concentrator. 
This item/service falls within the durable medical equipment and related supplies benefit category.  
 
Date of Service Code Allowed amount 15% Coinsurance 
February 12, 2022 E0431 $17.27 $2.59 
March 12, 2022 E0431 $17.27 $2.59 
March 12, 2022 E1390 $70.02 $10.50 
April 12, 2022 E0431 $17.27 $2.59 
April 12, 2022 E1390 $70.02 $10.50 
May 12, 2022 E0431 $17.27 $2.59 
May 12, 2022 E1390 $70.02 $10.50 
June 12, 2022 E0431 $17.27 $2.59 
June 12, 2022 E1390 $70.02 $10.50 
July 12, 2022 E0431 $17.27 $2.59 
July 12, 2022 E1390 $70.02 $10.50 
August 12, 2022 E0431 $17.27 $2.59 
August 12, 2022 E1390 $70.02 $10.50 
September 12, 2022 E0431 $17.27 $2.59 
September 12, 2022 E1390 $85.00 $12.75 
October 12, 2022 E0431 $17.27 $2.59 
October 12, 2022 E1390 $85.00 $12.75 
November 12, 2022 E0431 $17.27 $2.59 
November 12, 2022 E1390 $85.00 $12.75 
December 12 2022 E0431 $17.27 $2.59 
December 12, 2022 E1390 $85.00 $12.75 
January 12, 2023 E0431 $17.27 $2.59 
January 12, 2023 E1390 $85.00 $12.75 
February 12, 2023 E0431 $17.27 $2.59 
February 12, 2023 E1390 $85.00 $12.75 
March 12, 2023 E0431 $17.27 $2.59 
March 12, 2023 E1390 $85.00 $12.75 
 
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 the portable oxygen system and the oxygen concentrator 
provided from February 12, 2022, to March 12, 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 enrollee's best chance for a quick 
recovery and more favorable outcome will be with admission to a LTACH. The Plan denied your request. The 
Plan says the enrollee's records do not show that you need continued treatments and care that can only be given 
in an inpatient hospital 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 at this time and requires only short-term 
additional acute care services that can safely be provided at the current facility until more appropriate for a 
lower level of care. 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral - comprehensive series of radiographic images 
(D0210) provided on February 20, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. 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 February 20, 2023. 
Therefore, we decided that the Plan does not have to pay for intraoral - comprehensive series of radiographic 
images (D0210) provided on February 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve interventional radiology to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve interventional radiology. You say that you would like to know if the 
services can be covered. The Plan denied your request. The Plan says the enrollee must receive their care from 
a network provider (for more information about this, see Section 2 of Chapter 3). In most cases, care the 
enrollee receives from an out-of-network provider (a provider who is not part of the plans network) will not be 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers.  
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
interventional radiology to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the CT lung scan provided on January 3, 
2023. 
 
You asked the Plan to waive the copayment for the CT lung scan. You say that you should not be charged a 
copayment because your provider requested a follow-up scan. 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 $150 
copayment for each Medicare-covered magnetic resonance imaging (MRI), CT or positron emission 
tomography (PET) scan. For qualified individuals, a LDCT is covered every 12 months. You have been asked to pay $146.21, which is less than the standard $150 copayment for the CT lung scan. 
This CT scan falls within the outpatient diagnostic tests and therapeutic services and supplies and screening for 
lung cancer with low dose computed tomography (LDCTs) benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for the CT lung scan provided on January 3, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the intraoral radiographic images (D0220 and D0230) 
provided by an out-of-network provider on August 4, 2022. 
  You asked the Plan to pay more for the dental services. You say that because of your previous medical issues 
the dental services should be medically covered. 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 the intraoral radiographic images (D0220 
and D0230) provided by an out-of-network provider on August 4, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services provided on November 10, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not specify whether the ordering physician was in-network or out-
of-network with the Plan. The documentation submitted does not include prior notice from the Plan that these 
services would not be covered. Without this information, we cannot determine whether the laboratory order 
made constituted plan-directed care. This information should be provided by the Plan. Therefore, we decided 
that the Plan has to pay for the laboratory services provided on November 10, 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: 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 services are medically necessary for the 
enrollee's complex medical needs. The Plan denied your request. The Plan says the services the enrollee needs 
can be provided safely in another setting such as a skilled nursing 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 enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), the intraoral radiographic 
images (D0210), and a cleaning (D1110) provided by an out-of-network provider on March 28, 2023. 
 
You asked the Plan to pay for the dental services. You say that the dentist is an in-network provider, and the 
previous claim was overturned, and you plan on staying with the same dentist. The Plan denied your request. 
The Plan says the dental services were received from an out-of-network provider and are not covered by your 
supplemental benefits. Also, the previous overturned claim was made as an exception, and you were advised to 
use in-network providers. 
 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. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a periodic oral evaluation (D0120), the intraoral radiographic images (D0210), and a cleaning 
(D1110) provided by an out-of-network provider on March 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an in-network specialist visit provided on 
February 07, 2022, and February 14, 2022. 
 
 
You asked the Plan to waive the deductible for an in-network specialist visit . You say that you should not have 
to pay this much for appointments. 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 doctor and other health care 
provider services. At the time of these visits, you had not reached your deductible. The allowed amount of each 
visit was $97.07 and $58.86, totaling $155.93. 
 
The item or service you asked the Plan to waive the deductible for falls within the doctor and other health care 
provider services benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract 
that there is an $800 deductible which applies to doctor and other health care provider services.  This cost sharing is a contractual obligation that had not been met at the time an in-network specialist visit was 
received on February 7, 2022, to February 14, 2022. Therefore, we decided that the Plan does not have to 
waive the deductible for an in-network specialist visit provided on February 07, 2022, and February 14, 2022.