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 rehabilitation stay provided 
from November 14, 2022, to November 26, 2022. 
 
You asked the Plan to waive the copayment for the inpatient rehabilitation stay. You say that you got COVID-
19 and could not get the most of the services you received. 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 per day for days 1-6 of each inpatient hospital stay. Your contract with the Plan also clearly says you then pay a $0 copayment per day for any additional days of the same inpatient hospital stay.  
 
You have been asked to pay a $290 copayment per day for days 1-6 of the inpatient rehabilitation stay. This 
item/service falls within the inpatient hospital care benefit category. You have not been charged after day six or 
for the day you were discharged. You have been asked to pay a total of $1,740 for the inpatient hospital stay 
($290 copayment per day x 6 days = $1,740). 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 
rehabilitation stay provided from November 14, 2022, to November 26, 2022.
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 requires the level of care provided at an 
IRF. The Plan denied your request. The Plan says the IRF services requested do not meet the requirements for 
approval. 
 
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, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. There is not a reasonable expectation that this enrollee will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ultrasound provided on January 19, 2023, by an out-of-
network (OON) provider.  
 
 You asked the Plan to pay for ultrasound. You say that you are requesting reconsideration. 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. This means you will have to 
pay the provider in full for the services furnished. 
 
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 ultrasound provided on January 19, 2023, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 19, 2023. 
 
You asked the Plan to pay for an office visit. You say that the services rendered were medically necessary. 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 an office visit provided 
on January 19, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the inpatient hospital stay provided from 
December 30, 2022, to January 4, 2023. 
 
You asked the Plan to reduce the copayment for the inpatient hospital stay. You say that your hospital stay is 
overpriced. 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 $285 
copayment per day, for days 1 to 6 and a $0 copayment per day, for additional days for each Medicare-covered 
inpatient hospital stay.  
 
 You have been asked to pay a $285 copayment per day, for days 1 to 5 of the inpatient hospital stay. You have 
been asked to pay a total of $1,425 ($285 copayment x 5 days = $1,425). You have not been charged for any 
additional days. This item/service falls within the inpatient hospital care benefit category. This means that you 
have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to reduce the copayment for the inpatient hospital stay provided from December 30, 2022, to 
January 4, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the 2D oral/facial photographic image (D0350) and cone 
beam CT capture and interpretation (D0364) provided on February 21, 2023. 
 
You asked the Plan to pay for the dental services. You say that your provider never informed you these 
procedures would not be covered. The Plan denied your request. The Plan says these services are not covered 
under the Plan's dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 2D 
oral/facial photographic image (D0350) and cone beam CT capture and interpretation (D0364) provided on 
February 21, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device 
(HFCWOD). 
 
You asked the Plan to pre-approve an HFCWOD. The Plan denied your request. The Plan says this request is 
not medically necessary because the records show you do not have cystic fibrosis, bronchiectasis, or a 
neuromuscular disorder. The Plan also says it appears your current airway clearance regimen is effective, and 
you do not have documented failure of standard treatments. 
 The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are 
medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases.  
 
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 an HFCWOD. Our reviewer says that 
you do not meet the coverage criteria for a high frequency chest wall oscillation system. Our physician 
reviewer found the records in this case do not document cystic fibrosis, bronchiectasis, or one of the 
neuromuscular diseases for which an HFCWOD may be covered. The provided records in this case report use 
of an Acapella airway clearance device but make no mention of a mechanical in-exsufflation device (E0482). 
Our reviewer also found that you are reported to have a persistent cough and thick phlegm despite use of the 
Acapella device, but you do not have a qualifying diagnosis for the high frequency chest wall oscillation 
system.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an HFCWOD have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a high frequency chest wall oscillation device (HFCWOD).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy provided on December 30, 2022, to January 
03, 2023. 
 
You asked the Plan to pay for physical therapy. You say that you are appealing the claim payment denial. 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 physical therapy 
provided on December 30, 2022, to January 03, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on January 16, 2023. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. 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 17, 2021. 
Therefore, we decided that the Plan does not have to pay for the dental services on January 16, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an inversion/eversion correction device (A9285) and 
gravity assisted traction device (E0941). 
 
You asked the Plan to pre-approve an inversion/eversion correction device and gravity assisted traction device. 
The Plan denied your request. The Plan says an inversion/eversion correction device is not designed for the 
treatment of low back pain, and is not covered. The Plan also says a gravity assisted traction device is 
considered experimental and investigational because there is insufficient evidence to support their clinical 
value in treating low back pain or for other indications. 
 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 an inversion/eversion correction device 
and gravity assisted traction device. Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found there is limited published, large-
scale, long-term peer-reviewed literature that shows lumbar traction/inversion tables to be an effective and/or 
safe treatment for the noted pathology. No compelling rationale is presented, or extenuating circumstances 
noted to support the medical necessity of this request as an exception. Our reviewer found that therefore, the 
requested inversion/eversion correction device (A9285) and gravity-assisted traction device (E0941), in this 
case, are not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an inversion/eversion correction device and gravity assisted traction device 
have not been met. Therefore, we decided that the Plan does not have to pre-approve an inversion/eversion 
correction device (A9285) and gravity assisted traction device (E0941).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for two extractions and deep sedation/general anesthesia 
provided on January 27, 2023. 
 
You asked the Plan to pay for the dental services. You say that your providers estimated cost of the procedures 
was $642. 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 January 27, 2023. 
Therefore, we decided that the Plan does not have to pay for two extractions and deep sedation/general 
anesthesia provided on January 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete maxillary/mandibular denture (D5120, D5110) 
provided on September 16, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the 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 a complete maxillary/mandibular denture (D5120, D5110) provided on September 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the infliximab injection provided on 
November 25, 2022. 
 
You asked the Plan to waive the coinsurance for the infliximab injection. You say that you believed there 
would be no out-of-pocket cost for this injection. 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 in-network Medicare Part B drugs. 
 
You have been asked to pay 20% coinsurance for the infliximab injection. This item/service falls within the in-
network Medicare Part B drugs 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 
the infliximab injection provided on November 25, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total knee arthroplasty (27447). 
 
You asked the Plan to pre-approve a total knee arthroplasty. You say that a total knee arthroplasty is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says a total knee arthroplasty is not 
medically necessary. 
 
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 a total knee arthroplasty. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there is no documentation of steroid injection to the knee or if supervised 3-
month trial of physical therapy for the knee. More conservative measures are needed to demonstrate the 
medical necessity of a total knee arthroplasty. 
 
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 total knee arthroplasty have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a total knee arthroplasty (27447).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an interim partial maxillary and mandibular denture 
(D5820/D5821) provided on September 8, 2022. 
 
You asked the Plan to pay for D5820 and D5821. You say that you needed this dental work. The Plan denied 
your request. The Plan says the rendered dental services are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an interim 
partial maxillary and mandibular denture (D5820/D5821) provided on September 8, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-emergency wheelchair van transportation (A0130) 
provided on November 3, 2022. 
 
You asked the Plan to pay for the non-emergency wheelchair van transportation. You say that you are asking 
for reconsideration for the wheelchair transport. You also say that the submitted trip details are self-
explanatory. The Plan denied your request. The Plan says the enrollee's plan covers professional ambulance 
service for emergency transport only.  
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport 
services.  
 
The services you have asked the Plan to pay for are wheelchair van transport services. Therefore, we decided 
that the Plan does not have to pay for non-emergency wheelchair van transportation (A0130) provided on 
November 3, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided on March 1. 2023. 
 
You asked the Plan to pay for self-administered drugs. You say that the claim should be reprocessed. The Plan 
denied your request. The Plan says that self-administered drugs do not fall under Medicare Part B coverage. 
   
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs provided 
on March 1. 2023.  
 
Benefits for self-administered drugs may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
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 you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says that criteria for admission to the IRF setting have not 
been met.  
 
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 the enrollees nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical 
therapy and/or occupational therapy, there is no documented need for intensive rehabilitation services. 
Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that 
the enrollee 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.