Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown for tooth #6 provided on July 29, 2020. 
 
You asked the Plan to pay for the crown. You say that you expected all services to be covered. You say that 
you will have to ask for help if the balance isn't paid. The Plan denied your request. The Plan says only two 
crowns per calendar year are covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the Plan also has a maximum benefit 
of two crowns per calendar year. The Plan paid for a crown for tooth #4 and #5 provided on July 29, 2020, 
which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the crown for tooth 
#6 provided on July 29, 2020.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the molecular pathology (81401) provided on December 6, 2019. 
 
 
You asked the Plan to pay for the molecular pathology. You say that you would like reconsideration because 
these codes were billed correctly. The Plan denied your request. The Plan says that this claim was billed with 
an inappropriate place of service code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules also say that the Place of Service (POS) code is generally used to reflect the actual setting where the 
beneficiary receives the face to-face service. 
 
We find that CPT code 81401 is supported in the record. Specifically, the record shows that this claim was 
billed with the appropriate place of service code. The documentation suggests that this specimen was obtained 
in an office setting which is reflected by the billed place of service code. Based on this information, we decided 
that Medicare rules for coverage of the molecular pathology have been met. Therefore, we decided that the 
Plan has to pay for the molecular pathology (81401) provided on December 6, 2019. 
  
 
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 issue reimbursement for the eyeglasses (V2020) and the 
polycarbonate lenses (V2784) purchased. 
 
You asked the Plan to issue reimbursement. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says you have exhausted your routine vision 
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.  
 
 
We looked at the file and the Plan's rules.  Based on this information, we decided that the Plan's rules for 
reimbursement of the eyeglasses have not been met. Specifically, you were provided a $200 allowance for the 
eyeglasses purchased. You are responsible for any amount over $200 as well as upgrades to glasses. Your 
request exceeds the routine vision benefit. Therefore, we decided that the Plan does not have to issue 
reimbursement for the eyeglasses (V2020) and the polycarbonate lenses (V2784) purchased.  
 
Your complaint about the problems with the eyeglasses purchased is not a valid appeal for medical coverage. 
This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to 
make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics provided on August 4, 2020. 
 
You asked the Plan to pay for foot orthotics. You say that this is medically necessary. The Plan denied your 
request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pay for foot orthotics provided on August 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse more for the porcelain crown (D2740) provided on 
September 21, 2020. 
 
You asked the Plan to reimburse more for the dental service. You say that the Plan owes you money. The Plan 
denied your request. The Plan says the provider in this case is out of network. The Plan says there is a 75% 
coinsurance for crowns that you receive out of network. The Plan also says that the out of network provider 
may bill you for any amount greater than the payment made by the Plan to the provider. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, there is a 75% coinsurance for crowns 
that you receive out of network. This is a contractual obligation you agreed to when you enrolled in the Plan's 
dental coverage. Additionally, the Evidence of Coverage clearly states that you may be billed by the out of 
network provider for any amount greater than the payment made by the Plan to the provider. Therefore, we 
decided that the Plan does not have to reimburse more for the porcelain crown (D2740) provided on September 
21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided. 
 
You asked the Plan to pay for the limited oral evaluation. You say that this service was medically necessary 
and you did not have time to wait. The Plan denied your request. The Plan says the service exceeds the 
frequency limitation in benefit 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. The Plan covers the limited 
oral evaluation once every year.  
 
We looked at the file and Medicare rules. The file indicates that you also received the limited oral evaluation. 
Therefore, you had exhausted your benefit for 2020. Based on this information, we decided that the 
Plan's rules for coverage of the limited oral evaluation have not been met. Therefore, we decided that the Plan 
does not have to pay for the limited oral evaluation (D0140) provided.
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 requires prolonged 
hospitalization, and close physician monitoring. The Plan denied your request. The Plan says the enrollee is 
receiving appropriate inpatient acute care, and does not require transfer. 
 
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 physician 
reviewer found that LTACHs are certified as acute care hospitals, and in general, do not provide clinical 
services that are materially different than those of short term acute care hospitals. In this case, ongoing care 
needs include ventilator management, tracheostomy care, telemetry, surveillance laboratory studies, tube 
feeding, multiple wound management, and therapy services. The documentation does not support that the 
enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is 
currently receiving care. There are no required medical services identified that are available at the LTACH, that 
are not available at the current health care setting being offered by the health plan. Consequently, the requested 
LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of 
the enrollee 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 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 rendered on June 23, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says screening tests are not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The test at issue in this appeal, a prostate predictive screening test, was requested solely for screening purposes. 
Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not 
have to pay for the laboratory services rendered on June 23, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Cxbladder testing rendered on June 29, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the testing is not covered. 
 
The Plan must follow Medicare rules. The rules say that the CxBladder testing is non-covered. 
 
The test at issue is CxBladder. This test is not covered by Medicare. Therefore, we decided that the Plan does 
not have to pay for the Cxbladder testing rendered on June 29, 2020.
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 these services are medically necessary. The Plan 
denied your request. The Plan says that your care can be safely given in subacute care such as 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 above. 
 
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. The 
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. You were admitted for a stroke with right sided 
weakness. Your medical conditions are stable. There are no medical needs requiring inpatient admission. There 
are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including 
either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the 
medical record documents a need for physical and occupational therapy, it does not document a need for an 
intensive rehabilitation program. 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. Our physician reviewer 
found that your condition does not meet Medicare criteria for IRF 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: Partially Favorable

 
We decided that the Plan has to pay for the prophylaxis (D1110) and periodic oral evaluation (D0120). We 
decided that the Plan does not have to pay for the unspecified preventive procedure (D1999).  
 
You asked the Plan to pay for the prophylaxis (D1110), periodic oral evaluation (D0120) and unspecified 
preventive procedure (D1999). You say that it is unjustified to be penalized for going one day early from the 
sixth month requirement. You say that you should be reimbursed. The Plan says that a prophylaxis and periodic 
oral evaluation are only allowed once every 6 months and the unspecified preventive procedure is not a covered 
benefit. 
 
We decided that the Plan has to pay for the prophylaxis (D1110) and periodic oral evaluation (D0120).  
 
The contract says that a prophylaxis and periodic oral evaluation are covered every 6 months. The contract 
does not specify that the services are only covered 6 months to the day. The contract is not sufficiently clear 
that the enrollee would have a reasonable expectation that these services would not be covered. Therefore, we 
decided that the Plan has to pay for the prophylaxis (D1110) and periodic oral evaluation (D0120).  
 
  
We also decided that the Plan does not have to pay for the unspecified preventive procedure. 
 
The Plan contract includes a list of covered supplemental dental benefits. The unspecified preventive procedure 
is not on this list and is not a covered supplemental benefit. Therefore, we decided that the Plan does not have 
to pay for the unspecified preventive procedure. 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chest x-ray rendered on September 1, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim was billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that services for a registered inpatient must be billed 
with POS code 21. 
 
We looked at the file and Medicare rules. The file shows that the services were incorrectly billed with POS 
code 22 for an outpatient hospital facility. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the 
chest x-ray rendered on September 1, 2020.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health skilled nursing services provided from July 
5, 2020, to July 11, 2020 billed with code S9124. 
 
You asked the Plan to pay for the home health nursing services. You say that this should be paid due to medical 
necessity. The Plan denied your request. The Plan says this claim was not reported with a valid HIPPS code. 
 
The Plan must follow Medicare rules. Medicare rules say that home health skilled nursing visit are to be 
reported with code G0299 or G0300.  
 
The code description of S9124 is Nursing care, in the home; by licensed practical nurse, per hour. Home health 
billing rules require the use of code G0300 for this service. Therefore, we decided that the Plan does not have 
to pay for the home health skilled nursing services provided from July 5, 2020, to July 11, 2020 billed with 
code S9124.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit (99203) provided September 5, 
2020. 
 
You asked the Plan to pay for the office visit. You say that you feel that these services should be covered. The 
Plan denied your request. The Plan says this service is not covered when rendered by a chiropractor. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the outpatient office visit (99203) provided September 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the immediate denture - maxillary (D5130) and immediate 
denture - mandibular (D5140) provided on September 17, 2019. 
 
You asked the Plan to pay for the immediate denture - maxillary and immediate denture - mandibular. You say 
that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan 
says you have met the annual maximum for 2019. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers dental 
services at up to $2,500. 
 
We looked at the file and Medicare rules. The file indicates that you have exhausted your annual benefit of 
$2,500 for dental services and the remaining charges are your responsibility. Based on this information, we 
decided that the Plan's annual benefit for immediate denture - maxillary and immediate denture - mandibular 
has been met. Therefore, we decided that the Plan does not have to pay for the immediate denture - maxillary 
(D5130) and immediate denture - mandibular (D5140) provided on September 17, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (CPT Code 99221) provided on May 22, 
2020. 
 
You asked the Plan to pay for the service. You say that the initial hospital care provided was necessary prior to 
performing a surgical procedure. The Plan denied your request. The Plan says the provider did not submit 
anything in dispute of the denial reason Line 1 -Current preoperative procedure occurred within one day of 
associated surgical procedure (27245)". 
 
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 99221 is not supported in the medical record. Specifically, the service is not supported 
in the medical records provided. Based on this information, we decided that Medicare rules for coverage of the 
service have not been met. Therefore, we decided that the Plan does not have to pay for initial hospital care 
(CPT Code 99221) provided on May 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for an office visit provided on August 7, 2020. 
 
You asked the Plan to waive the deductible for an office visit. You say that you saw the doctor but decided 
against injections and disagree with the additional charges and feel that they are fraudulent. The Plan denied 
your request. The Plan says the claims were processed correctly and you are being charged the correct amount. 
 
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 $300 deductible for physician/practitioner services, including doctor's 
office visits.  
 
You had an office visit on August 7, 2020. The record shows that you had paid $0 toward the $300 deductible 
prior to receiving the services. Therefore, you are responsible to pay the allowed amount of $238.67, which is 
less than the $300 deductible.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category 
physician/practitioner services, including doctor's office visits. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $300 deductible for physician/practitioner services, including doctor's 
office visits. This cost sharing is a contractual obligation that had not been met at the time an office visit was 
received on August 7, 2020. Therefore, we decided that the Plan does not have to waive the deductible for an 
office visit provided on August 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an annual wellness visit provided on August 12, 2020. 
 
You asked the Plan to pay for the annual wellness visit. You say that you would like reconsideration because 
you had not previously received a wellness visit. The Plan denied your request. The Plan says this benefit is 
exhausted because you received a wellness visit on May 21, 2020. 
 
The Plan must follow Medicare rules. Medicare rules say that that plans must pay for a medical service or item 
if regular Medicare would pay for it in this case. The Plan contract says that annual wellness visits are covered 
once every 12 months.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the annual wellness visit have not been met. Specifically, the record indicates that an annual 
wellness visit was previously billed and paid for May 21, 2020. The appealed wellness visit was rendered 
within 12 months of the initial service. Therefore, we decided that the Plan does not have to pay for an annual 
wellness visit provided on August 12, 2020.  
 
Your complaint about never receiving a wellness visit in May 2020 is not a valid appeal for medical coverage. 
This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to 
make a decision about these types of complaints.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for CT Scan of the abdomen and pelvis (74177) provided on 
June 11, 2020. 
 
You asked the Plan to pay for the CT Scan. You say that you would like reconsideration because this claim 
denied as a duplicate in error. The Plan denied your request. The Plan says the submitted documentation 
supports 1 unit of 74177, which was previously approved/paid and there is no additional documentation 
supporting an additional study which was billed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined 
to be exact duplicates of another claim or claim line are denied. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the CT Scan have not been met. Specifically, the record indicates that 1 unit of CPT code 74177 
was rendered on the billed date of service. One unit of CPT code 74177 was already approved and paid. 
Therefore, we decided that the Plan does not have to pay for CT Scan of the abdomen and pelvis (74177) 
provided on June 11, 2020.