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

 
We decided that the Plan does not have to pay for bitewings - four radiographic images (D0274) provided on 
February 24, 2020. 
 
You asked the Plan to pay for the dental services. You say that you were only two (2) days aware from the 
procedure being covered. The Plan denied your request. The Plan says you exhausted your benefit frequency 
limit. 
 
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. 
 
You exhausted your benefit frequency limit, because you had this same service performed on February 26, 
2019. Your EOC states,  the Plan covers bitewing x-rays every twelve (12) months (one (1) set up to four (4) 
films). Therefore, we decided that the Plan does not have to pay for bitewings - four radiographic images 
(D0274) provided on February 24, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF services.
You asked the Plan to pre-approve the SNF services. The Plan denied your request. The Plan says you do not meet Medicare criteria for SNF care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is 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 SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that from a nursing perspective, you received oral and inhaled medications. You had stable vital signs and your lungs were clear. Regarding rehabilitation services, you received physical therapy (PT), speech therapy (ST) and occupational therapy (OT) in the acute hospital. You were at a moderate to maximal assist of 2 level with functional mobility. You required varying assist with activities of daily living. There are no identifiable skilled nursing services. Although there are identifiable skilled therapy service needs, it is not medically necessary and reasonable to provide these skilled nursing or skilled therapy services on a "daily basis." You do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 3D conformal radiation therapy (77263, 77280, 77290, 
77295, 77330, 77307, 77331, 77334, 77336, 77412, 77417, 77427, G6014). 
 
You asked the Plan to pre-approve 3D conformal radiation therapy. You say that this is medically necessary. 
The Plan denied your request. The Plan says the requested radiation therapy would not be precise enough. 
 
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 3D conformal radiation therapy. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found you have been prescribed conventionally fractionated radiotherapy for an 
invasive squamous cell carcinoma of the ear. An intensity-modulated radiation therapy (IMRT) plan was 
approved. Therefore, there is no need for a 3D conformal plan. Because IMRT is a more advanced form of 
radiotherapy, IMRT alone would be needed and not 3D conformal radiotherapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 3D conformal radiation therapy have not been met. Therefore, we decided that 
the Plan does not have to pre-approve 3D conformal radiation therapy (77263, 77280, 77290, 77295, 77330, 
77307, 77331, 77334, 77336, 77412, 77417, 77427, G6014).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical pathology services provided to the enrollee on 
March 11, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says there were no provider notes to substantiate the diagnosis, rationale for the surgical procedure, 
and subsequent pathology results of the skin lesion that was removed. 
 
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 has network providers 
available who can provide 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 surgical pathology services provided to the 
enrollee on March 11, 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 you disagree with the denial. The Plan denied your 
request. The Plan says the services are not medically necessary. 
 
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 
services are not medically necessary. Our physician reviewer found the enrollee was admitted to the hospital on 
July 31, 2020. Based on the submitted records, the complexity of her nursing, medical, and rehabilitation needs 
does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. She 
was admitted for abdominal pain and diagnosed with diverticulitis. She has improved with antibiotic therapy. 
All medical problems are stable. There are no complex nursing or rehabilitation needs. She may benefit from 
further therapy but does not require an intensive therapy program 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 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 the bitewing x-ray and the nitrous oxide provided on March 
9, 2020. 
 
You asked the Plan to pay for these services. You say that you are disappointed that the nitrous gas was denied 
because this is something you need due to extreme sensitivity. The Plan denied your request. The Plan says this 
service was denied as your Plan had already paid the $1500 maximum. As such, no further payment is required. 
 
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, this is limited to $1500 per year. The 
Plan paid out $1500 for services rendered on February 24, 2020. As such, the Plan is not required to make any 
further payment for dental services. Therefore, we decided that the Plan does not have to pay for the bitewing 
x-ray and the nitrous oxide provided on March 9, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services provided on March 4, 
2020. 
 
You asked the Plan to waive the copayment for laboratory services. You say that you disagree with the charges 
because the laboratory services were provided during a physical. 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for lab services provided in an outpatient hospital facility.  
 
You received laboratory services on March 4, 2020. Laboratory services are not included in annual wellness 
exams and are subject to separate cost-sharing charges. Therefore, you are responsible to pay the allowed 
amount of $35.19, which is less than the $40 copayment.  
 
You have been asked to pay $35.19 for laboratory services. Laboratory services fall within the outpatient 
diagnostic tests and therapeutic services and supplies 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 laboratory services provided on March 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home infusion therapy, implanted pump pain management 
infusion (S9328) provided to the enrollee from August 15, 2018 through October 29, 2018. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the Medicare rules have not been met. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the service have not been met. This service is not payable by 
Medicare. Therefore, we decided that the Plan does not have to pay for home infusion therapy, implanted pump 
pain management infusion (S9328) provided to the enrollee from August 15, 2018 through October 29, 2018.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy services coded S9328 provided from December 11, 2019 to January 6, 2020.
You asked the Plan to pay for the home infusion therapy services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.
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 S9328 is home infusion therapy, implanted pump pain management infusion; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem. We find that CPT code S9328 is not supported in the medical record. Specifically, this code has a status code of "I". A status code of I means that this code is not payable by Medicare. Medicare uses another code for reporting and payment of these services. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy services coded S9328 provided from December 11, 2019 to January 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for consultation - diagnostic service provided by dentist or 
physician other than requesting dentist or physician (D9310) provided on November 11, 2019. 
 
You asked the Plan to pay for the dental services. You say that the service was necessary. The Plan denied your 
request. The Plan says the service is not a covered benefit 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 Plan?s 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. This service is not listed in your EOC as a covered benefit; therefore, it 
is not covered. Therefore, we decided that the Plan does not have to pay for consultation - diagnostic service 
provided by dentist or physician other than requesting dentist or physician (D9310) provided on November 11, 
2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable


We decided that the Plan does not have to pre-approve an UpWalker Lite (upright walker). 
 
You asked the Plan to pre-approve walker. You say that you have had multiple surgeries and cannot use a 
normal walker. The Plan denied your request. The Plan says the denial of authorization for this item is correct, 
because you do not meet the criteria for this walker. 
 
The Plan follows Medicare rules. Medicare rules say that walkers may be covered for enrollees who meet 
certain clinical criteria. 
 
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 walker. Our reviewer says that you do 
not meet the Medicare criteria for a walker. Our physician reviewer found documentation does not show that a 
standard walker would not meet your needs for mobility-related activities or for proper ambulation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of walker have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an UpWalker Lite (upright walker).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pontic - cast high noble metal (D6210), retainer crown - 3/4 
cast high noble metal (D6780), retainer crown - full cast high noble metal (D6790), periodic oral evaluation - 
established patient (D0120) and prophylaxis - adult (D1110) provided from February 6, 2020 through March 2, 
2020 by a non-participating provider. 
 
You asked the Plan to pay for the dental services. You say that you are requesting reimbursement of services 
rendered. The Plan denied your request. The Plan says the claims were processed accordingly with your 2020 
EOC benefits. 
 
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. 
 
We reviewed the limited dental information from your out-of-network provider and it shows that you saw the 
dentist and received an examination with cleaning and a filling over several dental visits. The Plan has already 
processed payment for these services, with appropriate cost-sharing assigned for out-of-network services. Your 
appeal information indicates that you were aware that your provider was out-of-network but you are still 
unhappy with the reimbursement. Your request for additional reimbursement is not a covered benefit because 
Medicare does not cover routine dental services and the Plan has already provided appropriate reimbursement. 
Therefore, we decided that the Plan does not have to pay for pontic - cast high noble metal (D6210), retainer 
crown - 3/4 cast high noble metal (D6780), retainer crown - full cast high noble metal (D6790), periodic oral 
evaluation - established patient (D0120) and prophylaxis - adult (D1110) provided from February 6, 2020 
through March 2, 2020 by a non-participating provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMs HF System. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare may cover a Category B IDE device when 
criteria for the Category B IDE trial are met. 
 
We looked at the file and Medicare rules. The file shows that the requested CardioMEMs is part of a Category 
B IDE device trial; however, the services are being requested from a facility that is not enrolled in this trial. 
Therefore, we decided that the Plan does not have to pre-approve a CardioMEMs HF System.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for Stearns & Foster Adjustable Base Bed, Split King Bed Package and sales tax purchased on March 9, 2020.
You asked the Plan to pay for the items. You say that you are appealing for reconsideration of the denied charges. The Plan denied your request. The Plan says the items are not covered under Medicare or the Health Plan.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. Sales taxes where appropriate were included in the calculation of reasonable charges computed. They were also accounted for in the calculation of the base fee schedules for DME and orthotic/prosthetic devices. The Consumer Price Index used to update fee schedules also accounts for sales tax. Therefore, contractors do not make any additional payment for sales taxes and do not make adjustments in fees to reflect local changes in tax rates. Furthermore, an adjustable bed is not primarily used to serve a medical purpose and would be useful to a person in the absence of illness or injury. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pay for Stearns & Foster Adjustable Base Bed, Split King Bed Package and sales tax purchased on March 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the periodontal scaling and root planing for each 
quadrant. 
 
You asked the Plan to pre-approve the periodontal scaling and root planing for each quadrant. You say that the 
enrollee has generalized moderate supra, sub gingival calculus, 4-5 mm probe depths and 1-2 mm gingival 
recession. You say that the maximum benefit should be approved. The Plan denied your request. The Plan says 
the documentation submitted does not demonstrate the criteria required to qualify for this procedure under this 
plan. 
 
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 the 
periodontal scaling and root planing for each quadrant when the services are medically necessary and 
reasonable.  
 
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 periodontal scaling and root planing 
for each quadrant. Our reviewer says that the criteria for coverage has not been met. Our physician reviewer 
found there is not a significant amount of bone loss in general in any quadrant. Our physician reviewer found 
that the documentation does not support the need for four quadrants under the requested code. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the periodontal scaling and root planing for each quadrant have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the periodontal scaling and root planing for 
each quadrant.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Genicular nerve block for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that this is not covered by Medicare or the Plan. 
 
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 these services. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. The 
effectiveness of Genicular nerve blocks to treat knee pain has not been established. Genicular nerve blocks are 
considered experimental/investigational in nature. Our physician reviewer found that the enrollee's condition 
does not meet Medicare criteria for these services. 
 
We looked at this physician's review, the file, and Medicare rules. 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 pre-approve a Genicular nerve block for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve routine transportation services. 
 
You asked the Plan to pre-approve routine transportation. You say that you need to get to dialysis, or you will 
die. The Plan denied your request. The Plan says the denial of authorization for routine transportation is 
correct, because routine transportation is not covered by Medicare or the Plan under any conditions. 
 
The Plan must follow Medicare rules. Medicare does not cover transport in a vehicle that is not an ambulance. 
The Plan follows the same rule.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Medicare rules for coverage of routine transportation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve routine transportation services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the assembly and operation of a pump with oxygenator 
provided on March 13, 2020. 
 
You asked the Plan to pay for the heart-lung machine operation. You say that CPT code 99190 is for the setup 
and operation of the Heart Lung machine. It takes a half hour to an hour to set up the Heart Lung Machine. The 
perfusionist is required to be in the operating room during the length of the procedure. This should be paid. The 
Plan denied your request. The Plan says these services are paid to the hospital in the inpatient DRG and cannot 
be separately reimbursed. 
 
The Plan must follow Medicare rules. Medicare rules say all items and non-physician services furnished to 
inpatients must be furnished directly by the hospital or billed through the hospital under arrangements. 
 
Although these services may be appropriate, since this was rendered to a hospital inpatient, payment for them is 
made to the hospital which must then furnish these services either directly or under arrangements. As such, 
separate Medicare payment cannot be made for the services at issue. Therefore, we decided that the Plan does 
not have to pay for the assembly and operation of a pump with oxygenator provided on March 13, 2020.