Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care, per day (99309) 
rendered by the out-of-network (OON) provider on October 18, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
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 in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. 
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the subsequent nursing facility care, per day (99309) rendered by the out-of-network 
(OON) provider on October 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for caries risk assessment and documentation (D0602) provided 
by a participating provider on January 20, 2022. 
 
You asked the Plan to pay for caries risk assessment and documentation. You say that you do not feel like you 
should have to pay for this. The Plan denied your request. The Plan says this claim has been correctly 
processed and denied. 
 
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 caries risk 
assessment and documentation (D0602) provided by a participating provider on January 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown (D2750) and core buildup, including any pins 
when required (D2950) provided on January 31, 2022. 
 
You asked the Plan to pay for the crown and core buildup. You say that you were not advised that more 
extensive dental work would not be covered by the Plan. The Plan denied your request. The Plan says these 
services are not covered expenses under your dental plan. The Plan also says that when you contacted the Plan 
to verify benefits and provider eligibility, no misinformation was provided to you. 
 
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 crown 
(D2750) and core buildup, including any pins when required (D2950) provided on January 31, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor sensor. 
 
You asked the Plan to pre-approve a Freestyle Libre sensor. You say that the requested item is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for continuous 
glucose monitors and related supplies have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections or require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of a Freestyle 
Libre sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle 
Libre continuous glucose monitor sensor.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eliquis. 
 
You asked the Plan to pre-approve Eliquis. You say that the records provided support the need for the 
requested drug. The Plan denied your request. The Plan says the enrollee does not have pharmacy benefits 
administered under this contract. 
 
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 pre-approve Eliquis.  
 
Benefits for Eliquis 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional intraoral periapical x-ray (D0230) provided on 
January 20, 2022. 
 
You asked the Plan to pay for the additional intraoral periapical x-ray. You say that prior to receiving the 
services you confirmed with both the Plan and the treating provider that the treating provider was in-network. 
The Plan denied your request. The Plan says your benefits for this service have been satisfied and the frequency 
limitation has been exceeded. 
 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, intraoral x-rays are limited to 1 
procedure code per calendar year. The record shows that you received a first intraoral periapical x-ray (D0220) 
on January 20, 2022 and your intraoral x-rays benefit has been exhausted. Therefore, we decided that the Plan 
does not have to pay for the additional intraoral periapical x-ray (D0230) provided on January 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the TERT genetic analysis rendered on October 13, 2021. 
 
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 procedure code 81345 is not separately 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, we have confirmed that code 81345 
is a column II code to column I code 0089U. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the TERT genetic analysis rendered on October 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral - complete series of radiographic images 
(D0210) provided September 16, 2021. 
 
You asked the Plan to pay for the complete series of x-rays. You say that you had this procedure for the first 
time in 3 years. The Plan denied your request. The Plan says you have exceeded the frequency limit for this 
service. 
 
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 complete 
series of x-rays once every three plan years. 
 
We looked at the file and Medicare rules. The Plan provided documentation showing that a complete series of 
x-rays was previously covered on April 14, 2021. Based on this information, we decided that the Plan's frequency limit for coverage of the complete series of x-rays has been exceeded. Therefore, we decided that the 
Plan does not have to pay for the intraoral - complete series of radiographic images (D0210) provided 
September 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composite (D2392) provided on January 31, 
2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the resin-based composite. You say that you were having issues finding a dentist 
near you. You also say that this treating provider was closest to you who could get you in to repair your tooth, 
and you feel you should not be held responsible. The Plan denied your request. The Plan says the treating 
provider is not a plan participating provider. The Plan also says that your plan does not have OON 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the resin-
based composite (D2392) provided on January 31, 2022 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injection services provided to the enrollee on December 6, 
2021. 
 
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 the provider did not bill as required by Medicare coding regulations. 
 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, we have confirmed that code 11900 
is a column II code to column I code 11901. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for injection services provided to the enrollee on December 6, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on September 21, 
2021. 
 
You asked the Plan to waive the copayment for an office visit. You say that you returned to have stitches 
removed and a splint was applied. You say that this was an extra expense that was not needed. The Plan denied 
your request. The Plan says you have been charged the correct copayment 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 $35 
copayment for a specialist visit. Covered services include medically-necessary services furnished in a 
physicians office, certified ambulatory surgical center, hospital outpatient department, or any other location. 
 
 
 You have been asked to pay a $35 copayment for an office visit. The office visit falls within the 
Physician/Practitioner services, including doctor's office visits 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 an office visit provided on September 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), and prophylaxis (D1110) 
provided by an out-of-network provider on December 22, 2021. 
 
You asked the Plan to pay for a periodic oral evaluation and prophylaxis. You say that you would like the Plan 
to pay for this. The Plan denied your request. The Plan says this claim has been processed correctly. 
 
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.  
  
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of a periodic oral evaluation and prophylaxis have been applied correctly. Therefore, we decided that 
the Plan does not have to pay for a periodic oral evaluation (D0120), and prophylaxis (D1110) provided by an 
out-of-network provider on December 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a diagnostic consultation provided by a participating 
provider on February 1, 2022. 
 
You asked the Plan to pay for a diagnostic consultation. You say that you would like the Plan to reconsider 
paying for this claim. The Plan denied your request. The Plan says this claim has been processed correctly. 
 
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. Therefore, we decided that the Plan does not have to pay for a 
diagnostic consultation provided by a participating provider on February 1, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan does not have to pre-approve an expandable controller and accessories (E2377, 
E2311, E2313). 
 
You asked the Plan to pre-approve an expandable controller and accessories. You say that this equipment is 
medically necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that an expandable controller is subject to the criteria 
listed 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 an expandable controller and 
accessories. Our reviewer says that the requested expandable controller and accessories are medically 
necessary. Our physician reviewer found the enrollee is a 76-year-old female with past medical history of 
Parkinson's disease and post-polio syndrome with mobility impairments. In this case, an expandable controller 
is medically necessary to operate 3 power wheelchair actuators. Additionally, the clinical documentation states 
that the patient would have difficulty accessing individual power functions due to tremor and rigidity. The 
requested expandable controller and accessories are medically reasonable and 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 expandable controller and accessories have been met. Therefore, we decided 
that the Plan does not have to pre-approve an expandable controller and accessories (E2377, E2311, E2313).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from May 19, 2022, forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from May 19, 2022, forward. You say that the 
services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue are 
not medically necessary. 
 The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric care from May 19, 
2022, forward. Our reviewer says that the enrollee does not meet the criteria for acute inpatient mental health 
treatment beyond the date in question of May 19, 2022, forward. Our physician reviewer found the enrollee did 
not require inpatient mental health treatment beyond May 19, 2022, as she was not a danger to herself or others 
and did not have any delusions, auditory or visual hallucinations. It did not appear that active treatment was 
taking place beyond the date in question. It did not appear that the services for the dates in question were 
reasonably expected or medically necessary to improve the enrollees condition or for the purpose of diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care from May 19, 2022, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from May 19, 2022, 
forward.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the two surgical extractions (D7210 x2) provided on 
December 7, 2021. 
 
You asked the Plan to pay more for the surgical extractions. You say that this was a non-elective emergency 
procedure, and you believe it should be covered. The Plan denied your request. The Plan says you have met 
your annual maximum 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the Plan offers a $2,000 allowance for 
all covered dental services. The contract says that you pay 100% of charges beyond the $2,000 allowance or if 
you exceed a service limit. The record shows that you met the annual maximum benefit while processing this 
claim for the December 7, 2021 date of service and your annual maximum benefit has been exhausted. 
Therefore, we decided that the Plan does not have to pay more for the two surgical extractions (D7210 x2) 
provided on December 7, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency department services provided to the enrollee on 
November 24, 2021. 
 
You asked the Plan to pay for the services. You say that the plan underpaid this claim. The Plan denied your 
request. The Plan says they downgraded the claim and paid at the 99284 rate. 
 
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 the relevant codes in this case are: 
 
CPT code 99284: Emergency department visit for the evaluation and management of a patient, which requires 
these 3 key components: A detailed history; A detailed examination; and Medical decision making of moderate 
complexity. Counseling and/or coordination of care with other physicians, other qualified health care 
professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or 
family's needs. Usually, the presenting problem(s) are of high severity, and require urgent evaluation by the 
physician, or other qualified health care professionals but do not pose an immediate significant threat to life or 
physiologic function. 
 
CPT code 99285: Emergency department visit for the evaluation and management of a patient, which requires 
these 3 key components within the constraints imposed by the urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive examination; and Medical decision making of high 
complexity. Counseling and/or coordination of care with other physicians, other qualified health care 
professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or 
family's needs. Usually, the presenting problem(s) are of high severity and pose an immediate significant threat 
to life or physiologic function. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services Our 
reviewer found that based on the provided documentation, the patient's condition was of moderate severity and 
she was hemodynamically stable. There was no mention of complications with treatment, perforation, sepsis, or 
other severe condition that would justify a higher level code. There was no immediate threat to life or 
physiological function based on the provided documentation. Therefore, the Plan is justified in downgrading it 
to code 99284 which is a more appropriate CPT code for the care provided for this patient. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for emergency department services provided to the enrollee on November 24, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the Leuprolide acetate injection (J9217) 
and the chemotherapy administration (96402) provided on July 2, 2021. 
 
You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the coinsurance has been applied correctly to 
the services provided. 
 
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 20% 
coinsurance for each Medicare-covered chemotherapy drug and the administration of that drug.   
 
  
You have been asked to pay $128.35 ($122.44 + $5.91) for the chemotherapy drug and the chemotherapy 
administration provided. This includes the Plans allowed amount of $612.21 x 20% coinsurance=$122.44 for 
the chemotherapy drug provided. Additionally, this includes the Plans allowed amount of $29.56 x 20% 
coinsurance=$5.91 for the chemotherapy administration provided. 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 Leuprolide acetate injection (J9217) and the chemotherapy administration (96402) provided 
on July 2, 2021.