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

 
We decided that the Plan does not have to pay for a resin-based composite (D2392) for teeth #31, #29, and #28, 
provided by a participating provider on December 16, 2021. 
 
You asked the Plan to pay for a resin-based composite. You say that the Plan should pay for this. The Plan 
denied your request. The Plan says the annual maximum benefit amount has already been met and exhausted. 
 
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 up to a $1,500 
annual maximum benefit allowance. 
 
We looked at the file and Medicare rules. Evidence was provided to show that the annual maximum benefit 
allowance was already met and exhausted at the time of these rendered services. Based on this information, we 
decided that the Plan's rules for coverage of a resin-based composite have not been met. Therefore, we decided 
that the Plan does not have to pay for a resin-based composite (D2392) for teeth #31, #29, and #28, provided 
by a participating provider on December 16, 2021.
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 IRF care is medically necessary and you want to get 
back to your prior level of activity and to prevent permanent disability. The Plan denied your request. The Plan 
says IRF care is not medically necessary and your needs can be met at a lower level of care such as in a skilled 
nursing facility, at home with home health services or at home with outpatient therapy. 
 
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 your rehabilitation needs can be provided in an alternate and low intensity setting 
such as in a skilled nursing facility or in-home with 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 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: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the imaging services provided on January 25, 2022. 
 
You asked the Plan to pay for the imaging services. You say that your physicians are based in the hospital, and 
you rely on the hospital to obtain all the necessary paperwork. The Plan denied your request. The Plan says that 
the rendering provider is an out-of-network provider and there was no approved authorization. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for the imaging services by a contract provider. The file does not show that the plan 
provided notice that the imaging services would not be covered. Under Medicare rules, this means the imaging 
services is considered approved by the plan. Therefore, we decided that the Plan has to pay for the imaging 
services provided on January 25, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an inpatient hospital stay provided on 
October 23, 2021. 
 
You asked the Plan to waive the coinsurance for an inpatient hospital stay. You say that you are appealing this 
cost share to make sure it is your responsibility. The Plan denied your request. The Plan says you have been 
charged the correct cost sharing 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 10% 
coinsurance for an in-network inpatient hospital stay.  
 
You have been asked to pay $359.20, which is less than 10% coinsurance for an inpatient hospital stay on 
October 23, 2021. An inpatient hospital stay 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 waive the coinsurance for an inpatient hospital stay provided on October 23, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on August 13, 
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 the records do not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of the denied codes is: 
 
CPT 38572: 
 
Laparoscopy, surgical; with bilateral total pelvic lymphadenectomy and peri-aortic lymph node sampling 
(biopsy), single or multiple 
 
CPT 51990: 
 Laparoscopy, surgical; urethral suspension for stress incontinence 
 
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 at issue in 
this case were not supported by the medical records. Our reviewer found CPT code 51990 Laparoscopic 
urethral suspension is included within the performance of CPT 55866 and should not be reported separately 
unless the enrollee has stress incontinence prior to the radical prostatectomy. If the pelvic lymph nodes are 
removed, use CPT code 38571 Laparoscopy, surgical; with bilateral total pelvic lymphadenectomy. The 
records do not show that the peri-aortic lymph nodes were removed as is required for CPT code 38572.  
 
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 surgical services provided to the enrollee on August 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator (E0466). 
 
You asked the Plan to pre-approve the portable ventilator. You say that the ventilator is medically necessary. 
The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 portable ventilator. Our reviewer 
says that a portable ventilator is not medically necessary. Our physician reviewer found the provided 
documentation does not contain sufficient detailed information in the medical record to justify the treatment 
selected. The enrollee could be treated with a BiPAP machine with AVAPS capability. 
 
  
 
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 portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 24, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that this provider is a participating provider with the 
Plan, and no prior authorization is necessary for an office visit. The Plan denied your request. The Plan says the 
rendering provider is a non-participating provider, and there is no referring provider involved in these services. 
The Plan also says that they did not authorize any services for this provider. 
 
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 an office visit provided on February 24, 2022, by 
an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transit package for a power wheelchair. 
 
You asked the Plan to pre-approve the requested service. The Plan denied your request. The Plan says 
equipment for use outside the home cannot be covered. 
 The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. The item at issue in 
this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan 
covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a 
transit package for a power wheelchair.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ER visit provided from December 12, 2021, to December 13, 2021.

You asked the Plan to waive the copayment for the ER visit. You say that you were under the impression that ER charges are voided when you are admitted. The Plan denied your request. The Plan says the copayment was applied 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 $120 copayment for in-network emergency room services. 

You have been asked to pay a $120 for the ER visit. The ER visit falls within the "Emergency 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 waive the copayment for the ER visit provided from December 12, 2021, to December 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pontic - porcelain/ceramic (D6245) and retainer 
crowns - porcelain/ceramic (D6740) for a bridge. 
 
You asked the Plan to pre-approve a bridge. You say that you are in pain and need a bridge. The Plan denied 
your request. The Plan says this service is not covered under your 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 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
pontic - porcelain/ceramic (D6245) and retainer crowns - porcelain/ceramic (D6740) for a bridge.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone replacement graft for ridge preservation - per site 
(D7953). 
 
You asked the Plan to pre-approve bone replacement graft. You say that you would like the bone grafts to be 
covered. The Plan denied your request. The Plan says this service is not covered under your 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 pre-approve bone 
replacement graft for ridge preservation - per site (D7953).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implant /abutment supported removable denture for 
edentulous arch  maxillary (D6110), precision attachments, by report (D5862), and connecting bars  implant 
supported or abutment supported (D6055). 
 
You asked the Plan to pre-approve an implant/abutment supported removable upper denture, precision 
attachments and connecting bars. You say that you are currently unable to eat because of discomfort. The Plan 
denied your request. The Plan says these services are not covered under your 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 pre-approve an 
implant /abutment supported removable denture for edentulous arch  maxillary (D6110), precision 
attachments, by report (D5862), and connecting bars  implant supported or abutment supported (D6055).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the specialist office visits provided on 
January 12, 2022, and February 14, 2022. 
 
You asked the Plan to waive the copayments for the specialist office visits. You say that you should not have a 
copayment for follow up visits. The Plan denied your request. The Plan says the proper copayments were 
applied. 
 
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 $30 
copayment per visit for an in-network Specialist. The total combined copayment amount for both visits was 
$60 ($30 copayment + $30 copayment). 
 
  You have been asked to pay a $60 copayment for the specialist office visits. The specialist office visits falls 
within the Physician/Practitioner services, including doctors 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 copayments for the specialist office visits provided on January 12, 2022, and 
February 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a specialist office visit provided on September 21, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the specialist office visit. You say that you had a follow up with a different 
specialist that was approved so this visit should be approved. The Plan denied your request. The Plan says 
enrollees are covered for 1 follow-up visit after emergency services. There was no authorization for a second 
follow up visit with an out-of-area specialist. 
 
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 a specialist office visit provided on September 21, 
2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography coded 70450 provided on 
December 14, 2021. 
 You asked the Plan to pay for the computed tomography. 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 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 70450 
is a column II code to column I code 70496. 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 computed tomography coded 70450 provided on December 
14, 2021.
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 IRF care is medically necessary. The Plan denied 
your request. The Plan says IRF care is not medically necessary and your needs can be met at a lower level of 
care such as in a skilled nursing facility. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that your rehabilitation needs can be provided in an alternate and low intensity setting such as in a skilled nursing facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on June 8, 2021. 
 
You asked the Plan to waive the copayment for an office visit. You say that you feel because you were in the 
hospital you should not have to pay a copayment for an office visit. 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 each specialist visit, including outpatient clinic visits.  
 
You have been asked to pay a $35 copayment for an office visit. an office visit falls within the Outpatient 
hospital services 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 June 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiovascular risk assessment genetic screening testing 
(81479) provided December 30, 2020. 
 You asked the Plan to pay for the genetic screening. You say that you believe the treatment sought is medically 
necessary to treat the enrollee based on the enrollee's medical condition. Please reconsider the denial. The Plan 
denied your request. The Plan says the services do not meet coverage requirements. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. Per the Medicare Claims Processing Manual Chapter 
18-Preventive and Screening Services 100.1, only the following codes should be billed for Cardiovascular 
Disease Screening: CPT code 80061 (Lipid panel) which includes CPT codes: 82465 (Cholesterol, serum or 
whole blood, total), 83718 (Lipoprotein, direct measurement; high density cholesterol) and/or 84478 
(Triglycerides). 
 
The test at issue in this appeal, the genetic screening, 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 cardiovascular risk assessment genetic screening testing (81479) provided December 30, 2020.