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

 
We decided that the Plan does not have to pay for the dental cleaning (D1110) provided on August 25, 2022. 
 
You asked the Plan to pay for this dental service. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says your benefit for the service provided 
has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the service provided was exhausted on date of service May 23, 2022. Specifically, the 
Plan provides coverage for two dental cleanings per year. You previously received these services on 
 February 16, 2022 and May 23, 2022, which were paid for by the Plan. Therefore, you have exhausted the 
allowable benefit for this service. Therefore, we decided that the Plan does not have to pay for the dental 
cleaning (D1110) provided on August 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and 
first intraoral periapical x-ray (D0220) provided on August 23, 2022. 
 
You asked the Plan to pay for the problem focused limited oral evaluation and first intraoral periapical x-ray. 
You say that the Plan should pay a 50% coinsurance for preventive care. You also say that you had an x-ray to 
see if something was wrong, and believe this service should be covered. The Plan denied your request. The 
Plan says these services are not covered expenses under your dental plan. The Plan also says when you 
contacted the Plan prior to this date of service, you were advised that bitewing x-rays were covered, you did not 
specifically ask about intraoral x-rays or exam benefits, and you were sent a copy of 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 pay for the 
problem focused limited oral evaluation (D0140) and first intraoral periapical x-ray (D0220) provided on 
August 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a second pair of therapeutic shoes and inserts. 
 
You asked the Plan to pre-approve a second pair of therapeutic shoes and inserts. You say that these items are 
medically reasonable and necessary. The Plan denied your request. The Plan says the criteria for coverage have 
not been met. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have a pair of therapeutic shoes and inserts purchased in February 2022. These items 
serve the same purpose as a second pair of therapeutic shoes and inserts. Therefore, we decided that the Plan 
does not have to pre-approve a second pair of therapeutic shoes and inserts.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the eye exam (92004), refraction (92015), 
ophthalmic ultrasound (76514), and visual field examination (92083) provided on September 19, 2022, and 
September 28, 2022. 
 
You asked the Plan to waive the copayments for the eye exam, refraction, ophthalmic ultrasound, and visual 
field examination. You say that you would like to know why you are responsible for a copay because your plan 
says otherwise. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 
copayment for a specialist's office visit for Medicare covered vision services.  
 
 You have been asked to pay $45 copayments for the eye exam, refraction, ophthalmic ultrasound, and visual 
field examination. These services fall within the Vision 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. Specifically, the record shows that the diagnosis 
codes listed on both claims are for non-routine services, and will be processed under your medical benefits. 
You did not receive routine exams on these dates of service. Therefore, we decided that the Plan does not have 
to waive the copayments for the eye exam (92004), refraction (92015), ophthalmic ultrasound (76514), and 
visual field examination (92083) provided on September 19, 2022, and September 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lumbar-sacral orthosis (LSO) (L0648), knee orthosis 
(L1833), and suspension sleeve (L2397), provided on September 8, 2022. 
 
You asked the Plan to pay for the lumbar-sacral orthosis, knee orthosis, and suspension sleeve. You say that the 
items are medically necessary. The Plan denied your request. The Plan says the item is not covered. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 The record does not contain a valid proof of delivery for the supplies provided in this case. Neither the date on 
the packing slip or delivery slip match the date of service.. The record shows that the Plan made several 
attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not 
have to pay for the lumbar-sacral orthosis (LSO) (L0648), knee orthosis (L1833), and suspension sleeve 
(L2397), provided on September 8, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient hospital services provided from May 28, 2022, to May 30, 
2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says that the services 
are considered part of another service done on the same day. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
We looked at the file and the rules. The records show that the complete claim, which covers 3 days of services, 
was denied. The Plan has not provided an explanation or documentation how the services are inclusive to 
another service done on the same day. There was no Medicare ruling provided to show the services should not 
be covered. The Plan has not made reasonable and diligent efforts to gather and forward to us information 
regarding their decision to deny your request.  Therefore, we decided that the Plan has to pay for the inpatient 
hospital services provided from May 28, 2022, to May 30, 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 pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary for enrollee to 
return to prior level of function and be able to return home. The Plan denied your request. The Plan says the 
enrollee could receive care at a lower level. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that the shoe inserts are medically necessary to push 
your ankle back into the correct aligned position. 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 pre-approve foot orthotics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bone replacement graft for ridge preservation - per site tooth 
#19 (D7953), and surgical placement of implant body: endosteal implant tooth #19 (D6010) provided on June 
27, 2022. 
 
You asked the Plan to pay for the bone replacement graft for ridge preservation - per site tooth #19 (D7953), 
and surgical placement of implant body: endosteal implant tooth #19 (D6010). You say that you are requesting 
reconsideration. You also say that you paid out $4734.80 but the billed claim does not reflect that amount. The 
Plan denied your request. The Plan says these services are not covered under the benefit package. 
 
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 bone 
replacement graft for ridge preservation - per site tooth #19 (D7953), and surgical placement of implant body: 
endosteal implant tooth #19 (D6010) provided on June 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 33274 billed for date of service May 16, 
2022. 
 You asked the Plan to pay for the billed services. You say that the coding is correct as billed. The Plan denied 
your request. The Plan says the service was billed without an appropriate modifier and/or diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We looked at the file and the rules. We find that the leadless pacemaker services are not payable as billed. 
Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 33274 billed for date of service May 16, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computerized tomography (CT) scan of a smaller area 
to follow up on a prior study. 
 
You asked the Plan to pre-approve the CT scan. You say that it is medically necessary for the enrollee to get 
the CT scan done. The Plan denied your request. The Plan says it is not clear as to what the CT is being used 
for; therefore, the CT scan is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
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 CT scan. Our reviewer says that the 
CT scan is not medically necessary. Our physician reviewer found that the enrollee has had prior lumbar 
fusion. The enrollee had a bone scan including single photon emission CT on November 30, 2022, which 
detailed findings in the lumbar spine and also multiple extremities. The request for a limited CT, code 76380 
does not specify the reason or even the anatomical location of the area of interest. Without further clarification 
the medical necessity of the requested limited CT scan has not been established in the submitted records. 
 
  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 CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a computerized tomography (CT) scan of a smaller area to follow up on a prior study.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Oxygen concentrator (E1390) and shipping (99199), 
provided on August 10, 2022. 
 
You asked the Plan to pay for the Oxygen concentrator and shipping. You say that the items are medically 
necessary. The Plan denied your request. The Plan says this is not covered when purchased. 
 
The Plan must follow Medicare rules. Medicare rules say that payment is not made for purchases of oxygen 
equipment 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Oxygen concentrator and shipping have not been met. Therefore, we decided that the Plan does 
not have to pay for the Oxygen concentrator (E1390) and shipping (99199), provided on August 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on March 9, 2022. 
 
You asked the Plan to pay for the lab services. You say that medical records were provided. The Plan denied 
your request. The Plan says the claim was billed with an incorrect place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 
 We looked at the file and Medicare rules. In this case, the claim was billed with the laboratory POS code. The 
records do not support that the sample was taken in a laboratory setting. Based on this information, we decided 
that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan 
does not have to pay for the lab services provided on March 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on August 8, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that there is no agreement that these tests are 
included in the dialysis rate. The Plan denied your request. The Plan says Medicare does not separately pay for 
ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable.  
 
 
 Laboratories should bill the facility directly for laboratory services as they are considered part of the composite 
rate. No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay 
for the laboratory services related to end-stage renal disease (ESRD) provided on August 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9500 billed from October 22, 2021, to 
October 28, 2021. 
 
You asked the Plan to pay for procedure code S9500. You say that you were advised this is the correct coding. 
The Plan denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
In this case, the CPT Code Manual definition of code S9500 is home infusion therapy, antibiotic, antiviral, or 
antifungal therapy; once every 24 hours; administrative services, professional pharmacy services, care 
coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem. 
 We find that procedure code S9500 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9500 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for procedure 
code S9500 billed from October 22, 2021, to October 28, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on August 
9, 2022, to August 11, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you disagree with the 
copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $275 
copayment per day for days 1-6 for inpatient hospital care.  
 
You have been asked to pay a $275 copayment per day for days 1-6 for inpatient hospital care. The total 
amount you are being asked to pay is $550 ($275 x 2days= $550). This item/service falls within the inpatient 
hospital care benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayment for inpatient hospital care 
provided on August 9, 2022, to August 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675), provided on 
June4, 2022, through June 28, 2022. 
 
You asked the Plan to pay for a pneumatic compression device. You say that the item was medically necessary. 
The Plan denied your request. The Plan says this is not a covered item. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675), provided on June4, 2022, through June 28, 2022.
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 admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically 
necessary. 
 
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 reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to be improving but still requires additional short term acute care 
services that can be safely administered at the current facility until more stable and appropriate for a lower 
level of care. 
 
   
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Rituxan. 
 
You asked the Plan to pre-approve Rituxan. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the Plan requires a trial of Ruxience or Riabni before it will approve 
Rituxan. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Rituxan. Our reviewer says that the 
enrollee does not meet criteria for a step therapy exception for Rituxan. Our physician reviewer found the 
enrollee has not tried and failed the Plan's preferred drugs of Ruxience or Riabni. The record does not show 
that these drugs would likely be less effective and/or have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Rituxan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve use of Rituxan.