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

 
We decided that the Plan does not have to pay for admission to a skilled nursing facility (SNF) for the enrollee. 
 
You asked the Plan to pay for the admission. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not medically necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section 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 pay for the admission. Our reviewer says that the 
requested admission is not medically reasonable or necessary. Our physician reviewer found at the time of 
discharge from the hospital, the enrollee had stabilized medically. The enrollee did not require any skilled 
nursing or rehab services on a daily basis at an inpatient level of care. He was not expected to make measurable 
gains within a reasonable and predictable period of time or require skilled therapy to prevent deterioration with 
mobility or self-care tasks. The enrollee did not require skilled therapy to establish a safe and effective 
maintenance program. As a practical matter, the enrollee did not require any skilled services on an inpatient 
basis, at a SNF level of care at the time of discharge from the hospital. He was medically stable without any 
acute exacerbations of chronic medical problems. His physical function was at or near his new baseline and he 
could have received further services at a lower level of care. Admission to the nursing facility at a skilled level 
of care for inpatient skilled services was not medically 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 the admission have not been met. Therefore, we decided that the Plan does not 
have to pay for admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for arthroscopy shoulder surgery provided on 
December 10, 2021. 
 
You asked the Plan to waive the copayment for arthroscopy shoulder surgery. You say that your injury was 
caused by a fall not an automobile accident. The Plan denied your request. The Plan says copayment is correct. 
 
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 $290 for 
each Medicare-covered, in-network ambulatory surgical center visit.  
 
You have been asked to pay $290 copayment for arthroscopy shoulder surgery. Arthroscopy shoulder surgery 
falls within the Outpatient surgery 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 
arthroscopy shoulder surgery provided on December 10, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Glossectomy (41155) provided on June 14, 2021. 
 
You asked the Plan to pay for code 41155. You say that the medical records support the billing of code 41155 
provided on June 14, 2021. The Plan denied your request. The Plan says the medical records do not support the 
billing of code 41155 provided on June 14, 2021. 
 
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 41155 is Glossectomy; composite procedure with 
resection floor of mouth, mandibular resection, and radical neck dissection (Commando type).  
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 code 41155. Our reviewer says that the medical records do 
not support the billing of code 41155 provided on June 14, 2021. Our reviewer found the documentation 
submitted was reviewed, and the operative report does not include documentation to support this code 
description.  The operative report documents "The marginal mandibular branch of the facial nerve was 
identified along the body of the mandible. We then returned to the left neck incision and defined the remnant 
posterior free edge of the mylohyoid muscle.  The remainder of level IB was dissected to the level of the hyoid 
bone and left in continuity with the remainder of the specimen.  Therefore, this procedure cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 41155 have not been met. Therefore, we decided that the Plan does not 
have to pay for the Glossectomy (41155) provided on June 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950) 
and crown - porcelain/ceramic (D2740) provided August 12, 2021. 
 
You asked the Plan to pay for the core buildup and crown. You say that at the beginning of the year you were 
told that your 2021 coverage would be the same as the previous year and that you would still have coverage for 
crowns. 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 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 the core buildup, including any pins when required (D2950) and crown - porcelain/ceramic (D2740) provided August 12, 2021.  
 
Your complaint about potentially being provided misinformation when you signed up for your 2021 benefits is 
not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by 
the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital services provided to the enrollee on August 24, 
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 documentation does not indicate whether the patient was registered as inpatient or outpatient. 
 
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 99222 is "Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive 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 problem(s) 
requiring admission are of moderate severity. Typically, 50 minutes are spent at the bedside and on the patient's 
hospital floor or unit." 
 
 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 the documentation submitted does not 
include enough information to verify place of service was incorrect. An evaluation and management service 
provided documentation patient was an inpatient. The place of service on the document "eHUB Transaction 
Viewer" is not documented. The correct place of service in this case cannot be verified. 
 
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 hospital services provided to the enrollee on August 24, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 7 home health physical therapy visits (G0151). 
 
You asked the Plan to pre-approve home health services. You say that this is medically reasonable and 
necessary. The Plan denied your request. The Plan says the requested home health physical therapy visits are 
not medically reasonable and necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the requested home health services are not medically reasonable and necessary. Our physician 
reviewer found based on the documentation provided, the enrollee does not have documented, ongoing, home 
health physical therapy needs. As such, the requested, ongoing, home health physical therapy services are not 
medically necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 7 home health physical therapy visits (G0151).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown (D2740) provided on October 27, 2021. 
 
You asked the Plan to pay for the dental service. You say that you were in an accident that resulted in an injury 
to the left side of your mouth. You also say that you feel the services should be covered under your medical 
coverage. The Plan denied your request. The Plan says the annual maximum benefit of $500 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, the annual maximum benefit of $500 
has been exceeded. The record shows that the Plan paid $150 for services received on May 18, 2021, $126 for 
services received on August 6, 2021, and $224 for services received on October 27, 2021. $150 + $126 + $224 
= $500. Therefore, we decided that the Plan does not have to pay for the crown (D2740) provided on October 
27, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on November 17, 2021, by 
an OON provider. 
 
You asked the Plan to pay for the laboratory services. You say that you would like to appeal for the denied 
service. The Plan denied your request. The Plan says the rendering and referring providers are both OON 
providers and there was no approved authorization. Also, the service rendered was not urgent or emergent. 
  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 the laboratory services provided on November 17, 
2021, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the incision and drainage of abscess - extraoral soft tissue 
(D7520) provided December 2, 2021. 
 
You asked the Plan to pay for the incision and drainage of abscess. You say that this service was necessary to 
address a bad toothache. 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 pay for the 
incision and drainage of abscess - extraoral soft tissue (D7520) provided December 2, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for a wrist orthosis and an occupational therapy 
(OT) visit provided on April 14, 2021. 
 
You asked the Plan to waive the cost share for a wrist orthosis and an OT visit. You say that you refused the 
therapeutic exercises and was only given a piece of paper. You also say that you would not have gotten the 
DME if you had known the cost beforehand. 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 20% coinsurance for durable medical equipment (DME). The Plan contract also says that enrollees must pay a $40 
copayment for an occupational therapy visit. 
 
You have been asked to pay $86.17, which is 20% coinsurance of the allowed amount for a wrist orthosis 
($430.87 allowed amount x 20% coinsurance = $86.17). A wrist orthosis falls within the Durable Medical 
Equipment (DME) and Related Supplies benefit category. 
 
The record shows you had an occupation therapy visit on April 14, 2021. You have also been asked to pay the 
allowed amount of $33.85, which is less than the $40 copayment for an OT visit. An OT visit falls within the 
Outpatient Rehabilitation Services benefit category. You have been asked to pay a total of $120.02 ($86.17 
coinsurance and $33.85 copayment). 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 cost share for a wrist orthosis and 
an occupational therapy (OT) visit provided on April 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the automatic external defibrillator rental 
(K0606) provided on January 13, 2022. 
 
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 item 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 15% 
coinsurance for Medicare-covered durable medical equipment (DME) rendered by an in-network provider.  
 
 You have been asked to pay $485.25 (Plans allowed amount of  $3,235 x 15% coinsurance) for the durable 
medical equipment rental 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 automatic 
external defibrillator rental (K0606) provided on January 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on April 15, 
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 denied codes remain not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that 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. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Specifically, this claim was billed with the laboratory POS code. 
The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the 
Plan does not have to pay for laboratory services provided to the enrollee on April 15, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on August 9, 
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 denied codes remain not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that 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. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Specifically, this claim was billed with the laboratory POS code. 
The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the 
Plan does not have to pay for laboratory services provided to the enrollee on August 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for the limited oral evaluation (D0140), 
panoramic x-ray (D0330), and extraction (D7210) provided on January 6, 2022, by the out of network provider. 
 
You asked the Plan to pay an additional amount for the dental services. You say that the services should be 
covered at 100%. You say that when you called the plan you were advised the provider was in network. The 
Plan denied your request. The Plan says that the claim 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage and 1 panoramic or complete series x-
ray every 5 years, the frequency limit has been exceeded. The record shows that the Plan paid for a complete series x-ray that you received on May 25, 2021. The record also shows that the Plan paid the allowed amount 
for the oral evaluation and extraction. Out of network providers may bill you for any amount greater than what 
the plan pays. Additionally, the record shows that the Plan sent an email with in network endodontists to you 
following your call on January 3, 2022. Therefore, we decided that the Plan does not have to pay an additional 
amount for the limited oral evaluation (D0140), panoramic x-ray (D0330), and extraction (D7210) provided on 
January 6, 2022, by the out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ophthalmological services: medical 
examination and evaluation with initiation of diagnostic and treatment program; comprehensive, new patient 
(92004) provided October 25, 2021. 
 
You asked the Plan to waive the copayment for the medical eye exam. You say that the exam should be 
covered because it was medically necessary. The Plan denied your request. The Plan says the copayment has 
been 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 $50 copayment for Medicare-covered vision service provided in a specialists office. 
 
You have been asked to pay a $50 copayment for the medical eye exam. The medical eye exam falls within the 
Vision 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 the ophthalmological 
services: medical examination and evaluation with initiation of diagnostic and treatment program; 
comprehensive, new patient (92004) provided October 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided on January 25, 2022, by 
an OON provider. 
 
You asked the Plan to pay for the home health services. You say that it is the facilities responsibility to obtain 
the authorization and it was medically necessary to treat the enrollee. The Plan denied your request. The Plan 
says the rendering provider is an OON provider and there was no referral from an in-network provider or an 
approved authorization. Also, the service rendered was not urgent or emergent. 
 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 the home health services provided on January 25, 
2022, by an OON provider.