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

 
We decided that the Plan does not have to waive the copayment for outpatient surgery provided on June 28, 
2022. 
 
You asked the Plan to waive the copayment for outpatient surgery. 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 $225 
copayment for outpatient surgery.  
 
You have been asked to pay a $225 copayment for outpatient surgery. This item/service 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 outpatient surgery 
provided on June 28, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a CT scan of chest. 
 
You asked the Plan to pre-approve a CT scan of chest. You say that the services are necessary. The Plan denied 
your request. The Plan says that based on the documentation provided, coverage criteria has not been met. 
 
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 a CT scan of chest. Our reviewer says 
that the services are medically necessary. Our physician reviewer found the guidelines call for a follow-up in 3-
6 months for new nodules such as described in this report. This enrollee has a follow up visit planned in April, 
2023 so the request for a scan in March would be at 4 months in line with the guidelines. A repeat scan in late 
March or early April to be coordinated before her follow-up appointment is necessary. Such timing would 
allow for the scan to be closer to 6 months and still provide the information necessary for appropriate 
management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a CT scan of chest have been met. Therefore, we decided that the Plan has to 
pre-approve a CT scan of chest.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the retainer crown-porcelain/ceramic (D6740) and the 
pontics-porcelain/ceramic (D6245 x 2) provided on June 14, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not a covered benefit. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
the enrollees teeth or the structures directly supporting her teeth. These are dental services that are not covered 
or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the retainer crown-
porcelain/ceramic (D6740) and the pontics-porcelain/ceramic (D6245 x 2) provided on June 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown on tooth #11 (D2750), a prefabricated abutment 
on tooth #20 (D6056), an endosteal implant on tooth #19 (D6010), core build up on tooth #11 (D2950), 
abutment supported crowns on tooth #19 and 20 (D6059), resin-based composite fillings (D2332, D2335), and 
periodontal scaling and root planing (D4341). 
 
You asked the Plan to pre-approve the dental services. You say that you disagree with the denial of dental 
services. The Plan denied your request. The Plan says your benefit for crowns, prefabricated abutments, endosteal implants, core build up, fillings, and periodontal scaling has already been exhausted. The Plan also 
says that abutment supported crowns are not covered by your dental 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, certain limitations apply. The record 
shows your benefit for crowns, prefabricated abutments, endosteal implants, core build up, fillings, and 
periodontal scaling has already been exhausted. Abutment supported crowns are not covered under this benefit. 
Therefore, we decided that the Plan does not have to pre-approve a crown on tooth #11 (D2750), a 
prefabricated abutment on tooth #20 (D6056), an endosteal implant on tooth #19 (D6010), core build up on 
tooth #11 (D2950), abutment supported crowns on tooth #19 and 20 (D6059), resin-based composite fillings 
(D2332, D2335), and periodontal scaling and root planing (D4341).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service August 17, 
2022. 
 
You asked the Plan to pay for procedure code 76705. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment for code 76705 is bundled into 
payment for code 93976. 
 
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 76705 
is a column II code to column I code 93976. 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 procedure code 76705 billed for date of service August 17, 2022.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pay for skilled nursing facility services provided on June 15, 2022, through 
July 14, 2022. 
 
You asked the Plan to pay for skilled nursing facility services. The Plan denied your request. The Plan says that 
skilled nursing facility care is not medically necessary. 
 
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. 
 
Specifically the Plan has not made reasonable and diligent efforts to gather and forward to us information 
regarding their decision to deny your request. the Plan has not forwarded medical records to determine if their 
denial of this claim is correct. It is the burden of the Health Plan to substantiate their denial with evidence. In 
this case, the denial has not been substantiated so we must find in your favor. Therefore, we decided that the 
Plan has to pay for skilled nursing facility services provided on June 15, 2022, through July 14, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on 
August 24, 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 June 23, 2021. Specifically, the 
Plan contract provides coverage for a comprehensive oral evaluation once every three years. You previously 
received this service on June 23, 2021, which was 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 
comprehensive oral evaluation (D0150) provided on August 24, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee can participate in the 3 hours of therapy 
and can be seen by a physician daily which you feel would reduce the risk of returning to the hospital. The Plan 
denied your request. The Plan says based on Medicare guidelines and the information we have about the 
enrollee's condition they do not meet all the requirements. 
 
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 complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for surgical repair of a hip fracture after a fall. Medical problems are stable. There are no 
complex nursing or rehabilitation needs. While the medical records support a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. There is not a reasonable expectation that the enrollee will be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ultrasonic guidance for placement of radiation therapy 
fields. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is experimental and investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the treatment itself is not disputed in this case but rather the need for image guidance. Using 
ultrasound on a daily basis is not unreasonable to offer but not necessary. Billing for daily image-guided 
radiation therapy or daily simulations (also requested in this case) which would not be furnished in accordance 
with accepted standards of medical practice." 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve ultrasonic guidance for placement of radiation therapy fields.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99223 provided on September 6, 2021. 
 
You asked the Plan to pay for procedure code 99223. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as 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 code 99223 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 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 problem(s) requiring 
admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit. 
 
We find that CPT code 99223 is not supported in the medical record. Specifically, the file shows that the 
enrollee was admitted as an outpatient on the date of service at issue in this appeal. Code 99223 is an inpatient code. Based on this information, we decided that Medicare rules for coverage of procedure code 99223 have 
not been met. Therefore, we decided that the Plan does not have to pay for procedure code 99223 provided on 
September 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150). 
 
You asked the Plan to pre-approve the evaluation. The Plan denied your request. The Plan says dental services 
from an out-of-network provider are not covered by your supplemental 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. 
 
You are requesting dental services from an out-of-network provider. Though the Plan offers a dental benefit in 
excess of Medicare coverage, the requested items or services are not covered under this benefit when received 
from an out-of-network provider. Therefore, we decided that the Plan does not have to pre-approve a 
comprehensive oral evaluation (D0150).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for excision, malignant lesion including margins, face, ears, 
eyelids, nose, lips; excised diameter over 4.0 cm provided to the enrollee on June 23, 2022. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says the documentation received does not indicate that the services represented by CPT 
11646 were performed. 
 
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 11646 is "Excision, malignant lesion including margins, 
face, ears, eyelids, nose, lips; excised diameter over 4.0 cm." 
 
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 that the operative report does not 
describe the assistant's role in the operative report to support the necessity for an assistant for a procedure 
which does not allow for an assistant. 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter 
over 4.0 cm provided to the enrollee on June 23, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 
You asked the Plan to pre-approve Euflexxa. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that various polymers of hyaluronic acid have been 
approved and marketed as implanted prosthetic devices. 
 
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 Euflexxa. Our reviewer says that the services are not medically necessary. Our physician reviewer found in this case, the record indicates that you 
have a diagnosis of osteoarthritis of the knee. The record does not indicate that you have tried and failed a 
three-month course of conservative non-pharmacologic therapy. The record indicates the occurrence of recent 
trauma. The Food and Drug Administration has not stated that the requested drug is indicated for your 
condition. The Medicare approved drug compendia do not contain a supportive citation for the use of the 
requested drug in your clinical situation. The elements of the coverage criteria are not satisfied. The requested 
service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you are not able to be discharged at home because 
you are not able to walk and have a feeding tube. You say that you do not have any medical equipment at home 
and do not have any transportation. The Plan denied your request. The Plan says a SNF admission is not 
medically necessary, and your needs can be met at an alternate level of care. 
 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 pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the walker and seat attachment provided on 
August 04, 2022. 
 
You asked the Plan to waive the deductible for the walker and seat attachment. You say that you believe the 
claim was processed as out-of-network. 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 $680 
deductible for durable medical equipment (DME) and related supplies. 
 
You have been asked to pay a $680 deductible for the walker and seat attachment. This item/service falls 
within the durable medical equipment (DME) and related supplies benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Please note that the provider network status does 
not affect the cost in this case, as the deductible had not been met. Therefore, we decided that the Plan does not 
have to waive the deductible for the walker and seat attachment provided on August 04, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services. 
 
You asked the Plan to pay for the ambulance services. You say that you feel you should not have to pay for the 
ambulance ride. You also say that you did not know if you did not go to the emergency room it would not be 
covered by the Plan. The Plan denied your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on May 30, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services.