Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an inpatient hospital stay provided from 
October 21, 2021, to October 25, 2021. 
 
You asked the Plan to waive the deductible for the inpatient hospital stay. You say that you would like the cost 
share waived due to a COVID-19 emergency. The Plan denied your request. The Plan says the proper cost 
share was applied and during the time of service there was no cost share waivers in effect. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $1,000 deductible which applies to an inpatient hospital care. Prior to 
October 21, 2021, the total amount paid towards the $1,000 deductible was $733.01 leaving $266.99 ($1,000 
yearly deductible - $733.01 paid towards deductible) left to pay to hit the yearly deductible. The total amount 
allowed for the inpatient hospital stay was $299.19. The total deductible amount charged was $266.99 which 
means the yearly deductible was met and the plan paid the rest of the balance. 
 
  The item or service you asked the Plan to waive the deductible for falls within the What is your plan deductible 
benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a 
$1000 deductible which applies to is the amount you have to pay out-of-pocket before we will pay our share for 
your covered medical services. Until you have paid the deductible amount, you must pay the full cost of your 
covered services. Once you have paid your deductible, we will begin to pay our share of the costs for covered 
medical services and you will pay your copayment or coinsurance amount for the rest of the calendar year. This 
cost sharing is a contractual obligation that had not been met at the time the inpatient hospital stay was received 
on October 21, 2021, to October 25, 2021. Therefore, we decided that the Plan does not have to waive the 
deductible for an inpatient hospital stay provided from October 21, 2021, to October 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an out-of-network provider on 
January 10, 2022. 
 
You asked the Plan to pay for dental services. You say that you were led to believe that this provider was in-
network. The Plan denied your request. The Plan says this claim has been processed and paid 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. Benefits received out-of-
network are subject to any in-network benefit maximums, limitations, and/or exclusions. You may be billed by 
the out-of-network provider for any amount greater than the payment made by the Plan to the provider.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of dental services have not been met. Therefore, we decided that the Plan does not have to pay for 
dental services provided by an out-of-network provider on January 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive care management services (G2064) 
rendered by the out-of-network (OON) provider on November 15, 2021. 
 
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 the services were rendered by an out of 
network provider, without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 
 The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. 
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the comprehensive care management services (G2064) rendered by the out-of-
network (OON) provider on November 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Chiropractic Care services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve Chiropractic Care services. You say that you would like to appeal the 
denial. The Plan denied your request. The Plan says the provider requested is OON and the services are not 
emergent or urgent. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
Chiropractic Care services to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an arthrocentesis provided on September 
23, 2021. 
 
You asked the Plan to reduce the copayment for an arthrocentesis. You say that the clinic charged you for 
being in an observation or treatment room. You also say that you paid your $40 copayment when you were at 
the office. 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 a $325 
copayment for outpatient surgery at an outpatient hospital.  
 
The record shows this claim was approved, and you have a cost sharing amount. An arthrocentesis is 
considered a surgical procedure. You have been asked to pay the allowed amount of $242.59, which is less than the $325 copayment for an arthrocentesis. An arthrocentesis falls within the Outpatient Surgery and Other 
Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 reduce the copayment for an arthrocentesis provided on September 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power operated vehicle, group 1 standard, 3-wheeled 
motorized scooter (K0800). 
 
You asked the Plan to pre-approve a power operated motorized scooter. You say that the enrollee is diagnosed 
with bilateral osteoarthritis of knees. As a result, she experiences much difficulty maneuvering around and 
inside her house, especially in a walker or manual wheelchair. The Plan denied your request. The Plan says no 
new clinical information has been received despite being requested 4 times. There is no specific information 
related to the enrollee's inability to perform mobility related activities such as toileting, feeding, dressing, 
grooming, and bathing in customary locations in the home. 
 
 
 The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
The file does not include any clinical information to show that the enrollee has a mobility deficit that impairs 
their participation in MRADLs. There is no specific information related to the enrollees inability to perform 
mobility related activities such as toileting, feeding, dressing, grooming, and bathing in customary locations in 
the home. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a power operated vehicle, group 1 standard, 3-wheeled motorized 
scooter (K0800).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 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 daily 
skilled services are not necessary. Our physician reviewer found the enrollee does not have documented skilled 
nursing needs or documented skilled therapy needs. The enrollee is effectively bedbound. The enrollees care 
needs, custodial and intermittent, can, as a practical matter, can be provided at 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergency ambulance services (A0428) and ground 
mileage (A0425) provided from October 5, 2021, to October 6, 2021. 
 
You asked the Plan to pay for the ambulance services. You say that similar services were paid previously. The 
Plan denied your request. The Plan says the non-emergency ambulance services were not medically necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 ambulance services. Our reviewer says 
that the ambulance services are not medically necessary. Our physician reviewer found the provided 
documentation does not support that other means of transport (such as stretcher van, wheelchair van, taxi, 
private car, or other type of vehicle) were contraindicated for the enrollee on the dates of service in this case.  
 
 The documentation does not support that the enrollee needed the expertise, services and lifesaving and life-
sustaining equipment that only a fully-equipped ambulance can provide for safe transport. The documentation 
does not support that the ambulance transport on October 5, 2021, to October 6, 2021 was medically reasonable 
and necessary 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 the ambulance services have not been met. Therefore, we decided that the Plan 
does not have to pay for the non-emergency ambulance services (A0428) and ground mileage (A0425) 
provided from October 5, 2021, to October 6, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the various services provided to the enrollee on August 2, 
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 this claim was already processed, and there is no additional documentation supporting additional 
services which were billed and remain denied. 
 
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 36010: 
 
Introduction of catheter, superior or inferior vena cava 
 
CPT 37253: 
 
Intravascular ultrasound (noncoronary vessel) during diagnostic evaluation and/or therapeutic intervention, 
including radiological supervision and interpretation; each additional noncoronary vessel (List separately in 
addition to code for primary procedure) 
 
CPT 75822: 
 
Venography, extremity, bilateral, radiological supervision and interpretation 
 
CPT 76937: 
 
Ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites, 
documentation of selected vessel patency, concurrent realtime ultrasound visualization of vascular needle 
entry, with permanent recording and reporting (List separately in addition to code for primary procedure) 
 
CPT 99152: 
 
Moderate sedation services provided by the same physician or other qualified health care professional 
performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an 
independent trained observer to assist in the monitoring of the patient's level of consciousness and 
physiological status; initial 15 minutes of intraservice time, patient age 5 years or older 
 
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 documentation includes a 
Provider Remittance Advice; check date 10/8/21, claim number KCL 17389839-02. These procedures were 
paid. Additional units are not supported by the documentation submitted. 
 
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 the various services provided to the enrollee on August 2, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (93042) provided on September 12, 2021. 
 You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 
service. 
 
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 93042 
is a column II code to column I code 99291. 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 services (93042) provided on September 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the osseous surgery (D4261) provided on 
December 21, 2021. 
 
You asked the Plan to reimburse you for the dental service. You say that this procedure was needed as a 
precursor to a subsequent bridge repair that will be performed in the future. The Plan denied your request. The 
Plan says osseous surgery is not listed as a covered service. 
 
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 reimburse you for 
the osseous surgery (D4261) provided on December 21, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the computed tomography (CT) scans 
provided on December 10, 2021. 
 
You asked the Plan to waive the cost sharing for the CT scans. You say that the CT scans were necessary and 
appropriate. The Plan denied your request. The Plan says the cost sharing 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 4% 
coinsurance for each Medicare-covered diagnostic radiology and complex imaging service.  
 
 Date of Service Service 
Rendered 
Allowed 
Amount 
Deductible Cost Sharing per 
Contract 
Your Share 
December 10, 
2021 
Thorax CT scan $170.60 
($124.59 after 
deductible) 
$46.01 4% coinsurance $46.01 + 
$4.98 = $50.99 
December 10, 
2021 
Chest CT scan $87.65  4% coinsurance $3.51 
Total:     $54.50 
 
You have been asked to pay $54.50 for these services. The CT scans fall within the Outpatient diagnostic tests 
and therapeutic services and 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. Therefore, we decided that the Plan does not have to waive the cost sharing for 
the computed tomography (CT) scans provided on December 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided by a participating 
provider on December 22, 2021. 
 
You asked the Plan to pay for a limited oral evaluation. You say that this was necessary because the crown on 
your tooth had become detached. The Plan denied your request. The Plan says the benefit limit for D0140 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 Plan's coverage rules apply in this case. The Plan covers one limited 
oral evaluation per plan year. We looked at the file and Medicare rules. Evidence was provided to show that D0140 was previously provided on February 9, 2021. Based on this information, we decided that the Plan's rules for coverage of a limited oral evaluation have already been met. Therefore, we decided that the Plan does not have to pay for a limited oral 
evaluation (D0140) provided by a participating provider on December 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a partial lower 
denture (D5214). 
 
You asked the Plan to pre-approve the dental items. You say that  The Plan denied your request. The Plan says 
dentures are covered once every 5 plan years. The Plan also says that the frequency limit has been reached. 
 
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 and dentures are covered once every 5 
plan years, the frequency limit has been exceeded. The record shows that the Plan paid for a complete upper 
denture and partial lower denture that you received on August 14, 2020. Therefore, we decided that the Plan 
does not have to pre-approve a complete upper denture (D5110) and a partial lower denture (D5214).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and the laboratory services rendered by the 
out-of-network (OON) provider on September 29, 2021. 
 
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 the services were rendered by an out of 
network provider, without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the office visit and the laboratory services rendered by the out-of-network (OON) 
provider on September 29, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. 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 must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care.  
 Our reviewer says that the documentation does not support that the criteria for inpatient admission are met in 
this case. Our physician reviewer found the review has determined that the record does not show that at the 
time of inpatient admission the admitting physician reasonably expected that your necessary hospital care 
would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.