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

 
We decided that the Plan does not have to pay for bitewings (D0270) and a limited oral evaluation (D0140) 
provided on September 27, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for this. The Plan 
denied your request. The Plan says your benefit for the requested item or service 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 requested item or service was exhausted on date of service February 16, 2022. 
Therefore, we decided that the Plan does not have to pay for bitewings (D0270) and a limited oral evaluation 
(D0140) provided on September 27, 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 admission to a long-term acute care 
hospital is needed. The Plan denied your request. The Plan says services requested do not meet the 
requirements for approval. 
 
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 there is no evidence that the enrollee requires services that are not currently available, 
therefore; Therefore, there is no advantage in transferring the enrollee to the LTACH and the enrollee can 
remain at the current ACH until such time no acute services are required.  The enrollee can then be transferred 
or discharged to a lower level of care for any ongoing LTC needs. 
 
  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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76700 billed for date of service September 7, 
2022. 
 
You asked the Plan to pay for procedure code 76700. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 76700 is 1. The MAI value for this code is 3. Review of the file shows that 
one unit of this code was already processed and paid by the Plan under claim 5425695100/NTL for this date of 
service. There is no additional documentation or conformations that indicate or support an additional study that 
was billed. You billed more than one unit of this code, exceeding the MUE. You did not provide all the 
required evidence showing that the excess units were actually provided, were correctly coded, and were 
medically necessary. Based on this information, we decided that Medicare rules for coverage of procedure code 
76700 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 76700 
billed for date of service September 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient surgery provided on August 
24, 2022. 
 
You asked the Plan to waive the copayment for an 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 $325 
copayment for outpatient surgery/Medicare-covered surgery services provided at an ambulatory surgical center.  
 
You have been asked to pay a $325 copayment for an outpatient surgery. However, you are only being asked to 
pay $248.58. This item/service falls within the outpatient surgery/Medicare-covered surgery services provided 
at an ambulatory surgical center benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
an outpatient surgery provided on August 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional dental service (D9999) to be rendered by 
an out-of-network provider. 
 
You asked the Plan to pre-approve the additional dental service. 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 an 
additional dental service (D9999) to be rendered by an out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Optimizer Smart implantable pulse generator 
cardiac contractility modulation (CCM) system. 
 
You asked the Plan to pre-approve Optimizer Smart CCM system. You say that key clinical findings support 
medical necessity for this procedure. The Plan denied your request. The Plan says studies have not proven that 
this is helpful for treatment of the enrollee's health problem. 
 
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 Optimizer Smart CCM system. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found CCM remains the subject of multiple studies examining long-term efficacy 
and trials to quantify clinical efficacy. Until such statistically rigorous studies are completed, it is premature to 
presume clinical outcomes and benefits. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Optimizer Smart CCM system have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the Optimizer Smart implantable pulse generator cardiac contractility 
modulation (CCM) system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power operated vehicle (POV) (K0800). 
 
You asked the Plan to pre-approve a POV. You say that the item is medically necessary. The Plan denied your 
request. The Plan says this item is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a POIV is covered when all of the criteria listed in the 
Medicare Rules section is met. 
 
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 POV. Our reviewer says that you do 
not need this item. Our physician reviewer found there is insufficient clinical documentation regarding your 
level of mobility and why you require a power mobility device. you are noted to have full motor strength in the 
lower extremities. There is no information provided as to why a cane or walker would not suffice with regards 
to assistance with mobility and you are noted to currently have a manual wheelchair. There is also insufficient 
documentation regarding your ability to safely use a power mobility device and if your home is accessible for 
the requested device. 
 
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 POV have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a power operated vehicle (POV) (K0800).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 17, 2022. 
 
You asked the Plan to pay for the office visit. The Plan denied your request. The Plan says a Substance Abuse 
Facility is not eligible to enroll with Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that a Substance Abuse Facility is not 
eligible to participate in the Medicare program. 
 
We looked at the file and Medicare rules. The provider at issue in this case is a Substance Abuse Facility. 
Medicare says that a Substance Abuse Facility is not eligible to participate in the Medicare program.  
 
 
 
 
  
 
Therefore, we decided that the Plan does not have to pay for an office visit provided on May 17, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency 
transport (A0428), and ground mileage (A0425) provided on May 30, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that the transportation falls under covered 
services for end stage renal disease (ESRD). You also say that transportation is not subject to consolidated 
billing. The Plan denied your request. The Plan says the enrollees claim would be covered under Original 
Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of 
the month in which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage before rendering services and to know proper billing procedures for a Medicare Advantage 
member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency 
transport (A0428), and ground mileage (A0425) provided on May 30, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an outpatient mental health visit provided on August 24, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for outpatient mental health visit. You say that the records attached support the 
services provided. The Plan denied your request. The Plan says there is no authorization or referral on file for 
the services provided. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an outpatient mental health visit provided on 
August 24, 2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung 
cancer screening. 
 
You asked the Plan to pre-approve the requested LDCT scan. The Plan denied your request. The Plan says the 
requested service is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung 
cancer screening for enrollees who meet all the criteria described in the Medicare rules section of this letter.  
 
We reviewed the file and the Medicare rules. We find that the enrollee is not between the ages of 50 and 77 
years old. Therefore, we decided that the Plan does not have to pre-approve a low dose computed tomography 
(LDCT) scan for lung cancer screening.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wheelchair van transportation (A0130) and case worker 
or social worker (A0160) provided on April 5, 2021. 
 You asked the Plan to pay for the wheelchair van transportation and case worker or social worker. You say that 
you would like this claim to be reconsidered. The Plan denied your request. The Plan says these services are 
not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport 
services.  
 
The services you have asked the Plan to pay for are wheelchair van transport services. Therefore, we decided 
that the Plan does not have to pay for the wheelchair van transportation (A0130) and case worker or social 
worker (A0160) provided on April 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Zoster (shingles) vaccine (90750) and administration 
(90471) provided on February 8, 2022. 
 
You asked the Plan to pay for the vaccine services. You say that you are being denied for a shingles vaccine at 
your age. You also say that this should be covered. The Plan denied your request. The Plan says the shingles 
vaccine is not covered under Medicare Part B. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine services. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the vaccine 
services. Therefore, we decided that the Plan does not have to pay for the Zoster (shingles) vaccine (90750) and 
administration (90471) provided on February 8, 2022.  
 
Benefits for the vaccine services may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the partial lower denture (D5214). 
 
You asked the Plan to pre-approve the dental service. You say that you need the partial denture in order to eat 
and talk. The Plan denied your request. The Plan says your benefit for the requested item or service 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 requested item or service was exhausted on date of service September 11, 2020. 
Therefore, we decided that the Plan does not have to pre-approve the partial lower denture (D5214).
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. The Plan denied your request. The Plan says the enrollee's records 
do not show the need for an intensive team for care. The services needed may be safely provided in other 
settings, a skilled nursing facility, home health services or home with outpatient therapy. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found there is not a reasonable expectation that this enollee 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for Ankle foot orthosis (L1971) provided on September 27, 2022

You asked the Plan to pay for the foot orthotics. You say that the items should be covered as you disagree with the denial. The Plan denied your request. The Plan says the items denied correctly as the record indicates the enrollee has a primary insurance.

The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer.

The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has contacted the enrollee's primary insurance carrier and made efforts to obtain the primary insurance explanation of benefits. However, this payment information was not sent to the Plan. As the secondary insurer, the Plan cannot be held responsible for the foot orthotics until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for Ankle foot orthosis (L1971) provided on September 27, 2022
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you feel an LTACH is the best hospital 
for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet the guidelines for 
admission to an LTACH. 
 
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 has ongoing acute medical issues and still requires acute care services. 
The enrollee does not require services at the LTACH that are not available at the acute care hospital where they 
are currently receiving care. The Plan has approved ongoing care in the current acute care 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care (99232) provided on June 30, 
2022. 
 
You asked the Plan to pay for the hospital care. You say that the service should be paid. The Plan denied your 
request. The Plan says the enrollees claim would be covered under Original Medicare as it is responsible for 
coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is 
revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage before rendering 
services and to know proper billing procedures for a Medicare Advantage member on hospice.  
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on June 25, 2022. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for the subsequent hospital care 
(99232) provided on June 30, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided from May 23, 2022, to May 30, 
2022. 
 
You asked the Plan to pay for physician services. You say that you are appealin this denial. The Plan denied 
your request. The Plan says the enrollee was in a hospice program for these dates of service; therefore, the Plan 
is not responsible for payment of the claims. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for physician services provided from May 23, 2022, to May 30, 
2022.