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

 
We decided that the Plan does not have to waive the copayments for a skilled nursing facility (SNF) stay 
provided from November 21, 2019, to December 1, 2019, and from January 1, 2020, to January 12, 2020, and 
physical therapy (PT) services provided from December 22, 2019, to December 31, 2019.  
 
You asked the Plan to waive the copayments for a SNF stay and PT services. You say that you had to be placed 
in a nursing facility due to being unable to care for yourself and need help with basic daily necessities. You 
also say the facility wanted you discharged on December 21, 2019, but you were still unable to care for 
yourself. 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 $20 
copayment per day for days 1-20 for a skilled nursing facility stay. The contract says there is a $80 copayment 
for days 21-100. The Plan contract also says that enrollees must pay a $40 copayment for each rehabilitation 
therapy service during a non-covered skilled nursing facility stay. 
 
The Plan confirmed prior to this SNF stay you utilized 17 SNF days. You have been asked to pay a total of 
$620, which is $20 copayment per day for the remaining three days and a $80 copayment per day for seven 
days of a SNF stay from November 21, 2019, to December 1, 2019 ($20 copayment x 3 days = $60, $80 
copayment x 7 days = $560, $60 copayment + $560 copayment = $620). You have also been asked to pay a 
$80 copayment for a SNF stay on December 1, 2019. You have also been asked to pay a total of $800, which is 
a $80 copayment for 10 days of a SNF stay from January 2, 2020, to January 12, 2020. A SNF stay falls within 
the Skilled Nursing Facility (SNF) Care benefit category. 
 
You have been asked to pay a total of $320, which is a $40 copayment for each rehabilitation therapy service 
from December 22, 2019, to December 31, 2019 ($40 copayment x 8 therapies = $320). The rehabilitation 
therapy service falls within the Inpatient Stay: Covered Services Received in a Hospital or SNF During a Non-
Covered Inpatient Stay 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 copayments for a skilled 
nursing facility (SNF) stay provided from November 21, 2019, to December 1, 2019, and from January 1, 
2020, to January 12, 2020, and physical therapy (PT) services provided from December 22, 2019, to December 
31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99203) rendered by the out-of-network 
(OON) provider on April 20, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization or a referral. 
 
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 service at issue in this appeal. The Plan did not pre-approve the service at issue. 
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the office visit (99203) rendered by the out-of-network (OON) provider on April 20, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for microsurgical techniques, requiring use of operating 
microscope (List separately in addition to code for primary procedure) (CPT code 69990). 
 
You asked the Plan to pay for the service. You say that the service is necessary. The Plan denied your request. 
The Plan says none of the requested codes are allowable with CPT 69990. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
None of the approved requested codes are allowable with CPT 69990, CPT 69990 is unbundled and therefore, 
is upheld. The rules say that effective January 1, 2000, the replacement code (CPT 69990) for modifier -20 - 
microsurgical techniques requiring the use of operating microscopes may be paid separately only when 
submitted with specific CPT codes.   
Therefore, we decided that the Plan does not have to pay for microsurgical techniques, requiring use of 
operating microscope (List separately in addition to code for primary procedure) (CPT code 69990).
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve pontics - porcelain fused to high noble metal (D6240) for teeth 19 
and 20, and retainer crowns - porcelain fused to high noble metal (D6750) for teeth 21 and 18.  
 
You asked the Plan to pre-approve false tooth for bridge for teeth 19 and 20 and white glass with high gold 
content caps for bridge for teeth 21 and 18. You say that you need a bridge. The Plan denied your request. The 
Plan says that the x-rays the bridge appears to be intact and serviceable. The bridge does not need to be 
removed or replaced to do the root canals. 
 
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. The Plan covers false teeth for 
a bridge for teeth 19 and 20 and white glass with high gold content caps for a bridge for teeth 21 and 18 when 
the services are medically necessary and reasonable. 
 
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 false teeth for a bridge for teeth 19 and 
20 and white glass with high gold content caps for a bridge for teeth 21 and 18. Our reviewer says that the 
bridge is medically necessary. Our physician reviewer found that review of the documentation indicates that 
the original bridge was removed in order to do a root canal on tooth #18. There were no radiographs of the 
original bridge in place. The radiographs show tooth #21 with a completed root canal and in need of a post/ 
core and crown and tooth #18 for which a root canal has been prescribed also in need of a post/core and crown. 
It appears reasonable that since crowns are needed on teeth #'s 19 and 20 placement of pontics to replace the 
missing teeth #'s 19 and 20 and placement of a fixed bridge would be the standard of care. The documentation 
provided meets the criteria for coverage for a replacement bridge replacing missing teeth #'s 18 and 19 with 
pontics (D6240) using teeth #'s 18 and 21 as abutment retainers (D6750). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of false tooth for bridge for teeth 19 and 20 and white glass with high gold content 
caps for bridge for teeth 21 and 18 have been met. Therefore, we decided that the Plan has to pre-approve 
pontics - porcelain fused to high noble metal (D6240) for teeth 19 and 20, and retainer crowns - porcelain fused 
to high noble metal (D6750) for teeth 21 and 18.  
  
 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an addition, endoskeletal, knee-shin system, stance 
flexion feature, adjustable (L5845). 
 
You asked the Plan to pre-approve an endoskeletal, knee-shin system, stance flexion feature. You say that the 
requested part is medically necessary and approved by Medicare. The Plan denied your request. The Plan says 
the requested part is unbundled from the approved knee and cannot be requested separately. 
 
We looked at the file and Medicare rules. The records show that the requested part cannot be requested 
separately. Based on this information, we decided that Medicare rules for coverage of an endoskeletal, knee-
shin system, stance flexion feature have not been met. Therefore, we decided that the Plan does not have to pre-
approve an addition, endoskeletal, knee-shin system, stance flexion feature, adjustable (L5845).
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to waive the copayment for the lesion excision provided on May 5, 2021.

You asked the Plan to waive the copayment for the lesion excision. You say that you were told this was coded wrong and was listed as a procedure and not an office visit. The Plan denied your request. The Plan says that the copayment applied is correct.

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.

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Evidence of Coverage submitted does not list benefits in chapter 4 and we could not confirm the benefit submitted in the case summary is for the correct plan. This means that we could not confirm the copay you are being asked to pay is correct or justified by the Plan contract. Therefore, we decided that the Plan has to waive the copayment for the lesion excision provided on May 5, 2021. 

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 waive the copayment for a diagnostic eye exam provided on October 21, 2021.

You asked the Plan to waive the copayment for the eye exam. You say that you thought this was a routine exam. 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 $40 copayment for each exam to diagnose and treat diseases of the eye. 

The record shows that your exam was performed due to concerns of seeing flashes of light and blurriness. Due to these specific reasons, the exam is considered diagnostic. Therefore, you have been asked to pay a $40 copayment for the eye exam. The eye exam falls within the Vision Care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a diagnostic eye exam provided on October 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services you received on August 25, 2021. 
 
You asked the Plan to pay for the dental services. You say that you needed this care due to an accident so it 
should be covered. The Plan denied your request. The Plan says you have exhausted your annual dental 
maximum, so no further payment will be made for dental services. 
 
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. Your Plan only covers dental 
services up to $500 per year.  Your Plan has already paid this $500 maximum for these dental services. 
 
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 dental 
services you received on August 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 99053 billed for date of service July 8, 2021.

You asked the Plan to pay for procedure code 99053. You say that you have submitted medical records to support payment. The Plan denied your request. The Plan says this code is not separately payable.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

We find that CPT code 99053 has a status indicator of B on the Physician Fee Schedule. This means that CPT code 99053 is not separately payable. Based on this information, we decided that Medicare rules for coverage of procedure code 99053 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 99053 billed for date of service July 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lower extremity suspension sleeve (code L2397) billed for date of service August 4, 2021.

You asked the Plan to pay for the lower extremity suspension sleeve. You say that this claim was denied incorrectly. The Plan denied your request. The Plan says the medical documentation does not support payment for this item.

The Plan must follow Medicare rules. Medicare rules say that if the treating practitioner dispenses durable medical equipment, the medical record must include all of the elements that would have been present in a standard written order for durable medical equipment. In this case, the medical records you provided in support of your appeal are completely silent on the suspension sleeve in dispute. There is no indication that this was ordered or provided. There is no record of dispensing this item to the patient. There is no description of this item anywhere in the medical record that you provided. These elements are required to be documented in the medical record in order to support payment. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lower extremity suspension sleeve have not been met. Therefore, we decided that the Plan does not have to pay for the lower extremity suspension sleeve (code L2397) billed for date of service August 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two custom fabricated abutments (D6057 x2) and two 
abutment supported porcelain/ceramic crowns (D6058 x2) provided on December 7, 2021. 
 
You asked the Plan to pay for the custom fabricated abutments and abutment supported porcelain/ceramic 
crowns. You say that when you made the decision to have your teeth repaired, you knew you would be carrying 
a huge part of the financial burden, but expected at least half to be paid. The Plan denied your request. The Plan 
says there is no documentation that services were for extraction done in preparation for radiation treatment 
involving the jaw. The Plan also says that these services are not covered. 
 
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 two 
custom fabricated abutments (D6057 x2) and two abutment supported porcelain/ceramic crowns (D6058 x2) 
provided on December 7, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 22830 billed for date of service September 
22, 2021. 
 
You asked the Plan to pay for procedure code 22830. You say that the medical records support billing of this 
code. The Plan denied your request. The Plan says the medical records do not support billing of this code. 
 
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 22830 is exploration of spinal fusion. 
 
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 procedure code 22830. Our reviewer says that this code is 
not supported in the medical record. Our reviewer found the operative note does not describe exploration of a 
spinal fusion mass. 
 We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 22830 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 22830 billed for date of service September 22, 2021.
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 you need SNF care because you cannot stand for 
more than a minute at a time and that is with someone's help.  You said that it is not safe for you to return 
home. The Plan denied your request. The Plan says SNF care is not medically necessary for you. 
 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 you have stabilized medically and are ready 
for discharge from the hospital. You do not require skilled nursing and/or skilled therapy services on a daily 
basis. You are medically stable and can receive further rehab services at a lower level of care. Although further 
rehab services would be appropriate to improve function, as a practical matter, the intermittent skilled services 
can be provided at a lower level of care than a skilled nursing facility. You do not have any parental 
medication; complex wound care or nutrition given via a feeding tube. You are medically stable without any 
acute exacerbations of chronic medical problems. Your physical function is at or near her baseline and you can 
receive services 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services you received from an out-of-network dentist 
from March 25, 2021, to October 5, 2021. 
 
You asked the Plan to pay for the dental services. You say that you have submitted all of the codes and bills 
needed to be reimbursed. You said these bills are a burden. The Plan denied your request. The Plan says dental 
services with an out-of-network dentist are not covered. 
 
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. Your dental benefit only 
covers limited dental services. Those limited dental services must be received from a network dentist.  You did 
not use a network dentist, so none of the dental services you received are covered. 
 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 dental 
services you received from an out-of-network dentist from March 25, 2021, to October 5, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the destruction of benign lesions (17110) provided on May 
18, 2021. 
 
You asked the Plan to pay for code 17110. 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 the Medicare approved amount for global 
surgery procedures includes payment for the above services related to the surgery when furnished by the 
physician who performs the surgery. 
 
We looked at the file and Medicare rules. The procedure in question was provided within the 10-day global 
period for the surgical procedure (code 17111) that was provided on May 10, 2021. Code 17110 was not billed 
with a modifier indicating this was unrelated to the original procedure. This means that payment for the 
procedure was included in the payment for the original surgical procedure. Therefore, we decided that the Plan 
does not have to pay for the destruction of benign lesions (17110) provided on May 18, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services provided on November 5, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for the laboratory services by a contract provider. The file does not show that the 
plan provided notice that the laboratory services would not be covered. Under Medicare rules, this means the 
laboratory services are considered approved by the plan. Therefore, we decided that the Plan has to pay for the 
laboratory services provided on November 5, 2021.  
 
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.