Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the psychotherapy and hospital outpatient 
clinic visits provided from May 21, 2021, to April 4, 2022. 
 
You asked the Plan to waive the cost share for the psychotherapy and hospital outpatient clinic visits. You say 
that you are paying more to see a mental health specialist than you would a specialist for your physical health. 
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% 
coinsurance per visit.  
 
You have been asked to pay a 20% coinsurance per visit for the psychotherapy and hospital outpatient clinic 
visits for a total of $426.17. The psychotherapy and hospital outpatient clinic visits fall within the Outpatient 
Mental Health 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 cost share for the psychotherapy 
and hospital outpatient clinic visits provided from May 21, 2021, to April 4, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay on March 01, 2022, 
to March 07, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that you do not believe you 
should be liable for this inpatient acute hospital stay because you had complications to the initial surgery. The 
Plan denied your request. The Plan says the cost sharing you are being charged is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must each time 
you are admitted to an acute care hospital, you pay $475 copayment per day for days 1-4 and $0 after day 4. 
This applies to all admissions, including a transfer from another facility such as an acute rehabilitation or 
skilled nursing. Includes inpatient acute, inpatient rehabilitation, long-term care hospitals and other types of 
inpatient hospital services. Inpatient hospital care starts the day you are formally admitted to the hospital with a 
doctors order. The day before you are discharged is your last inpatient day. There were 6 days, you are being 
charged for the first 4 days. $475 x 4 = $1,900. Therefore, results in the total cost sharing amount of $1,900.  You have been asked to pay a $475 copayment for days 1-4 for inpatient hospital stay. Inpatient hospital stay 
falls within the Inpatient hospital 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 
inpatient hospital stay on March 01, 2022, to March 07, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a raised toilet seat. 
 
You asked the Plan to pre-approve a raised toilet seat. The Plan denied your request. The Plan says this item is 
not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered 
because they are not primarily medical in nature.  
 
While a raised toilet seat may be appropriate for C. Waiters, neither the Plan nor Medicare offers coverage of 
this item. Therefore, we decided that the Plan does not have to pre-approve a raised toilet seat.
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 for the enrollee. 
 
You asked the Plan to pre-approve the screening. You say that this is medically necessary. The Plan denied 
your request. The Plan says the smoking history of pack years was not given. 
 
The Plan must follow Medicare rules. Medicare rules say that LDCT scans are covered only when there is a 
statement that the enrollee is asymptomatic. 
 
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 screening. Our reviewer says that 
the requested services are not medically reasonable or necessary. Our physician reviewer found that the 
enrollee has a LDCT on 6/17/21 which revealed chronic changes. He would qualify based on age and smoking 
history; however, at the last visit, the enrollee was symptomatic. There were complaints of wheezing and 
shortness of breath. There must be evidence that the enrollee is asymptomatic to indicate this request. 
 
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 screening have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a low dose computed tomography (LDCT) scan for lung cancer screening for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a raised toilet seat. 
 
You asked the Plan to pre-approve a raised toilet seat. The Plan denied your request. The Plan says this item is 
not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered 
because they are not primarily medical in nature.  
 
While a raised toilet seat may be appropriate for O. Belmares, neither the Plan nor Medicare offers coverage of 
this item. Therefore, we decided that the Plan does not have to pre-approve a raised toilet seat.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for computed tomography (CT scan) on May 
13, 2022. 
 
You asked the Plan to waive the copayment for CT scan. You say that you told them you did not want the CT 
scan because you could not afford it and youre not going to pay it. The Plan denied your request. The Plan 
says the cost sharing you are being charged is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $300 
copayment for Medicare-covered diagnostic radiology services (not including X-rays). Covered services 
include but are not limited to other outpatient diagnostic tests, such as INR testing.  
 
 
 
 
 You have been asked to pay a $300 copayment for CT scan. 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 copayment for 
computed tomography (CT scan) on May 13, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a motion fluoroscopic evaluation of 
swallowing provided on March 29, 2022. 
 
You asked the Plan to waive the copayment for the swallowing evaluation. You say that you thought you were 
only there for an X-ray. 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 for outpatient diagnostic tests with a specialty physician.  
 
You have been asked to pay a $20 copayment for the swallowing evaluation. The swallowing evaluation falls 
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 copayment for a motion fluoroscopic evaluation of swallowing provided on March 
29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an eye appointment provided on April 13, 
2022. 
 
You asked the Plan to waive the copayment for an eye appointment. You say that you should not have to pay 
this copayment. The Plan denied your request. The Plan says the copayment applied was correct. You received 
a test during your eye exam which caused the copayment. 
 
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 vision care.  
 
You have been asked to pay a $40 copayment for an eye appointment. an eye appointment 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 an eye appointment 
provided on April 13, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous implantation of neurostimulator electrode 
array for the enrollee. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is not a covered benefit for this condition. 
 
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 procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that there is limited published, large-scale, long-term peer-reviewed literature that shows this 
request to be an effective and/or safe treatment for the noted pathology. There is no compelling rationale 
presented or extenuating circumstances noted to support the medical necessity of this request as an exception to 
guidelines. Therefore, the requested percutaneous implantation of neurostimulator electrode array, in this case, 
is not medically reasonable or necessary. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve percutaneous implantation of neurostimulator electrode array for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services (procedure code 95820) provided to the 
enrollee on January 12, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the denied code is inclusive to CPT 37238. 
 
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 75820 is "Venography, extremity, unilateral, radiological 
supervision and interpretation." 
 
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 separate charge for CPT 
75820 and venography should be denied as the venogram is considered part of the interventional procedure - 
CPT 37238. 
 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 imaging services (procedure code 95820) provided to the enrollee on January 12, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
August 25, 2021, to September 1, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the DRG was updated.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 872 (SEPTICEMIA OR SEVERE SEPSIS 
WITHOUT MV >96 HOURS WITHOUT MCC). 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 services. Our reviewer says that the services at issue in this case were not supported by the medical 
records. Our physician reviewer found that while it is acknowledged that the records include a physician-
documented diagnosis of sepsis, and that Systemic Inflammatory Response Syndrome (SIRS) signs were 
present along with an elevated lactic acid, the clinical findings in the record do not sufficiently support the 
diagnosis of sepsis based on Sepsis 3 criteria. The review indicates that the records did not support that A41.9 - 
sepsis, unspecified organism - was appropriate in this case. The records did not support DRG 872 in this case.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided to the enrollee from August 25, 2021, to September 1, 2021.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for primary percutaneous transluminal mechanical thrombectomy 
(procedure code 37184, 37185) provided to the enrollee on March 30, 2022. 
 
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 that the records do not support the services 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 
the denied codes is: 
 
CPT 37184: 
 
Primary percutaneous transluminal mechanical thrombectomy, noncoronary, non-intracranial, arterial or 
arterial bypass graft, including fluoroscopic guidance and intraprocedural pharmacological thrombolytic 
injection(s); initial vessel 
 
CPT 37185: 
 
Primary percutaneous transluminal mechanical thrombectomy, noncoronary, non-intracranial, arterial or 
arterial bypass graft, including fluoroscopic guidance and intraprocedural pharmacological thrombolytic 
injection(s); second and all subsequent vessel(s) within the same vascular family (List separately in addition to 
code for primary mechanical thrombectomy procedure) 
 
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 supported by the medical records. Our reviewer found that the documentation supports billing 
and coverage of codes 37184 and 37185. There is documentation that the thrombus in the anterior tibial artery 
and in the distal tibioperoneal trunk were present at the initial angiogram declaring that it was present prior to 
efforts at atherectomy and angioplasty. Therefore, the code used for rescue mechanical thrombectomy would 
not apply. In this case, there was documentation of mechanical thrombectomy of 2 distinct arteries and, 
therefore, coding of 37184 and 37185 was appropriate.  
 
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 been met. Therefore, we decided that the Plan has to pay for 
primary percutaneous transluminal mechanical thrombectomy (procedure code 37184, 37185) provided to the 
enrollee on March 30, 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 a pontic (D6205), a crown (D2710), and an alveoloplasty in 
conjunction with extractions (D7310), provided by an out-of-network provider on February 16, 2022. 
 
You asked the Plan to pay for a pontic, a crown, and an alveoloplasty in conjunction with extractions. You say 
that these services were medically necessary. The Plan denied your request. The Plan says the dental work that 
was provided are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a pontic (D6205), a crown (D2710), and an alveoloplasty in conjunction with extractions (D7310), provided by an out-
of-network provider on February 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cone beam computed tomography capture and 
interpretation (D0367) provided on April 12, 2022. 
 
You asked the Plan to pay for a cone beam computed tomography capture and interpretation. You say that the 
service was medically necessary. The Plan denied your request. The Plan says the service at issue is not a 
covered benefit. 
 
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 a cone 
beam computed tomography capture and interpretation (D0367) provided on April 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on March 29, 
2022. 
 
You asked the Plan to pay for an evaluation. You say that this service is a covered benefit and should be paid. 
The Plan denied your request. The Plan says a limited oral evaluation (D0140) is not covered when not 
performed by an oral surgeon. 
 
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 record shows the evaluation was performed by a general dentist. 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 
when not performed by an oral surgeon. Therefore, we decided that the Plan does not have to pay for a limited 
oral evaluation (D0140) provided on March 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the 2D oral photographic image (D0350) provided on April 
19, 2022. 
 
You asked the Plan to pay for the dental service. You say that you were never informed that the dental 
coverage was limited. You also say that you were assured by the representative assured you would receive 
$2,000 each year for dental services. The Plan denied your request. The Plan says the 2D oral photographic 
image is not listed as a covered dental service. 
 
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 2D oral photographic image is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 2D 
oral photographic image (D0350) provided on April 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on April 7, 2022. 
 
You asked the Plan to pay for the dental services. You say that you went to another dentist for a second 
opinion. 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 March 30, 2022. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on 
April 7, 2022.