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

 
We decided that the Plan does not have to pay for the laboratory services coded as 82728, 83540 and 83550. 
 
You asked the Plan to pay for the laboratory services. You say that at this time there is no contractual 
agreement in place which indicates that the CPT codes billed are included in the dialysis rate. The Plan denied 
your request. The Plan says laboratory testing related to treatment of end-stage renal disease is bundled into 
dialysis services and is not separately reimbursable. 
 
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 find that CPT code is not supported in the medical record. Specifically, the records show that 
the laboratory tests reported were related to treatment of end stage renal disease. Since ESRD was indicated for 
the reason for the laboratory tests and a separate professional visit unrelated to ESRD was not indicated in the 
medical rod, the laboratory tests are included in the dialysis services. Based on this information, we decided 
that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the 
Plan does not have to pay for the laboratory services coded as 82728, 83540 and 83550.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral - periapical first radiographic image (D0220) 
and intraoral - periapical each additional radiographic image (D0230) provided December 20, 2021. 
 
You asked the Plan to pay for the intraoral x-rays. You say that you would like these services covered. The 
Plan denied your request. The Plan says these x-rays are not covered under your 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 the 
intraoral - periapical first radiographic image (D0220) and intraoral - periapical each additional radiographic 
image (D0230) provided December 20, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services rendered on September 5, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
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 these services have not been met. Therefore, we decided that the Plan does not have to pay for the medical 
services rendered on September 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cleaning (D1110) provided on January 31, 2022. 
 
You asked the Plan to pay for the dental service. You say that at the time of your appointment, it was your 
understanding that the provider was still in network. The Plan denied your request. The Plan says the provider 
was not a participating PPO provider on the date of service in this case. 
 
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, dental services performed by a dentist 
that is not a participating PPO provider are not among those covered under this benefit. Therefore, we decided 
that the Plan does not have to pay for the cleaning (D1110) provided on January 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custom fabricated abutments - includes placement 
(D6057) and abutment supported retainers for porcelain fused to metal FPD (high noble metal) (D6069). 
 
You asked the Plan to pre-approve custom fabricated abutments and abutment supported retainers. You say that 
these services should be covered under the enrollee's medical benefits. The Plan denied your request. The Plan 
says these services are not covered under Medicare. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement 
of the enrollees teeth or the structures directly supporting the enrollees teeth. These are dental services that 
are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve 
custom fabricated abutments - includes placement (D6057) and abutment supported retainers for porcelain 
fused to metal FPD (high noble metal) (D6069).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment and coinsurance for the ER visit and outpatient 
hospital services provided from October 27, 2021, to October 30, 2021. 
 You asked the Plan to waive the copayment and coinsurance for the ER visit and outpatient hospital services. 
You say that you would like the charges to be covered. The Plan denied your request. The Plan says the 
copayment and coinsurance were 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 $90 
copayment for emergency services, 20% coinsurance for administration of drugs, a $275 copayment for 
advanced imaging services at an in-network outpatient hospital, a $110 copayment for basic radiological 
services at an in-network outpatient hospital and a $40 copayment for physical therapy at an in-network 
outpatient hospital.  
 
You have been asked to pay a total of $461.42 for the ER visit, intravenous (IV) therapy, chest x-ray, magnetic 
resonance imaging (MRI) and physical therapy (PT) evaluation. 
 
Date of Service Service Allowed Amount Standard Cost Member Liability 
October 27, 2021 ER Visit $271.93 $90 $90.00 
October 28, 2021 IV Therapy $79.60 20% $15.92 
October 28, 2021 IV Therapy $202.49 20% $40.50 
October 28, 2021 Chest X-Ray $80.50 $110 $80.50 
October 28, 2021 MRI $228.98 $275 $194.50 
October 29, 2021 PT Evaluation $96.31 $40 $40.00 
TOTAL:    $461.42 
 
The ER visit falls within the Emergency care benefit category. The IV therapy falls within the Medicare 
Part B prescription drugs benefit category. The chest x-ray and MRI fall within the Outpatient diagnostic 
tests and therapeutic services and supplies benefit category. The physical therapy evaluation falls within the 
Outpatient rehabilitation services 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 and 
coinsurance for the ER visit and outpatient hospital services provided from October 27, 2021, to October 30, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral exam (D0140), intraoral x-rays (D0220, 
D0230) and root canal services (D3320, D3331) provided on August 26, 2021. 
 
You asked the Plan to pay for the dental services. You say that you were assured by a Plan representative that 
your dental care would be covered prior to services. The Plan denied your request. The Plan says these services 
are not covered by your dental benefit. 
 
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 pay for the limited oral exam (D0140), intraoral x-rays (D0220, D0230) and root canal services (D3320, D3331) provided on August 26, 2021.  
 
Your complaint about potential misinformation from a Plan representative is not a valid appeal for medical 
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not 
permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve catheter placement. 
 
You asked the Plan to pre-approve catheter placement. You say that the enrollee had an abnormal stress test 
showing lateral ischemia. You say that the enrollee is having shortness of breath and palpitations. You say that 
the enrollee has other risk factors including sleep apnea, hypertension, and lipedema. The Plan denied your 
request. The Plan says the services being requested are not medically necessary. 
 
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 catheter placement. Our reviewer says 
that catheter placement is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee had an echocardiogram which showed normal ventricular function, and a 
radionuclide stress test which showed no electrocardiographic evidence of ischemia, with radionuclide imaging 
suggestive of ischemia in the lateral wall, at the same time showing reversed distribution...usually related to 
artifact in another aspect of the lateral wall. Documentation does not support the rationale for the requested 
invasive imaging study. Guidelines do not support a need for cardiac catheterization in this setting.  
 As a result, at this time cardiac catheterization would not be considered medically appropriate and necessary in 
this enrollees clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of catheter placement have not been met. Therefore, we decided that the Plan does 
not have to pre-approve catheter placement.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for the fillings provided on December 20, 2021. 
 
You asked the Plan to pay an additional amount for the dental services. You say that your bridge was loose. 
You say that you went to the dentist and they performed other services that you did not need. You say that your 
bridge was still lose when you left the office. You also say that you feel you should not be responsible for this 
bill. The Plan denied your request. The Plan says there is a 20% coinsurance for restorative services, including 
fillings. 
 
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 fillings are listed as covered, there 
is a 20% coinsurance that applies. This is a contractual obligation you agreed to when you enrolled in the Plan's dental coverage. Therefore, we decided that the Plan does not have to pay an additional amount for the 
fillings provided on December 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81404, 81442, and 81479) provided 
on June 9, 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 the services are not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test 
solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory 
services (81404, 81442, and 81479) provided on June 9, 2021.
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 you meet criteria for an LTACH 
admission, and your ongoing medical needs warrant an LTACH level of care to achieve a safe and sustainable 
discharge. The Plan denied your request. The Plan says based on Medicare guidelines, the requested LTACH 
services 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 that you are receiving appropriate care at the present acute care hospital. You do not 
require services at the LTACH that are not available at the acute care hospital where you are currently 
receiving care. There are no services available at the LTACH that you require that are not available at the 
health care setting being offered by the health plan. The requested LTACH services are not medically 
necessary, reasonable, and appropriate for your diagnosis and condition and able to be furnished safely and 
effectively only on an inpatient basis.  
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (64415) provided on November 29, 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 64415 is a column II code to column I code 01638. 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 (64415) provided on November 29, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services. 
 
You asked the Plan to pre-approve SNF care. You say that you need SNF care. The Plan denied your request. 
The Plan says based on Medicare guidelines, the requested SNF services do not meet the requirements for 
approval. 
 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 that you do not have daily skilled nursing 
needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not 
have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled 
professional therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a 
skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an out-of-network office visit (99211) for the 
implantation of a percutaneous nerve stimulator (64555, 63650). 
 
You asked the Plan to pre-approve an office visit for the implantation of a percutaneous nerve stimulator. You 
say that this is medically necessary. The Plan denied your request. The Plan says this is not covered. 
 
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 an office visit for the implantation of a 
percutaneous nerve stimulator. Our reviewer says that the requested services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found this is considered an experimental 
procedure. There are evidence-based therapies available that have not been used. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an office visit for the implantation of a percutaneous nerve stimulator have not 
been met. Therefore, we decided that the Plan does not have to pre-approve an out-of-network office visit 
(99211) for the implantation of a percutaneous nerve stimulator (64555, 63650).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from April 26, 2022, forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from April 26, 2022, forward. You say that the 
services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue are 
not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric care from April 
26, 2022, forward. Our reviewer says that you do not meet the criteria for acute inpatient mental health 
treatment beyond the date in question of April 26, 2022, forward. Our physician reviewer found you did not 
require inpatient mental health treatment beyond April 26, 2022, as you were not a danger to yourself or others 
and did not have any delusions, auditory or visual hallucinations. It did not appear that active treatment was 
taking place beyond the date in question. It did not appear that the services for the dates in question were 
reasonably expected or medically necessary to improve your condition or for the purpose of diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care from April 26, 2022, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from April 26, 
2022, forward.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the cataract surgery provided on July 7, 2021.
You asked the Plan to waive the coinsurance for the cataract outpatient surgery. You say that first cataract surgery in June was completely covered. You say that the second surgery should be covered. The Plan denied your request. The Plan says the coinsurance 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 enrollees must pay 20% coinsurance, up to $465, for each Medicare-covered visit to an outpatient hospital facility.
You have been asked to pay $465 for cataract surgery, which is the maximum allowed by your contract. The cataract surgery falls within the "Outpatient surgery, including 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 waive the coinsurance for the outpatient surgery provided on July 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an unspecified preventive procedure (D1999), a 
comprehensive oral evaluation (D0150), and intraoral imaging (D0210) provided by an out-of-network 
provider on January 16, 2022. 
 
You asked the Plan to pay for an unspecified preventive procedure, a comprehensive oral evaluation, and 
intraoral imaging. You say that you would like the Plan to pay for this. The Plan denied your request. The Plan 
says services provided out-of-network 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. The Plan covers a 
comprehensive oral evaluation and intraoral imaging when the services are provided in-network. An 
unspecified preventive procedure is not a covered dental benefit.  
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of an unspecified preventive procedure, a comprehensive oral evaluation, and intraoral imaging have 
not been met. Therefore, we decided that the Plan does not have to pay for an unspecified preventive procedure 
(D1999), a comprehensive oral evaluation (D0150), and intraoral imaging (D0210) provided by an out-of-
network provider on January 16, 2022.