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

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you believe inpatient rehab is both physically and 
medically necessary for the enrollee to return home at their maximum level of functioning with a decreased risk 
for readmission. The Plan denied your request. The Plan says the enrollee does not meet the medical necessity 
guideline for an IRF admission 
 
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 the enrollee has no medical complexity and no rehabilitation nursing needs other 
than routine nursing care. While the enrollee may benefit from physical and occupational therapy, the enrollee's 
rehabilitation needs can be safely met in an alternate and low intensity 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Negative Pressure Wound Therapy Electrical Pump 
(E2402). 
 You asked the Plan to pre-approve a Negative Pressure Wound Therapy Electrical Pump. 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 if criterion A or B in the Medicare Rules section is 
not met, the NPWT pump and supplies will be denied as not reasonable and necessary. 
 
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 Negative Pressure Wound Therapy 
Electrical Pump. Our reviewer says that this item is not medically necessary. Our physician reviewer found the 
beneficiary does not have a chronic Stage 3 or 4 pressure ulcer. 
 
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 Negative Pressure Wound Therapy Electrical Pump have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Negative Pressure Wound Therapy 
Electrical Pump (E2402).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99239 billed for date of service January 8, 2022. 
 
You asked the Plan to pay for code 99239. You say that the medical records support payment for these 
services. The Plan denied your request. The Plan says code 99239 is not supported in the medical record. 
 
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 99239 is hospital discharge day management: more than 
30 minutes. 
 
We find that CPT code 99239 is not supported in the medical record. Specifically, this code is a timed code, 
meaning that more than 30 minutes of hospital discharge day management services must be documented in the 
medical record. The medical records from January 8, 2022, that you provided do not document the length of 
time spent on this service. Based on this information, we decided that Medicare rules for coverage of code 
99239 have not been met. Therefore, we decided that the Plan does not have to pay for code 99239 billed for 
date of service January 8, 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 August 3, 
2022, and core build up on tooth #12 (D2950) provided on August 16, 2022. 
 
You asked the Plan to pay for an evaluation and core build up. You say that you are requesting reimbursement 
for the dental services you received. The Plan denied your request. The Plan says a limited oral evaluation 
(D0140) and core build up (D2950) are not covered by your supplemental dental 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 limited 
oral evaluation (D0140) provided on August 3, 2022, and core build up on tooth #12 (D2950) provided on 
August 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), a complete series 
of radiographic images (D0210), and a panoramic radiographic image (D0330) provided on July 13, 2022. 
 
You asked the Plan to pay for the dental services. You say that you want the Plan to pay for the services. The 
Plan denied your request. The Plan says your benefit for the requested items or services 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 items or services was exhausted on date of service May 25, 2021. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), a 
complete series of radiographic images (D0210), and a panoramic radiographic image (D0330) provided on 
July 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for tooth extractions provided during an emergency room visit 
on July 20, 2022. 
 
You asked the Plan to pay for the visit. You say that the enrollee was unable to get into his dentist until 
October. The Plan denied your request. The Plan says that extractions 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 tooth 
extractions provided during an emergency room visit on July 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for procedure code S9999 billed for date of service 
May 2, 2022. 
 You asked the Plan to reimburse you for procedure code S9999. You say that please reconsider the denial of 
your request for reimbursement of your claim without prior authorization for your lift chair. The Plan denied 
your request. The Plan says procedure code S9999 is considered bundled and 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 procedure code. 
 
We find that procedure code has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code S9999 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code S9999 have not been met. Therefore, we decided that the Plan does not have to 
reimburse you for procedure code S9999 billed for date of service May 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), panoramic 
radiographic image (D0330), and the intraoral-complete series of radiographic images (D0210) provided on 
August 22, 2022. 
 
You asked the Plan to pay for these dental services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says the dental services were received from 
an out-of-network provider and 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. 
 
 
 The record shows you received the dental services from an out-of-network provider. Though the Plan offers a 
dental benefit in excess of Medicare coverage, services provided under this benefit are not covered when 
received from an out-of-network provider. Therefore, we decided that the Plan does not have to pay for the 
comprehensive oral evaluation (D0150), panoramic radiographic image (D0330), and the intraoral-complete 
series of radiographic images (D0210) provided on August 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulator (TENS) device 
provided on May 20, 2022. 
 
You asked the Plan to pay for the TENS device. You say that this is an accepted procedure code. The Plan 
denied your request. The Plan says the device is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 We looked at the file, and Medicare rules. The records show that the device at issue was provided to treat low 
back pain. The device is not covered for this condition. Based on this information, we decided that Medicare 
rules for coverage of the TENS device have not been met. Therefore, we decided that the Plan does not have to 
pay for the transcutaneous electrical nerve stimulator (TENS) device provided on May 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on March 24, 2021. 
 
You asked the Plan to pay for dental services. You say that the provider never sent the claim to the Plan, so you 
sent it in and would like it covered. The Plan denied your request. The Plan says not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for dental services was not filed until September 19, 2022. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for dental services provided on March 24, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from March
17, 2022 to April 15, 2022.
You asked the Plan to pay for the SNF care. You say that the services which the enrollee required and received
are coverable under the Medicare Act. The Plan denied your request. The Plan says criteria for an SNF stay
have not been met.
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 pay for the SNF care. Our reviewer says that the
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized
skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy
needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The
enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a 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 the SNF care have not been met. Therefore, we decided that the Plan does not
have to pay for the skilled nursing facility (SNF) care provided from March 17, 2022 to April 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for adding metal substructures to acrylic full dentures (D5876) 
provided on January 25, 2022. 
 
You asked the Plan to pay for adding substructures to dentures. You say that you are asking for reconsideration 
for payment for this dental services. The Plan denied your request. The Plan says adding metal substructures to 
acrylic full dentures (D5876) is not covered by your supplemental dental 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 adding 
metal substructures to acrylic full dentures (D5876) provided on January 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost-sharing pay for dental services (D0220, D0230, 
D2950, D2751) provided on November 4, 2021 to December 15, 2021 
 
You asked the Plan to waive the cost-sharing pay for the dental services. You say that the services should be 
covered as you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied 
correctly based on the services provided. 
 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.    
 
You have been asked to pay a $100 deductible and 50% coinsurance for the dental services. This item/service 
falls within the dental 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 cost-sharing pay for dental 
services (D0220, D0230, D2950, D2751) provided on November 4, 2021 to December 15, 2021
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection services coded 96372 provided on July 20, 
2022. 
 
You asked the Plan to pay for the injection services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services are not payable as 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 code 96372 is therapeutic, prophylactic, or diagnostic injection 
(specify substance or drug); subcutaneous or intramuscular. 
 
We find that CPT code 96372 is not supported in the medical record. Specifically, this code has a status 
indicator of Q1. Code 99284 was billed on the same date of service with a revenue code of 450, which has a 
status indicator of "V" (clinic or emergency department visit). This means that code 96372 is not separately 
payable. Based on this information, we decided that Medicare rules for coverage of the injection services have 
not been met. Therefore, we decided that the Plan does not have to pay for the injection services coded 96372 
provided on July 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral-periapical first radiographic image (D0220) and 
extraction, erupted tooth req removal of bone, sectioning of tooth and including elevation of mucoperiosteal 
flap (D7210) x2 provided on June 15, 2022. 
 
You asked the Plan to pay for the dental services. You say that you say you should not have to pay for these 
services. You had a tough time finding an in-network provider, so you had to use an out-of-network provider. 
The Plan denied your request. The Plan says the dental services were received from an out-of-network provider 
and so you have a higher out-of-pocket cost. 
  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. This benefit includes coverage 
for the requested items or services, but when obtained by an out-of-network provider the plan only pay up to a 
certain amount. If you choose to see an out-of-network dentist you might be billed by that provider for any 
amount greater than what the plan pays, even for services listed as $0 copayment. 
 
The record shows you received the requested 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 covered at a higher 
out-of-pocket cost under this benefit when received from an out-of-network provider.  
 
 
Date of Service Service Billed Allowed 
Standard Cost off 
allowed amount 
Cost over allowed 
amount 
Member Liability 
June 15, 2022 X-ray $25 $14 0% $11 $11 
June 15, 2022 Extraction $450 $150 50%=$75 $300 $375 
June 15, 2022 Extraction $450 $150 50%=$75 $300 $375 
TOTAL      $761 
 
Therefore, we decided that the Plan does not have to pay for intraoral-periapical first radiographic image 
(D0220) and extraction, erupted tooth req removal of bone, sectioning of tooth and including elevation of 
mucoperiosteal flap (D7210) x2 provided on June 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an unspecified removable prosthodontic procedure (D5899) 
provided on July 29, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental 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 an 
unspecified removable prosthodontic procedure (D5899) provided on July 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for limited oral evaluation (D0140) and cone beam CT image 
capture field view both jaws (D0383) provided on July 21, 2022, to July 28, 2022 
 
You asked the Plan to pay for dental services. You say that you think the services should be paid for by the 
Plan. The Plan denied your request. The Plan says one service is not covered under your Plan and the other is a 
covered service but with limitations. 
 
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. This benefit includes limited 
oral evaluation (D0140)  one procedure every plan year. Cone beam CT image capture field view both jaws 
(D0383) is not covered under the Plans dental benefits. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested cone beam CT image 
capture field view both jaws (D0383) is not among those covered under this benefit. You previously received 
covered limited oral evaluation (D0140) on May 31, 2022. Therefore, this benefit has been exhausted. 
Therefore, we decided that the Plan does not have to pay for limited oral evaluation (D0140) and cone beam 
CT image capture field view both jaws (D0383) provided on July 21, 2022, to July 28, 2022
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for electrical stimulator supplies (code A4595) billed for date of 
service May 4, 2022. 
 
You asked the Plan to pay for the electrical stimulator supplies. You say that code A4595 is an accepted code, 
and it should be paid. The Plan denied your request. The Plan says the proof of delivery was insufficient, and 
you did not provide records to verify an established relationship between the patient and the referring provider 
despite multiple requests. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 The record does not contain a valid [ADJUDICATOR-DELETE WHAT DOES NOT APPLY] physician order, 
proof of delivery, or relevant medical records which support medical necessity for the supplies provided in this 
case. Specifically, the packing slip that you provided and the USPS tracking information you provided do not 
have matching tracking numbers.  There is nothing on the USPS tracking/delivery information that connects 
the specific items listed on the packing slip with what was actually delivered. The record shows that the Plan 
made several attempts to obtain the necessary documentation without success. Therefore, we decided that the 
Plan does not have to pay for electrical stimulator supplies (code A4595) billed for date of service May 4, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2740) and a core build-up (D2950) provided by a 
participating provider on July 8, 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 maximum dental allowance amount has been met and exhausted. Therefore, we decided that the 
Plan does not have to pay for a crown (D2740) and a core build-up (D2950) provided by a participating 
provider on July 8, 2022.