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

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the requested LTACH services are not medically 
necessary, reasonable, or appropriate for the diagnosis and condition of the enrollee currently. The enrollee can 
remain in the current acute care location until such time no further acute level care is needed. 
 
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 transfer to the LTACH is not medically necessary as the patient is not yet stable and 
as it would not be clinically advantageous. Completion of treatment at the current facility is recommended.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from March 9, 2022 to 
April 7, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that these services were medically 
necessary. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from March 9, 2022 to April 
7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the free soft tissue graft (D4278) and the biologic 
materials to aid in soft and osseous tissue regeneration (D4265). 
 
You asked the Plan to pre-approve the free soft tissue graft (D4278) and the biologic materials to aid in soft 
and osseous tissue regeneration (D4265). You say that your doctor says you need to have the implant fixed. 
The Plan denied your request. The Plan says the services 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 pre-approve the 
free soft tissue graft (D4278) and the biologic materials to aid in soft and osseous tissue regeneration (D4265).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health aide or certified nurse assistant (S9122) 
provided from June 7, 2022, to June 11, 2022. 
 
You asked the Plan to pay for the home health aide or certified nurse assistant (S9122). You say that when the 
enrollee was home on hospice, they were entirely bed-bound and required around the clock skilled care. The 
Plan denied your request. The Plan says the treating provider is not included in Medicares Supplier Directory 
as a certified provider, and there were providers available for the enrollee to have received the services. 
 
The Plan must follow Medicare rules. Medicare rules say that to receive payment for covered Medicare items 
or services, a provider or supplier must be enrolled in the Medicare program. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health aide or certified nurse assistant (S9122) have not been met. This provider is not 
part of the Medicare program and is not payable. Therefore, we decided that the Plan does not have to pay for 
the home health aide or certified nurse assistant (S9122) provided from June 7, 2022, to June 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ForeSee Home monitoring program (visual field 
assessment). 
 
You asked the Plan to pre-approve ForeSee Home monitoring program. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the requested services 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 ForeSee Home monitoring program. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the enrollee has a diagnosis of nonexudative age-related macular 
degeneration (AMD). The Foresee Home AMD monitoring program is considered investigational/experimental 
as additional clinical studies are needed to demonstrate that it affects visual outcomes. Therefore, the enrollee 
does not meet criteria for the requested services. 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ForeSee Home monitoring program have not been met. Therefore, we decided 
that the Plan does not have to pre-approve ForeSee Home monitoring program (visual field assessment).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services (D9230, D4266) 
 
You asked the Plan to pre-approve 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 pre-approve 
dental services (D9230, D4266)
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a rehabilitation shower chair (E1399). 
 
You asked the Plan to pre-approve this item. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a rehabilitation shower chair (E1399).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided from June 1, 2022, to 
June 2, 2022. 
 
You asked the Plan to pay for inpatient-only 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 as billed. 
 
The Plan must follow Medicare rules. The rules say that there is no payment under the OPPS for services that 
CMS designates to be inpatient-only services. These services have an OPPS status indicator of C in the 
OPPS Addendum B and are listed together in Addendum E of each years OPPS/ASC final rule.  
 
The services at issue in this appeal was billed with CPT code 22846. This code is listed with a status indicator 
of C on Addendum B of the 2022 OPPS/ASC final rule. This means the service has been designated as 
inpatient only, and therefore must be billed as part of an inpatient admission. The file shows that these 
services were billed on an outpatient claim. Therefore, we decided that the Plan does not have to pay for the 
inpatient hospital services provided from June 1, 2022, to June 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on August 19, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the services 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 the dental 
services on August 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the extractions, of an erupted tooth 
requiring removal of bone and/or sectioning of tooth (D7210 x 2), collection and application of autologous 
blood concentrate products (D7921 x 2), bone replacement graft for ridge preservation-per site (D7953), guided 
tissue regeneration-resorbable barrier, per site (D4266), surgical placement of an implant body: endosteal 
implants (D6010 x 2), intravenous moderate (conscious) sedation/analgesia-first 15 minutes (D9239), 
intravenous moderate (conscious) sedation/analgesiaeach subsequent 15 minute increment (D9243), and the 
non-covered item/service (A9270) provided on July 12, 2022. 
 
You asked the Plan to issue reimbursement for these items/services. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says these 
items/services are not a covered benefit. 
 Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to issue reimbursement for involve the care, treatment, filling, removal or 
replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not 
covered or paid for by Medicare. Therefore, we decided that the Plan does not have to issue reimbursement for 
the extractions, of an erupted tooth requiring removal of bone and/or sectioning of tooth (D7210 x 2), 
collection and application of autologous blood concentrate products (D7921 x 2), bone replacement graft for 
ridge preservation-per site (D7953), guided tissue regeneration-resorbable barrier, per site (D4266), surgical 
placement of an implant body: endosteal implants (D6010 x 2), intravenous moderate (conscious) 
sedation/analgesia-first 15 minutes (D9239), intravenous moderate (conscious) sedation/analgesiaeach 
subsequent 15 minute increment (D9243), and the non-covered item/service (A9270) provided on July 12, 
2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical nutrition therapy provided on June 20, 2022, by an 
OON provider. 
 
You asked the Plan to pay for the medical nutrition therapy. You say that you believe the services should be 
paid in full. The Plan denied your request. The Plan says the out-of-network services were not authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for medical nutrition therapy provided on June 20, 
2022, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dentures (D5214) provided on July 19, 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 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 02/24/2020. Therefore, 
we decided that the Plan does not have to pay for dentures (D5214) provided on July 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for immediate denture - maxillary (D5130) provided on April 6, 
2022. 
 
You asked the Plan to pay for dental services. You say that the requested services should be covered under my 
dental insurance. The Plan denied your request. The Plan says this service is not covered under your Plan. 
 
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. Immediate denture - maxillary 
(D5130) is not covered under the Plans dental benefits. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested immediate denture - 
maxillary (D5130) are not among those covered under this benefit. Therefore, we decided that the Plan does 
not have to pay for immediate denture - maxillary (D5130) provided on April 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99212) provided on July 26, 2022. 
 
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 this service is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit (99212) provided on July 26, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital services provided on 
August 19, 2022, to August 23, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital services. You say that you are disputing the 
share cost. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $325 
copayment per day for days 1 to 5 for inpatient hospital care. This inpatient hospital stay lasted 3 days, 
resulting in a total copayment amount of $975 ($325 per day for 3 days = $975). 
 
You have been asked to pay $325 copayment per day for days 1 to 5 for inpatient hospital services. This 
item/service 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 services provided on August 19, 2022, to August 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2740) provided on August 16, 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 your $1,000 dental benefit maximum 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 August 16, 2022. 
Therefore, we decided that the Plan does not have to pay for a crown (D2740) provided on August 16, 2022
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services (D6058-D6057) provided on July 19, 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 dental 
services (D6058-D6057) provided on July 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a 2D oral/facial photographic image (D0350) provided on 
August 18, 2022. 
 
You asked the Plan to pay for the 2D oral/facial photographic image. 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 a 2D 
oral/facial photographic image (D0350) provided on August 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a 2D oral/facial photographic image (D0350) provided on 
August 18, 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 a 2D 
oral/facial photographic image (D0350) provided on August 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periapical x-rays (D0220, D0230) provided on August 18, 
2022. 
 
You asked the Plan to pay for the x-rays. You say that you disagree with the denial of periapical x-rays. The 
Plan denied your request. The Plan says periapical x-rays (D0220, D0230) are not covered by 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 periapical 
x-rays (D0220, D0230) provided on August 18, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital services provided on 
August 4, 2022, to August 11, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital services. You say that you are disputing the 
share cost. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $290 
copayment per day for days 1 to 4 for inpatient hospital care. This inpatient hospital stay lasted 7 days, 
resulting a copayment amount of $1,160 ($290 per day for 4 days = $1,160). 
 
You have been asked to pay $290 copayment per day for days 1 to 4 for inpatient hospital services. This 
item/service 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 services provided on August 4, 2022, to August 11, 2022.