Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) and gradient 
pressure pneumatic appliance (E0673) provided July 8, 2021. 
 
You asked the Plan to pay for a pneumatic compression device and appliance. You say that the enrollee's 
physician had prescribed the use of a pneumatic compression device to prevent the formation of blood clots. 
The Plan denied your request. The Plan says pneumatic compression device is not covered by Medicare to 
prevent deep vein thrombosis during and/or following surgery. 
 The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. The enrollee used the equipment in the facility during 
and/or after surgery. Payment for this service would have been included under the facility claim. Payment for 
this service is the responsibility of the facility or hospital that provided the surgery. Therefore, we decided that 
the Plan does not have to pay for a pneumatic compression device (E0675) and gradient pressure pneumatic 
appliance (E0673) provided July 8, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from March 8, 2022, forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from March 8, 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 March 
8, 2022, forward. Our reviewer says that you do not meet the criteria for acute inpatient mental health treatment 
beyond the date in question of March 8, 2022, forward. Our physician reviewer found you did not require 
inpatient mental health treatment beyond March 8, 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 March 8, 2022, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from March 8, 
2022, forward.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical assistant services provided for cystourethroscopy 
provided on July 26, 2021, billed with code 52000-AS. 
 
You asked the Plan to pay for the surgical assistant services. You say that the services were medically 
necessary and should be reimbursed. The Plan denied your request. The Plan says only one of the two codes 
billed is eligible for assistant-at-surgery payment. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current 
Procedural Terminology (CPT) code 52000. The Medicare Fee Schedule Database contains a surgical indicator 
of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically 
necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for the surgical assistant services have not been met. Therefore, we decided that the Plan does not have to pay for the surgical assistant services provided for cystourethroscopy provided on July 26, 2021, billed with code 52000-AS.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation feature (E2300). 
 
You asked the Plan to pre-approve a power seat elevation feature. You say that this is medically necessary. The 
Plan denied your request. The Plan says this is statutorily non-covered by Medicare and the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that the power seat elevation feature is non-covered 
because it is not primarily medical in nature.  
 
We looked at the file and Medicare rules. The power seat elevation is not covered as it is not primarily medical 
in nature. Based on this information, we decided that Medicare rules for coverage of a power seat elevation 
feature have not been met. Therefore, we decided that the Plan does not have to pre-approve a power seat 
elevation feature (E2300).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve five surgical extractions (D7210) to be performed by an 
oral surgeon. 
 
You asked the Plan to pre-approve extractions. You say that you have an infection, and it is medically 
necessary to have these teeth removed. The Plan denied your request. The Plan says your benefit covers a 
maximum of one extraction of a tooth per year, and this service must be performed by a participating general 
dentist. The request for five surgical extractions exceeds what is covered by the benefit, and services performed 
by a dental specialist, such as an oral surgeon, are not covered under any circumstances. 
 
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. The Plan requires that 
supplemental dental care be performed by a participating general dentist. 
 
We looked at the file and the Plan's rules. The requested extractions exceed the frequency limitation for this 
service, and it is requested that these services be performed by an oral surgeon. Based on this information, we 
decided that the Plan's rules for coverage have not been met. Therefore, we decided that the Plan does not have 
to pre-approve five surgical extractions (D7210) to be performed by an oral surgeon.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete series of x-rays (D0210) provided on November 4, 2021. 
 
You asked the Plan to pay for the complete series of x-rays. You say that this x-ray should be paid because the 
one you had in March was initially denied. The Plan denied your request. The Plan says you had a previous 
complete series of x-rays provided in March 2021. While these services were denied initially, this claim was 
later re-processed with your in-network benefits and payment was made for this service. The Plan will pay for 
only one complete series of x-rays every five years. 
 
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. The Plan can cover one full 
mouth diagnostic x-ray every 5 years. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the x-ray is requested in a frequency 
that exceeds what is covered under this benefit. Documentation shows that while the Plan initially denied 
payment for the services received in March 2021, an exception was made at a later date and payment was issued for this service on December 14, 2021. The Plan only has to pay for one complete series of x-rays every 
five years. Therefore, we decided that the Plan does not have to pay for the complete series of x-rays (D0210) 
provided on November 4, 2021.  
 
Your complaint about a change in a coverage decision impacting benefits received before this change 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone replacement grafts for ridge preservation (D7953). 
 
You asked the Plan to pre-approve bone replacement grafts. You say that these services are medically 
necessary, and you would like the Plan to cover these services under either your dental or medical benefit. The 
Plan denied your request. The Plan says these services are not covered by your dental benefit and are not 
eligible for coverage under your medical 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. 
 
The services at issue involve the care, treatment, filling, removal or replacement of teeth or structures directly 
supporting the teeth. Therefore, these services are not eligible for coverage under your medical benefit or 
Original Medicare. 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 bone replacement grafts for ridge preservation (D7953).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation (99153) provided on April 22, 2021. 
 
You asked the Plan to pay for the moderate sedation. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says CPT code 99153 may not be paid if furnished 
to a hospital inpatients or patients in a hospital outpatient department. 
 
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 99153 is not supported in the record. Specifically. CPT code 99153 has a 
professional/technical component indicator of 3. This means that CPT code 99152 is a technical component 
only code. The records also indicate that this service was rendered in a facility setting. Payment for CPT code 
99153 is included in the payment to the facility and is the responsibility of the facility to any vendor. Based on 
this information, we decided that Medicare rules for coverage of the moderate sedation have not been met. 
Therefore, we decided that the Plan does not have to pay for the moderate sedation (99153) provided on April 
22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a shingles vaccine provided on July 16, 2021, under 
Medicare Part B. 
 
You asked the Plan to pay for this vaccine under Medicare Part B. You say that you were told this would be 
covered. The Plan denied your request. The Plan says the shingles vaccine is preventative and is not covered 
under Medicare Part B. Payment for this type of vaccine must be submitted to Medicare Part D coverage. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide this vaccine under 
Medicare Part B. The Plan follows the same rules. This vaccine is preventative in nature and is not covered 
under the Medicare Part B benefit. Therefore, we decided that the Plan does not have to pay for a shingles 
vaccine provided on July 16, 2021, under Medicare Part B.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided on May 25, 2021. 
 
You asked the Plan to pay for these services. You say that these services were covered in the past. The Plan 
denied your request. The Plan says review of the claims history for all chiropractic services does not show  
claims submitted with code 98941 from this provider or any other providers. Therefore, there is no evidence the 
Plan paid for this service in the past. 
 
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 chiropractic 
services provided on May 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the segmental gradient pressure pneumatic appliance 
(E0673) provided July 2, 2021. 
 
You asked the Plan to pay for the pneumatic appliance. You say that the records provided should support the 
necessity of the service in dispute. The Plan denied your request. The Plan says pneumatic compression devices 
are not covered by Medicare to prevent deep vein thrombosis during and/or following surgery. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 In this case, the enrollee used the equipment in the facility during and/or after surgery. Payment for this service 
would have been included under the facility claim. Payment for this service is the responsibility of the facility 
or hospital that provided the surgery. Therefore, we decided that the Plan does not have to pay for the 
segmental gradient pressure pneumatic appliance (E0673) provided July 2, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on June 29, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were 
billed with the incorrect place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or 
other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.  
 
We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 81. However, the records do not show that the specimen was collected in a laboratory setting. 
This means that the claim was billed with the incorrect POS code. Based on this information, we decided that 
Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab services provided on June 29, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need to recover before you can go home and the 
acute rehabilitation would be better for you since you suffered from a stroke. The Plan denied your request. 
The Plan says you do not meet Medicare criteria for coverage. 
 
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 that you do not appear to be stable for discharge from the acute care hospital. 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the initial hospital care rendered on September 7, 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 that procedure code 99223 is a column II code to 39010 and not separately payable. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan states that code 99223 (initial hospital care) is a column II code with a 
modifier indicator of 1 when billed with column I code 39010 (mediastinotomy with exploration) and was not 
billed with an appropriate modifier to allow for separate payment; however, there are no active National 
Correct Coding Initiatives (NCCI) procedure to procedure (PTP) edits for these codes. The Plan has not 
provided any documentation to support that 99223 is not payable as billed. Therefore, we decided that the Plan 
has to pay for the initial hospital care rendered on September 7, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4341) to be 
performed by an out-of-network provider. 
 
You asked the Plan to pre-approve periodontal scaling and root planing. You say that these services are 
necessary and should be approved as soon as possible. The Plan denied your request. The Plan says the 
provider in this case is not part of the Plan's dental network. You must visit an in-network dental provider in 
order to use 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. The Plan requires 
supplemental dental services be performed by providers who participate in the Plans dental network. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, items or services received from out-of-
network providers are not among those covered under this benefit. The provider requested in this case is not 
part of the Plans dental network. Therefore, we decided that the Plan does not have to pre-approve periodontal 
scaling and root planing (D4341) to be performed by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral exam (D0150), intraoral x-rays 
(D0220, D0230), bitewing x-rays (D0274) and cleaning (D1110) provided on August 2, 2021, by an out-of-
network provider. 
 
You asked the Plan to pay for the dental services. You say that these services were necessary and should be 
paid. The Plan denied your request. The Plan says the provider in this case is not part of the Plan's dental 
network. Out-of-network dental care is not covered by this plan. In addition, intraoral x-rays are not covered by 
this benefit regardless of the participation status of the provider. 
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. The Plan does not cover out-
of-network dental care. The Plan does not cover services which are not listed in the dental benefits chart section 
of the contract. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, items or services received from out-of-
network providers are not among those covered under this benefit. In addition, intraoral x-rays are not covered 
under this benefit. Therefore, we decided that the Plan does not have to pay for the comprehensive oral exam 
(D0150), intraoral x-rays (D0220, D0230), bitewing x-rays (D0274) and cleaning (D1110) provided on August 
2, 2021, by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custom abutments (D6057) for teeth # 15 and 19, and 
abutment supported crowns (D6059) for teeth # 15 and 19. 
 
You asked the Plan to pre-approve the dental services. You say that you need these services. The Plan denied 
your request. The Plan says the requested services are not listed as 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 custom abutments and 
abutment supported crowns are not among those covered under this benefit. Therefore, we decided that the 
Plan does not have to pre-approve custom abutments (D6057) for teeth # 15 and 19, and abutment supported 
crowns (D6059) for teeth # 15 and 19.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided on 
September 30, 2021. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that after having a blood test 
your oncologist told you to go right to the emergency room. 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 $90 
copayment for each emergency room visit. The Plan contract also says that the emergency room copayment will be waived if you received care from a primary care physician (PCP) within 24 hours prior to the 
emergency room visit.  
 
The records show you were treated at the emergency room and had not received care within the last 24 hours 
from your PCP. You have been asked to pay a $90 copayment for an emergency room visit. An emergency 
room visit falls within the Emergency 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 emergency room visit provided on September 30, 2021.