Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 15, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the visit was medically appropriate, and you would 
like the claim reprocessed. The Plan denied your request. The Plan says the rendering provider is an OON 
provider and there was no referral from an in-network provider or an approved authorization. Also, the service 
rendered was not urgent or emergent. 
 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 an office visit provided on March 15, 2022, by an 
out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140), personal protective 
equipment (D1999), antimicrobial agents (D4381), gingival irrigation (D4921), and scaling and root planing 
(D4342) provided on March 23, 2022. 
 
You asked the Plan to pay for the dental services. You say that you needed emergency dental services. You say 
that you are very disappointed with your policy. You also say that the in network providers could not get you in 
for 3 weeks. The Plan denied your request. The Plan says the services you received are not listed as covered 
services under the supplemental dental coverage. 
 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 services you received are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
limited oral evaluation (D0140), personal protective equipment (D1999), antimicrobial agents (D4381), 
gingival irrigation (D4921), and scaling and root planing (D4342) provided on March 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a power operated vehicle and accessory 
provided on August 19, 2021. 
 
You asked the Plan to waive the coinsurance for the power operated vehicle and accessory. You say that you 
were told you would owe less for the power operated vehicle. The Plan denied your request. The Plan says the 
proper coinsurance was applied, and the enrollee never contacted the Plan regarding the coinsurance amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for each Medicare-covered item. The total amount allowed for the power operated vehicle was 
$2,548.30 with a coinsurance amount of $509.66 ($2,548.30 total amount allowed x 20% coinsurance). The 
total amount allowed for the accessory was $68 with a coinsurance amount of $13.60 ($68 total amount 
allowed x 20% coinsurance). The total coinsurance amount for both items was $523.26 ($509.66 coinsurance + 
$13.60 coinsurance). 
 
  You have been asked to pay a $523.26 coinsurance for the power operated vehicle and accessory. The power 
operated vehicle and accessory falls within the Durable Medical Equipment (DME) and Related Supplies 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the coinsurance for a power operated vehicle and 
accessory provided on August 19, 2021.  
 
Your complaint about your experience with this provider 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 pay for skilled nursing services (99310) provided on November 20, 
2021. 
 
You asked the Plan to pay for skilled nursing services. You say that the services at issue were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met 
because you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that for all services (with two (2) exceptions), the 
Place of Service (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. Based on this information, we decided that Medicare rules for 
coverage of skilled nursing services have not been met. Specifically, this claim was billed with the POS code 
for a skilled nursing facility setting. The case record does not support that the enrollee was a patient in a skilled 
nursing facility at the time services were rendered. Therefore, we decided that the Plan does not have to pay for 
skilled nursing services (99310) provided on November 20, 2021.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay for the topical application of fluoride varnish (D1206). We decided that the 
Plan does not have to pay for the adjunctive pre-diagnostic test (D0431).  
 
You asked the Plan to pay for the topical application of fluoride varnish (D1206) and adjunctive pre-diagnostic 
test (D0431) provided on February 14, 2022. You say that you went to an in-network dental provider and your 
claim was denied because you did not have a previous cleaning. You also say that you had a deep cleaning 
done in the past. The Plan says that topical application of fluoride varnish and adjunctive pre-diagnostic test are 
not listed as covered services. 
 
We decided that the Plan has to pay for the topical application of fluoride varnish (D1206).  
 
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. 
 
We looked at the file and Medicare rules. The 2022 Evidence of Coverage (EOC) states fluoride treatments are 
covered once per calendar year. The contract does not clearly specify what type(s) of fluoride treatments are 
covered. The EOC also does not refer you to any other documents to check for criteria or to see if the service is 
covered prior to receiving the fluoride treatment. You reasonably believed the topical application of fluoride 
varnish would be covered because fluoride treatments are listed as a covered service. Based on this 
information, we decided that the Plan's rules for coverage of the topical application of fluoride varnish have 
been met. Therefore, we decided that the Plan has to pay for the topical application of fluoride varnish 
(D1206).  
 
We also decided that the Plan does not have to pay for the adjunctive pre-diagnostic test (D0431). 
 
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, adjunctive pre-diagnostic test (D0431) 
is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
adjunctive pre-diagnostic test (D0431). 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the special anesthesia services coded 99100 provided on 
December 7, 2021. 
 You asked the Plan to pay for the special anesthesia services. You say that you would like this claim 
reprocessed based on the medical records. The Plan denied your request. The Plan says no separate payment is 
made for this service according to Medicare rules. 
 
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 99100 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99100 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of the special anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay 
for the special anesthesia services coded 99100 provided on December 7, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary as you are still weak 
and need to regain your strength and endurance. The Plan denied your request. The Plan says IRF care is not 
medically necessary and your needs can be met at the skilled nursing facility you are currently at or at home 
with home health services. 
 
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 while you may benefit from physical therapy and occupational therapy, your 
rehabilitation needs can be safely provided in an alternate setting such as in a skilled nursing facility. 
 
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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the services you need can be provided safely in other settings. 
 
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. You 
are medically stable and does not need physical medicine and rehabilitation physician's supervision 3 times per 
week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. There are no acute rehab nursing needs identified or documented. You do not need intensive 
therapies consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary 
approach in an IRF. While you may benefit from physical and occupational therapy, your rehab needs can be 
safely provided in a lower intensity and alternate setting. Our physician reviewer found that your condition 
does not meet Medicare criteria for IRF care. 
 
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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2750) for tooth # 31. 
 
You asked the Plan to pre-approve a crown. You say that your dentist advised you need this tooth to be 
crowned to prevent anything from becoming stuck in the gap of the teeth. The Plan denied your request. The 
Plan says a crown for tooth # 31 is not medically necessary. 
 
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 covers a crown when 
the services are medically necessary and reasonable.  
 
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 crown. Our reviewer says that the 
requested crown for tooth # 31 is not medically necessary.  Our physician reviewer found the documentation 
provided does not indicated that there is a significant breakdown of the coronal structure of tooth # 31 due 
to caries or fracture to warrant a crown restoration. Therefore, the reviewer found that the requested crown 
is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of a crown have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a crown (D2750) for tooth # 31.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye refraction provided on December 10, 2021 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the eye refraction. You say that the treating provider was in-network, and this 
was an annual eye exam. The Plan denied your request. The Plan says this claim was not billed as a routine eye 
exam. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when it is performed during a routine eye exam. 
 
 
 
 
 
 
 
 We looked at the file and the Plan's rules. The record shows that you received an ophthalmological eye exam 
and eye refraction for a diagnosis of a presence of intraocular lens and presbyopia. Based on this information, 
we decided that the Plan's rules for coverage of the eye refraction have not been met. Therefore, we decided 
that the Plan does not have to pay for the eye refraction provided on December 10, 2021 by an out-of-network 
(OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service February 27, 2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the enrollee had multiple exams on the date 
in question. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 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 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service February 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided on February 16, 
2022. 
 
You asked the Plan to pay for the lumbar-sacral orthosis. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says documentation required for payment is 
missing. 
 
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 relevant medical records which support the medical necessity for the supplies 
provided in this case. In this case, the documentation provided does not indicate the ordering provider 
discussed the need for the medical equipment with the enrollee. 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 the lumbar-sacral orthosis (L0650) provided on February 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bitewings (D0274), a periodic oral evaluation (D0120), and 
prophylaxis (D1110), provided by an out-of-network provider on March 22, 2022. 
 
You asked the Plan to pay for dental services. You say that you would like the Plan to pay for this. The Plan 
denied your request. The Plan says in-network providers were available to provide these services. 
 
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 covered 
dental services when the services are provided by a participating provider. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of dental services have not been met. Therefore, we decided that the Plan does not 
have to pay for bitewings (D0274), a periodic oral evaluation (D0120), and prophylaxis (D1110), provided by 
an out-of-network provider on March 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on July 14, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the testing was medically necessary, and the 
enrollee's treating physician ordered the test. The Plan denied your request. The Plan says the rendering and 
referring providers are both OON providers and there was no approved authorization. Also, the service 
rendered was not urgent or emergent. 
 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 the laboratory services provided on July 14, 2021, 
by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the IRF services are medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
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 does not require intensive rehabilitation to recover from a hip fracture. 
She has no barriers to standard post hip fracture rehabilitation. 
 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost-sharing for Surgery and Part B drugs on March 17, 
2022. 
 
You asked the Plan to waive the cost-sharing for surgery and Part B drugs. You say that you want to appeal the 
amount being charged. The Plan denied your request. The Plan says the cost-sharing you are being charged is 
correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance of the total allowed amount for other Medicare Part B drugs and their administration. for Medicare 
Part B prescription drugs.  These drugs are covered under Part B of Original Medicare. Members of our plan receive coverage for these 
drugs through our plan. Covered drugs include Drugs that usually arent self-administered by the patient and 
are injected or infused while you are getting physician, hospital outpatient, or ambulatory surgical center 
services. You must also pay a $200 copayment for Medicare covered surgical (including diagnostic 
colonoscopy). The provider billed in the amount of $3,021.72 and the allowed amount is $1,107.30. The Plan 
paid $907.30. The provider also billed in the amount of $515 and the allowed amount is $402.72. The Plan paid 
$322.18. $200 + $80.54 = $280.54. Therefore, results in the total cost-sharing amount of $280.54. 
 
You have been asked to pay a 20% coinsurance for Part B drugs and a $200 copayment for surgery. Surgery 
and Part B drugs falls within the Medicare Part B prescription drugs and Outpatient surgery, including services 
provide 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 cost-sharing for Surgery and Part B drugs on March 17, 2022.