Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on May 18, 
2022, and December 1, 2022. 
 
You asked the Plan to pay for the dental service. You say that you received regular cleanings, and it should be 
covered. The Plan denied your request. The Plan says the denial of payment for this service is correct because 
periodontal maintenance is not covered by the Plan. Also, the provider verified the proper billing for the service 
that was rendered. 
 
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 item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
periodontal maintenance (D4910) provided on May 18, 2022, and December 1, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for inpatient hospital care, outpatient diagnostic 
tests and an outpatient surgery provided on February 1, 2022, to May 23, 2022. 
 
You asked the Plan to waive the cost share for inpatient hospital care, outpatient diagnostic tests and an 
outpatient surgery. You say that you disagree with the cost share. 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 a $335 
copayment per day for days 1-6 for inpatient hospital care, a 50% coinsurance for outpatient diagnostic tests/x-
ray services, a 50% coinsurance outpatient diagnostic tests/computed tomography (CT) scan, a 50% 
coinsurance outpatient diagnostic tests/magnetic resonance imaging (MRI) and a $325 for outpatient surgery.  
 
You have been asked to pay a $335 copayment per day for days 1-6 for inpatient hospital care, a 50% 
coinsurance for outpatient diagnostic tests/x-ray services, a 50% coinsurance outpatient diagnostic 
tests/computed tomography (CT) scan, a 50% coinsurance outpatient diagnostic tests/magnetic resonance 
imaging (MRI) and a $325 for outpatient surgery. From April 5, 2022, to April 12, 2022, you are being charged 
$2,010 ($335 x 6 days =$2,010). From April 13, 2022, to May 05, 2022, you are being charged $564 which is 
less than the required amount. This item/service falls within the inpatient hospital care, outpatient diagnostic 
tests/x-ray services/computed tomography (CT) scan/magnetic resonance imaging (MRI) and outpatient 
surgery benefit category. The total allowed amount for x-ray services is $8.70. You are being asked to pay 
$4.35 ($8.70 x 50% = $4.35). The total allowed amount for the out-of-network CT scans is $200.97. You are 
being asked to pay $100.48 ($200.97 x 50% = $100.48). The total amount for the in-network CT scan is $375. 
The total amount for all services rendered is $3,412.13 ($2,010 + $564 + $4.35 + $33.30 + $100.48 + $375 + 
$325 = $3,412.13). 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 share for inpatient hospital care, 
outpatient diagnostic tests and an outpatient surgery provided on February 1, 2022, to May 23, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that an LTACH admission will give the 
enrollee the best chance for a quicker recovery and more favorable outcome. The Plan denied your request. The 
Plan says the enrollee is receiving appropriate in-patient acute care and is currently unstable for transfer to an 
LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that all medically necessary care is being provided in the current acute care setting. 
There are no services available at the LTACH that the enrollee requires that are not available at the health care 
setting being offered by the Plan. The Plan has approved ongoing care in the current acute care setting. The 
requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for a cervical, multiple post collar, occipital/mandibular supports, 
adjustable (code L0180) provided on December 7, 2022. 
 
You asked the Plan to pay for the cervical, multiple post collar, occipital/mandibular supports, adjustable  
(code L0180). You say that the medical records provided support coverage for this item. The Plan denied your 
request. The Plan says that there is no claim on file in the members history to confirm the office visit. 
 
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. Specifically, the Plan has not provided a Medicare rule or a Plan rule to 
substantiate their denial. Therefore, we decided that the Plan has to pay for a cervical, multiple post collar, 
occipital/mandibular supports, adjustable (code L0180) provided on December 7, 2022.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services rendered from July 20, 2022, to 
July 29, 2022. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says the DRG was updated. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 853. 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 inpatient hospital services at the DRG originally billed. Our reviewer says 
that the services at issue in this case were not supported by the medical records. Our physician reviewer found 
that in this case, there was no clinical or laboratory evidence of sepsis or acute tubular necrosis. The review has 
determined that  the documentation does not support diagnosis codes A41.9 - sepsis, unspecified organism or 
N17.0 - acute kidney failure with tubular necrosis. The records more support DRG 418.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services rendered from July 20, 2022, to July 29, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on September 23, 2022. 
 
You asked the Plan to pay for the services. 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 the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the services have been met. The non-
contract provider did not submit medical records for the date of service in question. The only records submitted with the case file are for September 13, 2022, and August 31, 2022. Therefore, we decided that the Plan does 
not have to pay for the services provided on September 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 14-day continuous glucose monitor 
(CGM) sensor (A4239). 
 
You asked the Plan to pre-approve a Freestyle Libre CGM sensor. You say that the enrollee has type 2 diabetes 
and is insulin treated, one to two times per day. The enrollee is not using a pump and does not require frequent 
adjustment based on glucose testing results. The Plan denied your request. The Plan says the enrollee does not 
meet criteria of approval of the CGM. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections or require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of a Freestyle 
Libre CGM sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Freestyle Libre 14-day continuous glucose monitor (CGM) sensor (A4239).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT), of the thorax, diagnostic; 
without contrast material (71250). 
 
You asked the Plan to pre-approve this service. You say that the requested service is medically necessary. The 
Plan denied your request. The Plan says you do not meet criteria for coverage of the requested service. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically 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 this service. Our reviewer says that the 
requested service is not medically necessary. Our physician reviewer found that while there is no smoking 
history detailed, your last CT scan of July 12, 2022, was a low dose computed tomography (LDCT) scan, 
implying there is a smoking history in order for you to have qualified for the scan. You do have a history of 
endometrial cancer so it is assumed you can be classified as high risk. Your 5 mm nodule was stable between 
February and July 2022. Given that stability, a six month short term follow-up is not indicated based on 
Fleischner Society criteria but you would be eligible for a 12 month follow-up from your July 2022 scan 
provided. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve computed tomography (CT), of the thorax, diagnostic; without contrast material (71250).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial mental health hospital admission. 
 
You asked the Plan to pre-approve a mental health hospital admission. You say that you are having a difficult 
time in life right now. The Plan denied your request. The Plan says a partial hospitalization is 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 a mental health hospital admission. Our reviewer says that a partial mental health hospital admission is not medically necessary. Our physician 
reviewer found the enrollee was not showing any aggressive behaviors. It did not appear medically necessary 
and reasonable to have psychiatric care provided at the partial hospitalization level of care rather than a lower 
level of care as she did not have any suicidal or homicidal thoughts or behavioral disturbance. 
 
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 mental health hospital admission have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a partial mental health hospital admission.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro 2 Motion G device (L8702). 
 
You asked the Plan to pre-approve the orthotic device. You say that the MyoPro is appropriate for the enrollee 
including for the duration and frequency/ The Plan denied your request. The Plan says this device is considered 
investigational as there is not enough research to show that myoelectric controlled upper-limb orthoses improve 
health outcomes for people with upper limb weakness or paresis. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the orthotic device have not been met. Therefore, we decided that the Plan does not have to pre-
approve the MyoPro 2 Motion G device (L8702).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70544 billed for date of service May 7, 2022. 
 
You asked the Plan to pay for procedure code 70544. You say that the member had multiple exams done on 
this date of service. The Plan denied your request. The Plan says payment for code 70544 is bundled into 
payment for code 70551. 
 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 70544 
is a column II code to column I code 70551. 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 70544 billed for date of service May 7, 2022.
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 enrollee requires a multidisciplinary approach to 
maximize function for a safe discharge home. The Plan denied your request. The Plan says the enrollee could 
receive care in another setting. 
 
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 documents do not support necessity for admission to an IRF. The complexity of the 
enrollee's nursing, rehab, and medical needs does not require an acute hospital inpatient rehab stay with an 
interdisciplinary approach to rehabilitative care. While the medical record supports a need for physical and 
occupational therapy, necessary care can be provided in a different level of care 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740), and a core build-up (D2950). 
 
You asked the Plan to pre-approve the dental services. You say that you would like the Plan to pre-approve 
these services. 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 October 20, 2022. 
Therefore, we decided that the Plan does not have to pre-approve a crown (D2740), and a core build-up 
(D2950).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for adding a tooth to existing partial denture (D5650) and a 
surgical extraction (D7210) for tooth #22 provided on December 1, 2022. 
 
You asked the Plan to pay for the dental services. You say that you called prior to treatment and were told 
emergency dental services were covered. The Plan denied your request. The Plan says the denial of payment 
for these services is correct, because adding a tooth to existing partial denture and surgical extractions are not 
covered by the Plan. Also, the Plan verified the enrollee was told emergency care was limited to palliative care 
to relieve pain only and surgical extractions were 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 adding a 
tooth to existing partial denture (D5650) and a surgical extraction (D7210) for tooth #22 provided on 
December 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 3 continuous glucose monitor (CGM), 
and supplies. 
 
You asked the Plan to pre-approve a CGM and supplies. You say that the CGM is medically necessary. The 
Plan denied your request. The Plan says a Freestyle Libre 3 is not a covered benefit. 
 
We looked at the file and Medicare rules. The requested Freestyle Libre 3 is not specified as a product that may 
be classified using code E2103. Therefore, this device is not covered by Medicare at this time. Based on this 
information, we decided that Medicare rules for coverage of a CGM and supplies have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 3 continuous glucose 
monitor (CGM), and supplies.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the osseous surgery (D4261), the bone graft around a tooth 
(D4263), the bone replacement grafts (D4264), and the biological materials (D4265) provided on April 28, 
2022. 
 
You asked the Plan to pay for the dental services. You say that you never received a EOC and requested one 
but did not receive it until after the dental work was completed. The Plan denied your request. The Plan says 
the denial of payment for these services is correct because the osseous surgery, bone grafts around a tooth, 
bone replacement grafts, and biological materials are not covered by the Plan. Also, the provider called prior to 
the date of service and were advised the enrollee had preventative dental coverage only. 
 
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 
osseous surgery (D4261), the bone graft around a tooth (D4263), the bone replacement grafts (D4264), and the 
biological materials (D4265) provided on April 28, 2022.