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

 
We decided that the Plan does not have to pay for inpatient hospital services provided from January 17, 2022 to 
January 19, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that 
diagnosis codes A41.9, J15.6, and N17.9 were supported, and you would like the Plan's denial to be overturned. 
The Plan denied your request. The Plan says sufficient supporting documentation was not found within the 
submitted medical record to validate this diagnosis. 
 
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 principal diagnosis code, A41.9, defined as Sepsis 
unspecified organism, secondary diagnosis code J15.6, defined as pneumonia due to other gram-negative 
bacteria, and diagnosis code, N17.9, defined as acute kidney failure unspecified. 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 diagnosis codes included for this admission (A41.9, J15.6, and N17.9) were not 
supported in the documentation. Our physician reviewer found there was no sputum culture or other testing to 
confirm a gram-negative bacteria was causing the pneumonia infection. Kidney function testing did not reveal 
evidence of a significant enough worsening to meet criteria for acute kidney failure. Our reviewer found that 
Sepsis 3 criteria was not met as the enrollee did not have sufficient evidence to show Sequential Organ Failure 
Assessment (SOFA) score of 2 or more. Our physician reviewer also found that there was no evidence of a 
systemic infection or organ failure related to such to justify the sepsis diagnosis.  
 
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 provided from January 17, 2022 to January 19, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone replacement graft  retained natural tooth  first 
site in quadrant tooth #'s 9 and 29 (D4263). 
 
You asked the Plan to pre-approve the bone replacement graft  retained natural tooth  first site in quadrant 
tooth #'s 9 and 29 (D4263). You say that you need to get the teeth replacement. You also say that you cannot 
smile or talk and are losing your confidence and it's embarrassing. The Plan denied your request. The Plan says 
this service is not covered under the benefit package. 
 
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 a 
bone replacement graft  retained natural tooth  first site in quadrant tooth #'s 9 and 29 (D4263).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a Gammagard injection provided on September 01, 2022. 
 
You asked the Plan to pay for a Gammagard injection. You say that this was medically necessary and should be 
covered. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a Gammagard injection 
provided on September 01, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit provided on October 31, 
2022. 
 
You asked the Plan to waive the copayment for the office visit. You say that you were told that you did not 
have a copayment for the visit. 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 $45 
copayment for each in-network Medicare-covered eye exam related to the diagnosis and treatment of diseases 
and conditions of the eye.  
 
You have been asked to pay a $41.29 copayment, which is less than the standard amount, for the office visit. 
This item/service falls within the vision care benefit category. The record shows diagnoses of squamous 
blephartitis and meibomian gland dysfunction of the right eye which makes the office visit medical in nature. 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 the office visit provided on October 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on November 3, 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 November 3, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on February 9, 2021. 
 
You asked the Plan to pay for laboratory services. The Plan denied your request. The Plan says Original 
Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for laboratory services provided on February 9, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services. 
 
You asked the Plan to pay for laboratory services. You say that the enrollee received the services after hospice 
ended. The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 The enrollee ended Medicare Hospice benefits on February 25, 2022. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for laboratory services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for immediate maxillary and mandibular dentures (D5130, 
D5140) provided on January 31, 2022, and the extraction of tooth #12, 13, and 14 (D7140, D7210), a bone 
replacement graft on tooth #12 (D7953), and alveoloplasty in the upper left and right quadrants (D7310) 
provided on February 7, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial for the dental 
services. The Plan denied your request. The Plan says that immediate maxillary and mandibular dentures 
(D5130, D5140), extractions (D7140, D7210), a bone replacement graft (D7953), and an alveoloplasty 
(D7310) are not covered by your supplemental dental benefits. 
 Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
immediate maxillary and mandibular dentures (D5130, D5140) provided on January 31, 2022, and the 
extraction of tooth #12, 13, and 14 (D7140, D7210), a bone replacement graft on tooth #12 (D7953), and 
alveoloplasty in the upper left and right quadrants (D7310) provided on February 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crowns (D2750) for tooth #7 and tooth #10. 
 
You asked the Plan to pre-approve the crowns. You say that the enrollee had new crowns placed on tooth #8 
and #9. The crowns on tooth #7 and #10 do not match because they were done over 15 years ago. The Plan 
denied your request. The Plan says there is no clinical evidence to support medical necessity. 
 
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 crowns 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 the crowns. Our reviewer says that the 
documentation provided does not meet the criteria for coverage for replacement crowns (D2750) for tooth #7 
and tooth #10. Our physician reviewer found that a review of the documentation indicates the presence of 
crowns on tooth #7 and tooth #10. These crowns do not appear to be defective and no recurrent marginal caries 
is evident. Aesthetical concerns are not criteria for coverage. 
 We looked at this physicians review, the file, and Medicare rules. Based on this information, we decided that 
the Plans rules for coverage of the crowns have not been met. Therefore, we decided that the Plan does not 
have to pre-approve crowns (D2750) for tooth #7 and tooth #10.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on August 29, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that the records attached support the services provided. 
The Plan denied your request. The Plan says there is no authorization on file for the services rendered. 
 
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 August 29, 2022, by an 
out-of-network (OON) provider.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) of the upper extremity. 
 
You asked the Plan to pre-approve the MRI. You say that the MRI is medically necessary. The Plan denied 
your request. The Plan says that there is no documentation of 6-weeks of provider directed treatment. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 the MRI. Our reviewer says that the 
MRI of the upper extremity is medically necessary. Our physician reviewer found that the enrollee has had 
persistent pain for greater than 17 months, with objective findings consistent with probable rotator cuff 
pathology. There are x-rays that showed degenerative changes. The enrollee has trialed oral anti-
inflammatories, home physical therapy, and 2 subacromial injections with persistent symptoms. Therefore, the 
requested MRI of the left shoulder, in this case, is medically reasonable and necessary. 
 
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 MRI have been met. Therefore, we decided that the Plan has to pre-approve 
a magnetic resonance imaging (MRI) of the upper extremity.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repeat epidural steroid injections (ESIs) (codes 64483 
and 64484). 
 
You asked the Plan to pre-approve repeat ESIs. You say that you believe the ESI has been denied because your 
doctor did not approve an x-ray for you. The Plan denied your request. The Plan says you have already 
received these injections, but it has not yet been three months since the last injection. 
 
The Plan follows Medicare rules. Medicare rules say that a repeat epidural steroid injection (ESI) when the first 
injection directly and significantly provided improvement of the condition being treated may be considered 
medically reasonable and necessary when the medical record documents at least 50% of sustained 
improvement in pain relief and/or improvement in function measured from baseline using SAME scale for at 
least three months. 
 
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 repeat ESIs. Our reviewer says that the 
request is deemed not medically reasonable and necessary. Our physician reviewer found you had 
transforaminal epidural steroid injections on November 8, 2022. Our reviewer also found that insufficient time 
has passed to meet the criteria of 3 months of pain relief. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of repeat ESIs have not been met. Therefore, we decided that the Plan does not 
have to pre-approve repeat epidural steroid injections (ESIs) (codes 64483 and 64484).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infusion supplies provided on August 05, 2022, to August 
13, 2022. 
 
You asked the Plan to pay for infusion supplies. You say that this is an incorrect denial. The Plan denied your 
request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for infusion supplies 
provided on August 05, 2022, to August 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services provided on July 20, 
2022. 
 
You asked the Plan to waive the copayment for laboratory services. You say that you disagree with the 
copayment. 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 $45 
copayment for outpatient diagnostic tests/lab services.  
 
You have been asked to pay a $45 copayment for laboratory services. This item/service falls within the 
outpatient diagnostic tests/lab services benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
laboratory services provided on July 20, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99497 billed for date of service May 18, 
2022. 
 
You asked the Plan to pay for procedure code 99497. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  In this case, the MUE for CPT code 99497 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage have not 
been met. Therefore, we decided that the Plan does not have to pay for procedure code 99497 billed for date of 
service May 18, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) of the head or brain (70450), 
CT of the cervical spine (72125), chest x-ray (71045), pelvis x-ray (72170), shoulder x-ray (73030), and wrist 
x-ray (73110) provided on July 11, 2022. 
 
  You asked the Plan to pay for the additional CT of the head or brain, additional CT of the cervical spine, 
additional chest x-ray, additional pelvis x-ray, additional shoulder x-ray, and additional wrist x-ray. You say 
that this claim was denied as a duplicate in error. You also say that you would like this claim to be reviewed 
and reprocessed for reimbursement. The Plan denied your request. The Plan says the records submitted do not 
indicate the same services were performed twice the same day and read by the same radiologist. 
 
The Plan must follow Medicare rules. Medicare rules say that all exact duplicate claims or claim lines are auto-
denied or rejected. 
 
We asked our coder 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 additional CT of the head or brain, additional CT of the 
cervical spine, additional chest x-ray, additional pelvis x-ray, additional shoulder x-ray, and additional wrist x-
ray. Our reviewer says that the additional CT of the head or brain, CT of the cervical spine, chest x-ray, pelvis 
x-ray, shoulder x-ray, and wrist x-ray are not supported in the medical records. Our reviewer found the enrollee 
had only one of each of the exams on July 11, 2022. Our reviewer also found that the contention 2 of each of 
these exams were done on July 11, 2022, amounts to a duplicate claim and should be denied as such. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the additional CT of the head or brain, additional CT of the cervical spine, 
additional chest x-ray, additional pelvis x-ray, additional shoulder x-ray, and additional wrist x-ray have not 
been met. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) of the 
head or brain (70450), CT of the cervical spine (72125), chest x-ray (71045), pelvis x-ray (72170), shoulder x-
ray (73030), and wrist x-ray (73110) provided on July 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a white glass with metal cap for bridge (D6751) and 
pontics (D6241) for tooth #18, #19, #20, #21. 
 
You asked the Plan to pre-approve the dental services. You say that you need a bridge so you can eat. The Plan 
denied your request. The Plan says the enrollee is not missing only 1 upper front tooth or only 2 lower front 
teeth. 
 
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 the dental 
services 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 the dental services. Our reviewer says 
that the white glass with metal cap for bridge and pontics for tooth #18, #19, #20, #21 is not medically 
necessary. Our physician reviewer found that the documentation does not meet the criteria for coverage for a 
fixed bridge replacing missing posterior teeth #18 and #19 using teeth #17, #20 and #21 as abutment retainers. 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 the dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a white glass with metal cap for bridge (D6751) and pontics (D6241) for tooth #18, 
#19, #20, #21.