Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient surgery services provided on 
December 9, 2021. 
 
You asked the Plan to waive the copayment for outpatient surgery services. You say that no one explained to 
you that there would be a cost share applied. The Plan denied your request. The Plan says the copayment was 
applied 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 $150 
copayment for Medicare-covered surgery or other services provided to you at an ambulatory surgical center, 
including but not limited to hospital or other facility charges and physician or surgical charges. You have been asked to pay a $150 for outpatient surgery services. Outpatient surgery services fall within the 
Outpatient Surgery and Other Medical Services Provided 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 copayment for the outpatient 
surgery services provided on December 9, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the CT scan provided on December 17, 
2021. 
 
You asked the Plan to waive the copayment for the CT scan. You say that you should not be charged $275 for 
the CT scan. The Plan denied your request. The Plan says the copayment was applied 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, when in 
network, for diagnostic radiology services, $275 per day, per provider, for Medicare-covered diagnostic 
radiology services. 
 
 
  You have been asked to pay $275 for the CT scan. CT scans fall within the Diagnostic radiology 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 the CT scan provided on December 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the spinal injection provided on November 29, 2021. 
 
You asked the Plan to pay for the spinal injection. You say that this was denied using epidural injection rules, 
and the injection provided is subarachnoid. This treatment was necessary for the enrollee's condition. The Plan 
denied your request. The Plan says the records provided do not support medical necessity. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare requires that services 
provided/ordered/certified be authenticated by the persons responsible for the care of the beneficiary in 
accordance with Medicare's policies. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the spinal injection have not been met. Specifically, the documentation submitted does not include 
a valid signature from the persons responsible for the care of the beneficiary. Review of the progress note shows that the field for electronic signature is blank, and the only potential signature is typed and undated. In 
addition, the progress note does not have a date of service specified, meaning it cannot be confirmed that this 
note is for the services provided on the date of service at issue. Therefore, we decided that the Plan does not 
have to pay for the spinal injection provided on November 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay the in network rate for the filling (D2330) and root canal 
(D3310) provided on December 2, 2021. 
 
You asked the Plan to pay the in network rate for the dental services. You say that you did not know that your 
dentist was not a participating dentist. You also say that no one explained this when you contacted the plan. 
The Plan denied your request. The Plan says the claim processed correctly. 
 
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 and the fillings are listed as covered, dental services received out of network have a higher cost sharing amount. The record shows that while you did 
contact the plan prior to receiving the services, you did not ask about in network providers. Therefore, we 
decided that the Plan does not have to pay the in network rate for the filling (D2330) and root canal (D3310) 
provided on December 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180), 
consultation (D9310), and two preventive procedures (D1999 x2) provided from July 21, 2020, to August 13, 
2020 by an out-of-network (OON) provider 
 You asked the Plan to pay for the comprehensive periodontal evaluation, consultation, and preventive 
procedures. You say that you would like to appeal these services. The Plan denied your request. The Plan says 
this claim was submitted after the timely filling limit. The Plan also says that services are not covered when 
they are rendered by an OON provider. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the comprehensive periodontal evaluation, consultation, and preventive 
procedures was not filed until January 20, 2022. This means that more than one calendar year from the date of 
service had passed before a claim was filed. The contract also says that services rendered OON are not covered. 
Therefore, we decided that the Plan does not have to pay for the comprehensive periodontal evaluation 
(D0180), consultation (D9310), and two preventive procedures (D1999 x2) provided from July 21, 2020, to 
August 13, 2020 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 bitewings - four radiographic images (D0274), intraoral - 
periapical first radiographic image (D0220), periodic oral evaluation - established patient (D0120), and 
prophylaxis - adult (D1110) provided October 26, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the bitewing x-rays, periapical x-ray, periodic oral exam and dental cleaning. 
You say that you would like these services paid. The Plan denied your request. The Plan says the periodic oral 
exam and bitewing x-rays have processed correctly according to your OON benefits. The remaining services 
are not covered in this case. 
 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 bitewing 
x-rays, periodic oral exam and dental cleaning once per calendar year with 50% coinsurance when provided 
OON.  
 
We looked at the file and Medicare rules. The Plan provided documentation showing that you have been asked 
to pay 50% of the allowed amount for the periodic oral exam and bitewing x-rays. Additionally, you are 
responsible for the difference between the allowed amount and the total amount billed by the OON provider. 
Based on this information we decided that the Plan does not have to provide additional payment for the 
periodic oral evaluation and bitewing x-rays provided October 2021, by an out-of-network provider. The Plan 
provided documentation showing that a dental cleaning was previously covered on March 23, 2021. Based on 
this information, we decided that the Plan's frequency limit for coverage of the dental cleaning has been 
exceeded. Though the Plan offers dental benefits in excess of Medicare coverage, the periapical x-ray is not 
among those covered services. Therefore, we decided that the Plan does not have to pay for the intraoral - 
periapical first radiographic image (D0220) and prophylaxis - adult (D1110) provided October 26, 2021.
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 the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does not meet criteria.

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 the enrollee requires ongoing acute care services. The enrollee continues to receive acute care services, and these have not been denied.  The medical record does not indicate that the enrollee requires services that he is not currently receiving but that would be available at the LTACH 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 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic respiratory virus detection testing provided on 
January 7, 2022. 
 
You asked the Plan to pay for the genetic testing for respiratory viruses. You say that this is a payable code and 
is for medically necessary testing. The Plan denied your request. The Plan says this code is not supported. 
 
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, the CPT Code Manual definition of code 87631 is Infectious agent detection by nucleic acid (DNA 
or RNA); respiratory virus (eg, adenovirus, influenza virus, coronavirus, metapneumovirus, parainfluenza 
virus, respiratory syncytial virus, rhinovirus), includes multiplex reverse transcription, when performed, and 
multiplex amplified probe technique, multiple types or subtypes, 3-5 targets. 
 
We find that CPT code 87631 is not supported in the medical record. Specifically, the lab results clearly show 
that many more than 5 targets were tested for. Based on this information, we decided that Medicare rules for coverage of the genetic testing for respiratory viruses have not been met. Therefore, we decided that the Plan 
does not have to pay for the genetic respiratory virus detection testing provided on January 7, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee has stabilized medically and 
is ready for discharge from the hospital. The enrollee does not require skilled nursing and/or skilled therapy 
services on a daily basis. He is medically stable and can receive further rehab services at a lower level of care. 
Although further rehab services would be appropriate to improve function, as a practical matter, the 
intermittent skilled services can be provided at a lower level of care than a skilled nursing facility. His physical 
function is at or near his baseline and he can receive services at a lower level of care. Admission to a SNF for 
inpatient skilled rehab services is not medically 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 admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient physician services provided on April 12, 2021, 
billed with codes 99291 and 93010. 
 You asked the Plan to pay for the inpatient physician services as billed. You say that these services were 
medically necessary and should be paid. The Plan denied your request. The Plan says these codes are not 
supported. 
 
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 93010 is a column II code to column I code 99291. This was not 
billed with a modifier as required by Medicare billing rules. This was correctly denied and does not require 
coder review.  
 
The CPT code definition of code 99291 is critical care, evaluation and management of the critically ill or 
critically injured patient; first 30-74 minutes.  
 
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 services billed under code 99291. Our reviewer says that 
the use of code 99291 is not supported. Our reviewer found the use of code 99291 is not supported. 
 
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 inpatient physician services as billed have not been met. Therefore, we 
decided that the Plan does not have to pay for the inpatient physician services provided on April 12, 2021, 
billed with codes 99291 and 93010.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140), and intraoral imaging 
(D0220) provided by a participating provider on March 2, 2022. 
 
You asked the Plan to pay for a limited oral evaluation and intraoral imaging. You say that you went for a 
second opinion for a tooth that was causing you pain. The Plan denied your request. The Plan says these 
services have been correctly denied. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a limited 
oral evaluation (D0140), and intraoral imaging (D0220) provided by a participating provider on March 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the occlusal adjustment (D9951) provided on January 3, 2022. 
 
You asked the Plan to pay for the dental service. You say that you had a broken tooth. You say that your dentist 
realized your teeth were misaligned. You also say that at no time were you informed that this was a chargeable 
thing. The Plan denied your request. The Plan says occlusal adjustment is not listed as a covered service. 
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the occlusal adjustment is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the occlusal 
adjustment (D9951) provided on January 3, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450-26 billed for date of service January 4, 
2022. 
 You asked the Plan to pay for procedure code 70450-26. You say that the patient had multiple exams on this 
date of service. The Plan denied your request. The Plan says payment for code 70450-26 is bundled into 
payment for code 70496-26 
 
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 
70450-26 is a column II code to column I code 70496-26. 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 70450-26 billed for date of service 
January 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), and intraoral 
imaging (D0210) provided by a participating provider on November 3, 2021. 
 
You asked the Plan to pay for a comprehensive oral evaluation and intraoral imaging. You say that you would 
like the Plan to pay for this. The Plan denied your request. The Plan says the enrollee does not have a dental 
rider. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation 
(D0150), and intraoral imaging (D0210) provided by a participating provider on November 3, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 3, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 February 3, 2022 by an 
out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay from December 14, 
2021 through December 16, 2021. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that you were admitted to the 
hospital for pneumonia that is related to an automobile accident you were in. The Plan denied your request. The 
Plan says copayment 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 $350 
copayment for each Medicare-covered day, for days 1-5 and $0 for each additional day for inpatient stay.  
 
  You have been asked to pay $700 for the inpatient hospital stay ($350/day x 2 days = $700). The inpatient 
hospital stay falls within the Inpatient hospital care benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for inpatient hospital stay from December 14, 2021 through December 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the root canal (D3320) provided on December 14, 2021. 
 
You asked the Plan to pay for the dental service. You say that you have already paid $400 out of pocket. You 
say that you receive a bill for $112. You also say that you are living on a fixed income and can barely make 
ends meet. The Plan denied your request. The Plan says the annual allowance of $1,000 has 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, the annual allowance of $1,000 has 
been exhausted. The record shows that the Plan paid $199 for services received on December 1, 2021, $268 for 
services received on December 7, 2021, and $533 for services provided on December 14, 2021. $199 + $268 + 
$533 = $1,000. Therefore, we decided that the Plan does not have to pay for the root canal (D3320) provided 
on December 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a core build-up (D2950) provided by a participating provider 
on December 16, 2021. 
 
You asked the Plan to pay for a core build-up. You say that you were told that these services would be covered. 
The Plan denied your request. The Plan says this claim has been correctly denied. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a core 
build-up (D2950) provided by a participating provider on December 16, 2021.