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

We decided that the Plan does not have to pay for the Prodigy test strips (A4253) and caliber solution (A4256), and the True Plue lancets (A4259), provided on March 27, 2020.
You asked the Plan to pay for the diabetes testing supplies. You say that the items are medically necessary. The Plan denied your request. The Plan says these are not the Plan's preferred brands.
The Plan follows Medicare rules. Medicare rules say that MA plans may specify brands and manufacturers as preferred and charge lower cost-sharing for the preferred brands or may limit the Durable Medical Equipment (DME) to only those preferred brands and manufacturers. 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 diabetes testing supplies. Our reviewer says that the service is not medically necessary. Our physician reviewer found there is no indication these items are medically necessary over the Plan's preferred brands. 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 diabetes testing supplies have not been met. Therefore, we decided that the Plan does not have to pay for the Prodigy test strips (A4253) and caliber solution (A4256), and the True Plue lancets (A4259), provided on March 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pontics (D6241) for teeth # 24 and 25, retainer crowns 
(D6751) for teeth # 23 and 26, and custom fabricated abutments (D6057) for teeth # 18, 19, 23, 26, 30, and 31. 
 
You asked the Plan to pre-approve the dental services. You say that you are in the middle of your treatment. 
You also say that the second part should not have been denied. The Plan denied your request. The Plan says the 
requested services are 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 and the retainer crowns and pontics are 
listed as covered, the bridge would be entirely implant supported, and implant related services are not a covered 
expense the bridge itself is not a covered service. Additionally, custom fabricated abutments are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve pontics 
(D6241) for teeth # 24 and 25, retainer crowns (D6751) for teeth # 23 and 26, and custom fabricated abutments 
(D6057) for teeth # 18, 19, 23, 26, 30, and 31.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care after April 26, 2022. 
 
You asked the Plan to pre-approve SNF care after April 26, 2022. You say that the continued admission to a 
SNF is medically necessary. The Plan denied your request. The Plan says the continued admission to a SNF 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 SNF care after April 26, 2022. Our 
reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not 
have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled 
professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized skill, 
knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled nursing 
and/or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care after April 26, 2022, have not been met. Therefore, we decided that 
the Plan does not have to pre-approve skilled nursing facility (SNF) care after April 26, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a biopsy provided on November 29, 2021. 
 
You asked the Plan to waive the copayment for the biopsy. You say that this procedure was done in the doctor's 
office so you should not have a copayment. The Plan denied your request. The Plan says there was an error on 
the original claim, and it was reprocessed. Per the provider's office the physician bills a facility fee with the 
charges because they are located at the hospital. Therefore, the proper copayment was applied. 
 
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 $200 
copayment for each Medicare-covered visit to an ambulatory surgical center or outpatient hospital facility. The 
total amount allowed was $78 which is less than the $200 copayment. Therefore, only $78 was charged for the 
copayment. 
 
  You have been asked to pay a $78 copayment for the biopsy. The biopsy falls within the Outpatient surgery, 
including 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 a biopsy provided on November 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the labial veneer (D2962) provided on December 17, 2021. 
 
You asked the Plan to pay for the dental service. You say that you slipped and fell resulting in a chipped front 
tooth. You say that you split your upper lip. You also say that you feel the veneer is necessary as part of a 
covered medical procedure to prevent your upper lip from constantly being split. The Plan denied your request. 
The Plan says labial veneer 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the labial veneer is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the labial veneer 
(D2962) provided on December 17, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the physical therapy provided on December 
29, 2021. 
 
You asked the Plan to waive the copayment for the physical therapy. You say that you were told you had other 
insurance to cover this service. The Plan denied your request. The Plan says the copayment applied 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 
copayment for physical therapy.  
 
 
  You have been asked to pay a $20 copayment for the physical therapy. The physical therapy falls within the 
Outpatient rehabilitation 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 
the physical therapy provided on December 29, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve six additional physical therapy (PT) sessions (97139). 
 
You asked the Plan to pre-approve six additional PT sessions. You say that additional PT will continue to 
improve your mobility and ability. The Plan denied your request. The Plan says additional PT does not appear 
to be medically necessary at this time. 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 six additional PT sessions. Our 
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration 
of the enrollee's condition. Based on the medical records provided there is no documentation that the unique 
skills of a professional therapist are required to safely and effectively provide treatment, that the services can 
be safely and effectively performed only by a therapist or under the supervision of a therapist. Based on the 
medical records provided there is no documentation that the specialized skill, knowledge and judgment of a 
qualified therapist is required to establish, design and/or deliver a program to maintain the patient's current 
condition or to prevent or slow further deterioration. Based on the available records the patient appears to have 
improved with therapy but still has core weakness. He has demonstrated competence with a home exercise 
program. The six approved additional physical therapy visits then utilization of the home exercise program 
appears appropriate at this point. Further skilled therapy beyond the six additional visits recently approved does 
not appear to meet Medicare criteria for 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 six additional PT sessions have not been met. Therefore, we decided that the 
Plan does not have to pre-approve six additional physical therapy (PT) sessions (97139).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care, first hour (99291) provided on May 18, 2021. 
 
You asked the Plan to pay for critical care. You say that this care was billed appropriately and is supported in 
the medical record. The Plan denied your request. The Plan says the medical records do not include a critical 
care evaluation and management note supporting 30-74 minutes of critical care were provided on the billed 
date of service. 
 
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 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, the time spent providing this 
service is not noted in the record. Based on this information, we decided that Medicare rules for coverage of critical care have not been met. Therefore, we decided that the Plan does not have to pay for critical care, first 
hour (99291) provided on May 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the office visit (99214) provided on 
December 15, 2021. 
 
You asked the Plan to waive the deductible. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the deductible has been applied correctly to 
the service provided.  
 
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 combined in-network and out-of-network medical 
deductible of $400. This is the amount you have to pay out-of-pocket before the Plan will pay their share for 
your covered medical services. Until you have paid the deductible amount, you must pay the full cost for most 
of your covered services. Once you have paid your deductible, the Plan will begin to pay their share of the 
costs for covered medical services and you will pay your share (your copayment or coinsurance amount) for the 
rest of the plan year.  
 
You have been asked to pay $126.87 for the office visit provided as you had not previously met the annual 
deductible. This is the Plans allowed amount for this service provided. 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 
deductible for the office visit (99214) provided on December 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the osseous surgery (D4261) provided on November 15, 2021. 
 
You asked the Plan to pay for the dental service. You say that no one told you that certain procedures would 
not be covered. The Plan denied your request. The Plan says osseous surgery 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 osseous surgery is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the osseous surgery 
(D4261) provided on November 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic services rendered on December 8, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. The file shows that the 
chiropractor submitted a claim for procedure code 99203 (office visit). Therefore, we decided that the Plan 
does not have to pay for the chiropractic services rendered on December 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a folding cane seat.  
You asked the Plan to pre-approve the seat. You say that you had a hip replacement and need something to sit 
on. The Plan denied your request. The Plan says the requested item remains denied as it is not considered 
reasonable and necessary to treat injury or illness. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
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 seat. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. The documentation does 
not support that your needs cannot be met by a standard cane over a folding cane seat. It is not clear that the 
seat feature serves a primary medical need. The medical necessity of the requested item is not supported by the 
documentation per Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-02, 
Medicare Benefit Policy Manual, Chapter 15, Section 110.1 and  National Coverage Determination (NCD) - 
Durable Medical Equipment (DME) Reference List (280.1). 
 
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 seat have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a folding cane seat.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal maintenance (D4910), gingival irrigation 
(D4921 x 4), take home drugs (D9630 x 2), and fluoride varnish (D1206). 
 
You asked the Plan to pre-approve the dental services. You say that you would like this to be covered as 
routine preventive care. You also say that you want to avoid losing your teeth and bone. The Plan denied your 
request. The Plan says periodontal maintenance, gingival irrigation, take home drugs, and fluoride varnish are 
not 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested periodontal maintenance, 
gingival irrigation, take home drugs, and fluoride varnish are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve periodontal maintenance (D4910), gingival 
irrigation (D4921 x 4), take home drugs (D9630 x 2), and fluoride varnish (D1206).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided by a physical therapy 
assistant on October 8, 2021. 
 
You asked the Plan to pay for physical therapy services. You say that plans are required to pay non-contract 
providers at the preferred provider rate when services are not available from preferred providers in the service 
area. You say that the in-network benefits should be honored, and the claim processed for payment. The Plan 
denied your request. The Plan says the code is not appropriate for the service billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the services of a physical therapy assistant (PTA) 
shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they 
do not meet the qualifications of a therapist.  
  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of physical therapy services have not been met. Specifically, the billing provider is a nurse 
practitioner, and not a licensed therapist. As such, PTA services cannot be paid incident to this provider's 
professional services. Therefore, we decided that the Plan does not have to pay for physical therapy services 
provided by a physical therapy assistant on October 8, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the arterial x-ray rendered on October 8, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 75716 is not separately payable. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
The provider submitted a claim for procedure codes 75716 (arterial x-ray) and 37225 (endovascular 
revascularization). Code 75716 is a column II code with a modifier indicator of 1 when billed with column I 
code 37225. Code 75716 was not billed with an appropriate modifier to allow for separate payment. The -XU 
modifier is not supported as a separate and distinct procedural service. Therefore, we decided that the Plan does 
not have to pay for the arterial x-ray rendered on October 8, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health skilled nursing services for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this level of care is not needed. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 
 
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 services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found that in this case, 
the documentation doesnt support that the enrollee requires skilled nursing services or to provide treatment 
that is medically necessary. The enrollee does not require skilled nursing services to effectively provide 
treatment, care, and/or services in order to improve the members condition, perform a maintenance program to 
maintain the members condition and/or prevent deterioration. The enrollee has been medically stable without 
any recent exacerbations of chronic medical problems or hospitalizations. The requested home health services 
are 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve home health skilled nursing services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildup, including any pins when required (D2950). 
 
You asked the Plan to pre-approve core buildup. You say that this service is medically necessary. The Plan 
denied your request. The Plan says this service is not covered under your benefits. 
 
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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve core 
buildup, including any pins when required (D2950).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve deep sedation (D9222, D9223 x 2), and therapeutic 
parenteral drug (D9610). 
 
You asked the Plan to pre-approve the dental services. You say that your dentist feels you need this anesthesia. 
You say that your filling is falling out. You say that you are already in a lot of pain. You also say that you 
cannot have surgery until May. The Plan denied your request. The Plan says the claim was denied 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, 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 deep 
sedation (D9222, D9223 x 2), and therapeutic parenteral drug (D9610).