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

 
We decided that the Plan has to pay for the acute inpatient hospital care provided April 13, 2022, to April 15, 
2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that these services were medically 
necessary. The Plan denied your request. The Plan says that services could have been provided at a lower level 
of care. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the enrollee was considered medically stable for discharge on 4/15/2022 with scheduled 
outpatient follow-up. The review has determined that the record showed that at the time of inpatient admission 
the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier ED 
and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided April 13, 2022, to April 15, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a chiropractic visit provided on August 05, 2022. 
 
You asked the Plan to pay for a chiropractic visit. You say that your plan says chiropractic services are 
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). there was no preauthorization by a primary care provider (this is different than a 
referral) for an out-of-network (OON) provider or facility, and this was not an emergency. Therefore, the 
decision is upheld. Therefore, we decided that the Plan does not have to pay for a chiropractic visit provided on 
August 05, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 85060 billed for date of service June 2, 2022. 
 
You asked the Plan to pay for procedure code 85060. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says this code is included in the facility payment and is not separately 
payable. 
 
 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was outpatient. Per the Physician Fee 
Schedule, there is a Professional/Technical indicator of 8 for CPT code 85060. This means the professional 
component of clinical laboratory codes for which separate payment may be made only if the physician 
interprets an abnormal smear for hospital inpatients. Based on this information, we decided that Medicare rules 
for coverage of procedure code 85060 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code 85060 billed for date of service June 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9083 billed for date of service September 
14, 2022. 
 
You asked the Plan to pay for procedure code S9083. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure code S9083 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9083 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9083 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9083 billed for date of service September 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a partial maxillary denture (D5225) 
provided by a participating provider on February 17, 2022. 
 
You asked the Plan to waive the coinsurance for a partial maxillary denture. You say that you believe the Plan 
should be paying more. 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 70% 
coinsurance for removable partial denture/in-network.  
 
You have been asked to pay a 70% coinsurance of the allowed amount for a partial maxillary denture. The total 
allowed amount is $1,057. The total amount you are being asked to pay is $739.90 ($1,057 x 70% coinsurance 
= $739.90). This item/service falls within the removable partial denture/in-network benefit category. This 
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for a partial maxillary denture (D5225) provided by a 
participating provider on February 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an extraction (D7140) provided on August 17, 2022. 
 
You asked the Plan to pay for an extraction. You say that your tooth was loose, so you had it pulled. The Plan 
denied your request. The Plan says the enrollee does not have dental benefits. 
 
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 an extraction (D7140) provided 
on August 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A4550 billed for date of service August 2, 
2022. 
 
You asked the Plan to pay for procedure code A4550. You say that this should be paid for. The Plan denied 
your request. The Plan says procedure code A4550 is considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code A4550 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code A4550 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code A4550 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code A4550 billed for date of service August 2, 2022.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for the ultrasound coded 76641 provided on September 6, 2022. 
 
You asked the Plan to pay for the ultrasound. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says that the services are not payable as billed. 
 
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 76641 is ultrasound, breast, unilateral, real time with image documentation, including axilla when 
performed; complete. 
 
The Plan states that this code has a MUE of 1. In this case, the MUE for CPT code 76641 is two (2). Two units 
of this code were billed. The Plan did not provide any other argument as to why these cannot be paid. The Plan 
did not substantiate their denial. Based on this information, we decided that Medicare rules for coverage of the 
ultrasound have been met. Therefore, we decided that the Plan has to pay for the ultrasound coded 76641 
provided on September 6, 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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for a right piriformis muscle trigger point injection provided to the enrollee 
on July 25, 2022. 
 
You asked the Plan to pay for the injection. You say that this should be paid for. The Plan denied your request. 
The Plan says that this was not reported with an appropriate diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that services are covered if they are medically 
necessary and meet specific coverage criteria. 
 
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 injection. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee has tried ultrasound, chiropractic therapy, acupuncture, relaxation, and physical therapy. 
The enrollee presents with right buttock pain and sciatica. The injection was 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 injection have been met. Therefore, we decided that the Plan has to pay for a 
right piriformis muscle trigger point injection provided to the enrollee on July 25, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for prophylaxis (D1110), intraoral imaging (D0220), 
palliative (emergency) treatment of dental pain (D9110), and a periodic oral evaluation (D0120), provided by 
an out-of-network provider on January 15, 2022, to August 25, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you believe that the Plan should be paying 
more of this. The Plan denied your request. The Plan says you are responsible for any charged amount above 
the Plans cost-sharing amount when your services are received from an out-of-network provider. 
 
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. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for prophylaxis (D1110), intraoral imaging 
(D0220), palliative (emergency) treatment of dental pain (D9110), and a periodic oral evaluation (D0120), 
provided by an out-of-network provider on January 15, 2022, to August 25, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ultrasound, abdominal aorta, real time with image 
documentation, screening study for abdominal aortic aneurysm provided to the enrollee on June 20, 2022. 
 You asked the Plan to pay for the services. You say that the service was performed at the request of the 
referring provider under medical necessity. The Plan denied your request. The Plan says the diagnosis code is 
inconsistent with the procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the smoking and family history are not listed. Thus, the complete documentation for qualifying for 
the once in a lifetime AAA screening has not been completely included in the dictated reason for the 
examination and chart notes. The necessary additional information has not been submitted. 
 
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 pay for an ultrasound, abdominal aorta, real time with image documentation, screening study for 
abdominal aortic aneurysm provided to the enrollee on June 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for dental services provided by an out-of-network provider 
on July 28, 2022, to August 4, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you thought that this provider was in-
network. The Plan denied your request. The Plan says you are responsible for any charged amount above the 
Plans cost-sharing amount when your services are received from an out-of-network provider. 
 
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. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for dental services provided by an out-of-
network provider on July 28, 2022, to August 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oral hygiene instructions (D1330) and periodontal scaling 
and root planing (D4341) provided by a participating provider on August 25, 2022. 
 
You asked the Plan to pay for oral hygiene instructions and periodontal scaling and root planing. You say that 
you were shocked to get a bill this high. The Plan denied your request. The Plan says the rendered dental 
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 oral 
hygiene instructions (D1330) and periodontal scaling and root planing (D4341) by a participating provider on 
August 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the photochromatic tint (V2744), anti-reflective coating 
(V2750), progressive lens (V2781), hi-index lens (V2782), and miscellaneous vision item or service (V2799) 
purchased on July 22, 2022. 
 
You asked the Plan to pay for the lens enhancements. You say that the lens replacement procedure was 
approved by the Plan, and you were hopeful it would resolve the situation. You also say that because the vision 
in your left eye had deteriorated, you decided to replace your old glasses with a corrected pair that would 
improve your vision. The Plan denied your request. The Plan says the lens enhancements you received are not 
covered. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers single vision or lined multi-focal lens.  
We looked at the file and the Plan's rules. [Insert determination explanation]. Based on this information, we 
decided that the Plan's rules for coverage of the lens enhancements have not been met. Therefore, we decided 
that the Plan does not have to pay for the photochromatic tint (V2744), anti-reflective coating (V2750), 
progressive lens (V2781), hi-index lens (V2782), and miscellaneous vision item or service (V2799) purchased 
on July 22, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance transport provided on January 30, 2022. 
 
You asked the Plan to pay for the ambulance transport. You say that the enrollee was being discharged from 
the hospital via ambulance for continuing care. The Plan denied your request. The Plan says our policy only 
covers non-emergency ambulance transportation when it is the only way to safely and adequately transport a 
member, or if other means of transporting a member are unsafe due to a medical condition. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 ambulance transport. Our reviewer says 
that transportation via ambulance from the emergency department to the senior living facility was not 
medically necessary. Our physician reviewer found the enrollee did not require the expertise of trained 
personnel or the equipment available only on an ambulance in order to effectuate a safe transport. 
Transportation could have been provided by other means without endangering the enrollee's condition. 
 
 
 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 ambulance transport have not been met. Therefore, we decided that the Plan 
does not have to pay for ambulance transport provided on January 30, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for angiography services (procedure code 75726, 75774) provided to the 
enrollee on June 23, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that the denied 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, the CPT Code Manual definition of 
the denied codes is: 
 
CPT 75726: 
 
Angiography, visceral, selective or supraselective (with or without flush aortogram), radiological supervision 
and interpretation 
 
CPT 75774: 
 
Angiography, selective, each additional vessel studied after basic examination, radiological supervision and 
interpretation (List separately in addition to code for primary procedure) 
 
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. Our reviewer says that the services at issue in 
this case were supported by the medical records. Our reviewer found that the documentation supports coverage 
of the codes in question.  Diagnostic angiography performed at the time of tumor embolization is not bundled 
and is separately reportable. CPT 75726 codes a visceral angiogram. There is satisfactory documentation of a 
superior mesenteric artery (SMA) angiogram performed with satisfactory description to support coverage of 
supervision and interpretation. Likewise, CPT 75774 codes for additional angiography when the catheter is 
placed in a separate vessel, there is satisfactory documentation that selective access initially via the celiac 
artery and subsequent branches and angiography was performed to identify the location of the tumor blush. 
There is not enough documentation to justify that these codes have been performed, and they are not a 
component of care for any of the previously covered codes, including CPT 37243. 
 
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 services have been met. Therefore, we decided that the Plan has to pay for 
angiography services (procedure code 75726, 75774) provided to the enrollee on June 23, 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.