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

 
We decided that the Plan does not have to pay for the inpatient admission provided from February 4, 2022, to 
February 11, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient level of care was most 
appropriate for this enrollee. The Plan denied your request. The Plan says it is a very common finding for 
elderly enrollees to have transient mental status changes during hospitalizations, and discharge was delayed due 
to placement issues 
 
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 does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found that the review indicates that the record showed that at the time of inpatient 
admission the admitting physician reasonably expected that the patient'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 not been met. Therefore, we decided that the 
Plan does not have to pay for the inpatient admission provided from February 4, 2022, to February 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve the requested services. You say that you need to keep a better handle on 
your diabetes. The Plan denied your request. The Plan says you do not meet the criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 
 We looked at the file and Medicare rules. The documentation does not indicate that you use insulin with at least 
three daily injections or require frequent self-adjustment of insulin dosage based on the blood glucose testing 
results. Based on this information, we decided that Medicare rules for coverage of the requested services have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for chemotherapy on February 28, 2022. 
 
You asked the Plan to waive the coinsurance for chemotherapy. You say that you want to appeal the amount 
being charged. The Plan denied your request. The Plan says the cost sharing you are being charged 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% 
coinsurance for chemotherapy drugs at specialists office or outpatient hospital. These drugs are covered under 
Part B of Original Medicare. Members of our plan receive coverage for these drugs through our plan. Covered 
drugs include drugs that usually aren't self-administered by the patient and are injected or infused while you are 
getting physician, hospital outpatient, or ambulatory surgical center services. The provider billed in the amount 
of $9,221 and the allowed amount is $2,974.69. The Plan paid $2,381.89. $2,974.69 - $2,381.89 = $592.80. 
Therefore, results in the total cost sharing amount of $592.80. 
 
 
 You have been asked to pay a 20% coinsurance for chemotherapy. Chemotherapy falls within the Medicare 
Part B prescription drugs 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 
chemotherapy on February 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the walker billed for date of service July 28, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the date of 
service should be the date of discharge. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We looked at the file and the rules. The records show that the walker was delivered prior to the enrollee being 
discharged from inpatient care. The enrollee was discharged on July 27, 2021. Pre-discharge delivery of items 
intended for use upon discharge are considered provided on the date of discharge.  Based on this information, we decided that Medicare rules for coverage of the services provided have not been 
met. Therefore, we decided that the Plan does not have to pay for the walker billed for date of service July 28, 
2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from April 20, 2021, to April 30, 2021.  
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 the medical records contains only the 5 day Minimum Data Set (MDS) assessment, and no other 
medical records to support the coding. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage have been met. The provider has only 
sent in the MDS assessment for this case. They must send in any clinical records that would support their 
PDPM score of ODXE1. There must be supporting documentation to verify the diagnoses for each of the 
alphanumeric characters.. Therefore, we decided that the Plan does not have to pay for skilled nursing facility 
(SNF) services provided to the enrollee from April 20, 2021, to April 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a 16-inch width walker. 
 
You asked the Plan to pre-approve a 16-inch width walker. You say that this is medically necessary. The Plan 
denied your request. The Plan says there is no record of a mobility evaluation to support the need for a different 
walker. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have an 18-inch width walker. This walker serves the same purpose as a 16-inch width 
walker. There is no medical documentation that the current walker is unable to serve your medical needs. 
Therefore, we decided that the Plan does not have to pre-approve a 16-inch width walker.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for the home health services provided from January 5, 2022, to February 3, 
2022. 
 
You asked the Plan to pay for the home health services. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says that the NOA document is required to 
process the final claim. 
 
The Plan must follow Medicare rules. Medicare rules say that only one NOA is required for any series of HH 
periods of care beginning with admission to home care and ending with discharge. 
 
We looked at the file and Medicare rules. In this case, the Plan has denied payment stating that an NOA is 
required for payment with the final claim and the NOA submitted in this case had the incorrect admission date. 
However, the file shows a claim with type of bill (TOB) 32A was submitted with the admission date of 
September 3, 2021, correctly.  Based on this information, we decided that Medicare rules for coverage of the 
home health services have been met. Therefore, we decided that the Plan has to pay for the home health 
services provided from January 5, 2022, to February 3, 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: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to waive the cost for the laboratory services. We decided that the Plan does not 
have to waive the copayment for the intravenous infusion.  
 
You asked the Plan to waive the cost for the laboratory services and intravenous infusion. You say that you 
never had to pay for this in the past. The Plan says that the cost share applied is correct.  We decided that the Plan has to waive the cost for laboratory services.  
 
The Plan says you must pay the allowed amount of $13.58 for the laboratory services. The Plan contract clearly 
says that you pay $0 for Medicare covered lab services. Therefore, we decided that the Plan has to waive the 
cost for the laboratory services.  
 
We also decided that the Plan does not have to waive the copayment for the intravenous infusion. 
 
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 $165 
copayment for each admission to an outpatient hospital facility. You have been asked to pay $158, which is 
less than the standard $165 copayment for the infusion. Therefore, we decided that the Plan does not have to 
waive the copayment for the intravenous infusion. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the lithium battery (Q0506) provided on 
November 22, 2021. 
 
You asked the Plan to waive the coinsurance for the battery. You say that you feel you are not responsible for 
the coinsurance. You say that your device did not come with a battery. You also say that you were not 
informed a battery would be needed. The Plan denied your request. The Plan says the claim processed 
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 20% 
coinsurance for Durable Medical Equipment (DME) and Supplies.  
 
You have been asked to pay a 20% coinsurance for the battery. The battery falls within the Durable Medical Equipment (DME) and Supplies 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. The record shows that the Medicare allowed amount for the battery is $$863.72, 
times 20% coinsurance equals $172.74. Therefore, we decided that the Plan does not have to waive the 
coinsurance for the lithium battery (Q0506) provided on November 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cervical or vaginal cancer screening provided on April 9, 
2022. 
 
You asked the Plan to pay for the cervical or vaginal cancer screening. You say that you would like this claim 
paid by the Plan. The Plan denied your request. The Plan says you have had a previous screening pelvic exam 
within the last 23 months. 
 
The Plan must follow Medicare rules. The rules say that payment is made for screening pelvic exams only after 
at least 23 months have passed following the month during which the beneficiary received her last covered 
screening pelvic exam. 
 
We looked at the file and Medicare rules. In this case, the documentation confirms you last received a covered 
pelvic exam in 2021. Based on this information, we decided that Medicare rules for coverage of the cervical or 
vaginal cancer screening have not been met. Therefore, we decided that the Plan does not have to pay for the 
cervical or vaginal cancer screening provided on April 9, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 12054 billed for date of service December 
22, 2021. 
  You asked the Plan to pay for procedure code 12054. You say that these codes are appropriately identified as 
separate procedures and the claim should be processed for payment. The Plan denied your request. The Plan 
says payment for code 12054 is bundled into payment for code 29260. 
 
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 12054 
is a column II code to column I code 29260. 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 12054 billed for date of service December 22, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to increase the reimbursement for a stone model (D0470) provided on 
October 6, 2021. 
 
You asked the Plan to increase the reimbursement for a model. You say that your reimbursement should have 
been $399 more than what you received. The Plan denied your request. The Plan says you have been 
reimbursed the correct amount. 
 
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 have a $2,000 
combined allowance for supplemental preventive and comprehensive dental services every year. 
 
You have been reimbursed the allowed amount of $100 for a model. A model falls within the Dental Services 
benefit category. This means that you have been reimbursed 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 increase the reimbursement for a stone model (D0470) provided on 
October 6, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 0349T billed for date of service October 8, 
2021. 
  You asked the Plan to pay for procedure code 0349T. You say that the attached medical notes justify billing 2 
units of 0349T, and additional payment should be made. The Plan denied your request. The Plan says payment 
for code 0349T is bundled into payment for code 77401. 
 
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 0349T 
is a column II code to column I code 77401. 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 0349T billed for date of service October 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120) and periodontal 
maintenance (D4910) provided on January 18, 2022. 
 
You asked the Plan to pay for an evaluation and periodontal maintenance. You say that you disagree with the 
denial of dental services. The Plan denied your request. The Plan says that the enrollee does not have active 
dental coverage. 
 
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 periodic oral evaluation 
(D0120) and periodontal maintenance (D4910) provided on January 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture - flexible base (including 
retentive/clasping materials, rests, and teeth) (D5225) and mandibular partial denture - flexible base (including 
retentive/clasping materials, rests, and teeth) (D5226). 
 
You asked the Plan to pre-approve the dental services. You say that you really need these partial dentures. The 
Plan denied your request. The Plan says your benefit for the requested partial dentures has already been 
exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for partial dentures was exhausted on date of service April 15, 2021. Therefore, we decided 
that the Plan does not have to pre-approve a maxillary partial denture - flexible base (including 
retentive/clasping materials, rests, and teeth) (D5225) and mandibular partial denture - flexible base (including 
retentive/clasping materials, rests, and teeth) (D5226).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for post-operative office visit (D0171) provided by an out-of-
network provider on February 7, 2022. 
 
You asked the Plan to pay for post-operative office visit. You say that you believe that this should be covered. 
The Plan denied your request. The Plan says the rendered dental work is not a covered benefit. 
 
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 post-
operative office visit (D0171) provided by an out-of-network provider on February 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive periodontal evaluation (D0180) provided 
on April 7, 2022. 
 
You asked the Plan to pay for an evaluation. You say that you disagree with the denial of dental services. The 
Plan denied your request. The Plan says a comprehensive periodontal evaluation (D0180) is not covered by 
your routine 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 a 
comprehensive periodontal evaluation (D0180) provided on April 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custom fabricated abutment services (D6057). 
 
You asked the Plan to pre-approve custom fabricated abutment services. You say that this dental service is 
medically necessary. The Plan denied your request. The Plan says this dental service is not covered under the 
Plan's supplemental dental benefit. 
 
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 
custom fabricated abutment services (D6057).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown on tooth T (D2740) and a prefabricated post and 
core in addition to core on tooth T (D2954). 
 
You asked the Plan to pay for the dental services. You say that you still have your primary teeth, and these 
services should be covered as billed. The Plan denied your request. The Plan says the requested items and 
services are not covered for your primary 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. 
 
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 when performed on your primary teeth. Therefore, we decided that the 
Plan does not have to pay for a crown on tooth T (D2740) and a prefabricated post and core in addition to core 
on tooth T (D2954).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for extractions of tooth #13 and 19 (D7210) and periapical x-
rays (D0220, D0230) provided on March 5, 2022. 
 
You asked the Plan to pay for the dental services. You say that this was an emergency, and your regular dentist 
was closed. The Plan denied your request. The Plan says the dental services were received from an out-of-
network provider and are not covered by your supplemental 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 
covered under this benefit when received from an out-of-network provider. Therefore, we decided that the Plan 
does not have to pay for extractions of tooth #13 and 19 (D7210) and periapical x-rays (D0220, D0230) 
provided on March 5, 2022.