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

 
We decided that the Plan does not have to pay for the arthroscopy services coded 29826-RT provided on March 
16, 2021. 
 
You asked the Plan to pay for the arthroscopy services. You say that you would like this code reprocessed and 
approved for payment based on the medical records. The Plan denied your request. The Plan says the operative 
report did not document the services 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 29826 is arthroscopy, shoulder, surgical; decompression 
of subacromial space with partial acromioplasty, with coracoacromial ligament (ie, arch) release, when 
performed (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 arthroscopy services. Our reviewer says that the 
documentation does not support payment for the billed CPT code 29826-RT. Our reviewer found the operative 
report does not describe all criteria per the CPT code description. In this case, the operative report documents: 
"Arthroscope was introduced in the subacromial space. A subacromial decompression was performed. The 
rotator cuff footprint was then debrided down to the bleeding bone...Once we were satisfied with our rotator 
cuff repair, the wounds were then copiously irrigated. The portal sites closed with 3-0 nylon." In this case, 
operative report does not support partial acromioplasty with coracoacromial ligament release. Therefore, this 
procedure code cannot be verified. 
 
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 arthroscopy services have not been met. Therefore, we decided that the Plan 
does not have to pay for the arthroscopy services coded 29826-RT provided on March 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the vertical shock reducing pylon feature (L5988) and 
vacuum pump (L5781). 
 
You asked the Plan to pre-approve the requested prosthetic equipment. You say that this equipment is 
medically necessary for the enrollee. The Plan denied your request. The Plan says the criteria for coverage have 
not been satisfied for the requested prosthetic additions. 
 
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 pre-approve the requested prosthetic equipment. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the device coded L5988 is a vertical shock reducing pylon. In this case, the 
documentation does not reveal that you are currently participating in high impact activities or had extenuating factors such as large bony limb prominences on a physical exam of the residual limb that requires this pylon. 
Therefore, the requested vertical shock reducing pylon exceeds your functional and medical needs. 
 
In addition, the requested vacuum pump has not been proven superior to a standard socket. The current 
literature reviewed indicates that further research is needed with clinical trials that recruit larger sample sizes 
and report long-term outcome data for the requested vacuum suspension system. At this time, the requested 
vacuum pump exceeds your medical needs. 
 
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 requested prosthetic equipment have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the vertical shock reducing pylon feature (L5988) and vacuum pump 
(L5781).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing services provided on January 8, 2022, and 
January 9, 2022. 
 
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required 
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee 
had made maximal gains and their highest practical level was achieved. The Plan also says that therapy was 
discontinued, and the enrollee was receiving custodial care as of January 8, 2022, and January 9, 2022. 
 
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 pay for the skilled nursing services. Our reviewer 
says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the 
enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment 
of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the 
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did 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 the skilled nursing services have not been met. Therefore, we decided that the 
Plan does not have to pay for the skilled nursing services provided on January 8, 2022, and January 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 67028 billed for date of service February 10, 2022. 
 
You asked the Plan to pay for procedure code 67028. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment for code 67028 is bundled into 
payment for code 65800. 
 
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 67028 
is a column II code to column I code 65800. 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 67028 billed for date of service February 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for first-hour critical care (99291) billed for date of service May 
14, 2021. 
 
You asked the Plan to pay for first-hour critical care. You say that the service at issue was a medical necessity 
for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met because the 
available medical records do not support the service 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 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 available medical 
records do not document the time spent in providing critical care on the date of service at issue. Based on this 
information, we decided that Medicare rules for coverage of first-hour critical care have not been met. 
Therefore, we decided that the Plan does not have to pay for first-hour critical care (99291) billed for date of 
service May 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the advanced payment on dentures received in 2022. 
 
You asked the Plan to reimburse you for the advanced payment. You say that you should be reimbursed for the 
$350 you paid for your dentures. The Plan denied your request. The Plan says your annual allowance for dental 
services has been exhausted. 
 
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 $1,000 combined allowance for supplemental preventive and comprehensive dental services every year. The contract 
says the enrollee is responsible for any amount over and above the allowance amount. 
 
The record shows your $350 payment was applied to the dentures you received in 2022. The record also shows 
your annual allowance for dental services has been exhausted.  Dentures fall within the Dental 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 reimburse you for the advanced payment on dentures received in 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair accessory, electronic connection 
between wheelchair controller and one power seating system motor, including all related electronics, indicator 
feature, mechanical function selection switch, and fixed mounting hardware (E2310). 
 
You asked the Plan to pre-approve a power wheelchair accessory. You say that the enrollee needs the requested 
items due to immobility and significant risk for skin breakdown and injury. The Plan denied your request. The 
Plan says the electrical connection between the wheelchair controller and one motor (E2310) cannot be 
covered. The Plan also says while one power feature is requested on this wheelchair (power tilt), there is not a 
medical need to control this power option through the joystick. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a power wheelchair accessory, electronic connection 
between wheelchair controller and one power seating system motor, including all related electronics, indicator 
feature, mechanical function selection switch, and fixed mounting hardware (E2310).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99053 billed for date of service September 
15, 2021.  You asked the Plan to pay for procedure code 99053. You say that the correct codes were billed, and no coding 
changes were required. You say that the attached information should be reviewed and reconsidered for 
payment. The Plan denied your request. The Plan says procedure code 99285 has been overturned. The Plan 
also says procedure code 99053 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 99053 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99053 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99053 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99053 billed for date of service September 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical removal of erupted tooth provided on  
March 1, 2022. 
 
You asked the Plan to pay for surgical removal of erupted tooth (D7210). You say that when you made the 
dental appointment, you were told the extractions would be covered. The Plan denied your request. The Plan 
says the Plan does not cover extractions. 
 
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 surgical 
removal of erupted tooth (D7210) provided on March 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation  problem focused (code D0140) 
provided on March 30, 2022. 
 
You asked the Plan to pay for a limited oral evaluation  problem focused. The Plan denied your request. The 
Plan says the limited oral evaluation is not listed among the covered dental codes. 
 
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  problem focused (code D0140) provided on March 30, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the application of desensitizing medicament (code D9910) provided on 
August 24, 2021. 
 
You asked the Plan to pay for the medicament. You say that the plan paid for the crowns the medicine was 
used for. The Plan denied your request. The Plan says that there is no coverage for this service unless it is billed 
with a covered procedure. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not provided medical records or documentation 
showing what procedure the medicament was used for. This means that we cannot determine if the medicament 
was indeed used with a covered procedure. It is the burden of the Health Plan to substantiate their decision with 
evidence. In this case, the decision has not been substantiated so we must find in your favor.  Therefore, we 
decided that the Plan has to pay for the application of desensitizing medicament (code D9910) provided on 
August 24, 2021.  
 
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: Partially Favorable

 
We decided that the Plan has to pay the 50% coinsurance for the root canal. We decided that the Plan does not 
have to pay any additional amount beyond the 50% coinsurance for the root canal.  
 You asked the Plan to pay any additional amount beyond the 50% coinsurance the dental service. You say that 
the claim should have been sent to your other plan first because they pay more. You also say that you cannot 
afford to pay the full cost of this service. The Plan denied your request. The Plan says out of network providers 
may bill you for any amount greater than what the plan pays the provider. 
 
We decided that the Plan has to pay the 50% coinsurance for the root canal.  
 
The Plan must follow Medicare rules. Medicare rules say that for services paid on a fee schedule, Medicare 
secondary payment amounts are determined by a formula. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the dental service have not been met. Specifically, the file shows that the lowest formula is the 
Medicare allowed amount, or $477, times the 50% coinsurance. $477 x 50% = $238.50. This is a contractual 
obligation you agreed to when you enrolled in the Plans dental coverage. Therefore, we decided that the Plan 
has to pay the 50% coinsurance for the root canal.  
 
We also decided that the Plan does not have to pay any additional amount beyond the 50% coinsurance 
for the root canal. 
 
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 root canal is listed as a covered 
service, there is a 50% coinsurance that applies. This is a contractual obligation you agreed to when you 
enrolled in the Plans dental coverage.  Therefore, we decided that the Plan does not have to pay any additional 
amount beyond the 50% coinsurance for the root canal. 
 
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 pay for diabetic supplies (K0553) provided January 26, 2022.
You asked the Plan to pay for the diabetic supplies. You say that the items were medically necessary. The Plan denied your request. The Plan says this brand is not covered.
The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred brands and manufacturers. We looked at the file and Medicare rules. The brand provided is not covered by the plan. There is no record of a medical exemption. Based on this information, we decided that Medicare rules for coverage of the diabetic supplies have not been met. Therefore, we decided that the Plan does not have to pay for diabetic supplies (K0553) provided January 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral-periapical each additional film (D0230) provided 
on March 21, 2022. 
 
You asked the Plan to pay for intraoral-periapical each additional film. The Plan denied your request. The Plan 
says periapical x-rays are covered 1 procedure code per calendar year. The member already received the 
allowed frequency of D0220 Intraoral - Periapical First Radiographic Image on the appealed claim. The 
member received an additional 1 D0230 Intraoral - Periapical Each Additional Radiographic Image at the same 
visit. 
 
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. The benefit covers 1 procedure code per calendar year. Therefore, we 
decided that the Plan does not have to pay for intraoral-periapical each additional film (D0230) provided on 
March 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a periodic oral evaluation (code D0120) and 
prophylaxis-adult (code D1110) provided on January 12, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you were never informed the provider was 
no longer 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 a periodic oral evaluation (code D0120) and 
prophylaxis-adult (code D1110) provided on January 12, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for a periodic oral evaluation (D0120) and prophylaxis (D1110) provided 
on November 18, 2021. 
 
You asked the Plan to pay for an evaluation and prophylaxis. You say that you were never advised that you 
would need to submit an explanation of benefits from your primary dental carrier. The Plan denied your 
request. The Plan says that there is another carrier listed as primary and the Plan requires an explanation of 
benefits to process the claim. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is responsible for paying for services 
after the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has not met its obligation with regards to coordination of benefits. Specifically, the Plan has not sent 
the bill directly to the primary insurer for payment, directed the provider to send the bill directly to the primary 
insurer or paid for the services and then submitted a bill for reimbursement to the primary insurer. As the 
secondary insurer, the Plan can be held responsible for an evaluation and prophylaxis. Therefore, we decided 
that the Plan has to pay for a periodic oral evaluation (D0120) and prophylaxis (D1110) provided on November 
18, 2021.  
 
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.