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

 
We decided that the Plan does not have to pay for the skilled nursing facility services provided from November 
17, 2021, to November 30, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the 
documentation does not support respiratory treatment for at least 15 minutes per day for 7 days. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
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 for the services provided. Our coder found that the enrollee has 
diagnoses that include chronic respiratory failure with hypoxia, essential (primary) hypertension, heart failure, 
unspecified, and edema, unspecified. It is noted that the head of the bed was elevated due to shortness of breath 
while lying flat on the dates in question. There is documentation of respiratory evaluation by nurse with 
respiratory rate, quality and sound documented. The case file does not contain documentation of minutes spent 
by a respiratory therapist or respiratory nurse that involved resident evaluation/assessment, treatment 
administration and monitoring, and setup and removal of treatment equipment for the dates in question.  
 
We looked at the coders review, the file, and the rules. 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 skilled nursing facility services provided from November 17, 2021, to November 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an out-of-network provider. on 
April 6, 2022. 
 
You asked the Plan to pay for the dental services. You say that you verified this provider was in-network. 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. 
 
The record shows you received the requested dental services from an out-of-network provider. 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. This provider became out-of-network on January 
31, 2022. Therefore, we decided that the Plan does not have to pay for dental services provided by an out-of-
network provider on April 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the radiation therapy services provided from 
November 17, 2021, to November 24, 2021. 
 
You asked the Plan to waive the cost share for the radiation therapy services. You say that it is not clear to you 
why you should be paying anything let alone such a large amount. The Plan denied your request. The Plan says 
you have been charged the correct cost sharing 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 must pay a 20% 
coinsurance for radiation therapy.  
 
You have been asked to pay a 20% coinsurance for the radiation therapy services for a total of $570.39. The 
radiation therapy services fall within the Outpatient Diagnostic Tests and Therapeutic Services 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. Therefore, we decided that the Plan does not have to waive the cost share for the radiation therapy services 
provided from November 17, 2021, to November 24, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vertebral corpectomy (63081) provided on January 3, 
2022. 
 
You asked the Plan to pay for the vertebral corpectomy (63081). You say that a more extensive corpectomy 
was performed and the claim should be reviewed for reprocessing. The Plan denied your request. The Plan says 
procedure code 63081 is not supported by the medical records submitted. 
 
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 63081 is vertebral corpectomy (vertebral body resection), 
partial or complete, anterior approach with decompression of spinal cord and/or nerve root(s); cervical, single 
segment. 
  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 vertebral corpectomy (63081). Our reviewer says that the 
documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer found that 
the operative report does not include enough information to confirm a partial or complete corpectomy was 
performed. Therefore, this procedure 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 vertebral corpectomy (63081) have not been met. Therefore, we decided that 
the Plan does not have to pay for the vertebral corpectomy (63081) provided on January 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete maxillary denture (D5110), the unspecified 
removable prosthodontic procedure (D5899 x2), and the complete mandibular complete denture (D5120) 
provided by an out-of-network provider on February 10, 2022. 
 
You asked the Plan to pay for the complete maxillary denture (D5110), the unspecified removable 
prosthodontic procedure (D5899 x2), and the complete mandibular denture (D5120). You say that you were 
advised that the provider was in-network, and you would only be responsible for $1,300. The Plan denied your 
request. The Plan says the unspecified removeable prosthodontic procedure (D5899 x 2) is not a covered 
benefit and you have been charged the correct coinsurance amounts for the dentures (D5110, D5120). 
 
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 unspecified removable prosthodontic procedure (D5899 x 2) 
is not among those covered under this benefit.  
 
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 75% 
coinsurance for the complete maxillary and mandibular dentures when received by an out-of-network provider. 
The Plan also clearly says you may be billed by the out-of-network provider for any amount greater than the 
payment made by the Plan to the provider. 
 
You have been asked to pay a total of $1,237.50 for the dentures. See chart below. 
 
Date of 
Service 
Service Provider 
Charges 
(PC) 
Allowed 
Amount 
(AA) 
Difference 
Between PC 
and AA 
Coinsurance Coinsurance 
Amount 
(CA) 
Total 
February 
10, 2022 
D5110 $1,339 $825 $514 75% $618.75 $1,132.75 
($514 + 
$618.75) 
February 
10, 2022 
D5120 $1,339 $825 $514 75% $618.75 $1,132.75 
($514 + 
$618.75) 
February 
10, 2022 
D5899 $650     $650 
February 
10, 2022 
D5899 $650     $650 
Total       $3,565.50 
 
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 pay for the complete maxillary denture (D5110), the unspecified removable 
prosthodontic procedure (D5899 x2), and the complete mandibular complete denture (D5120) provided by an 
out-of-network provider on February 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for limited oral evaluation (D0140), intraoral - 
periapical first radiographic image (D0220), pulp vitality test (D0460), and root canal (D3310) provided from 
November 22, 2021, to November 29, 2021. 
 
You asked the Plan to reimburse you for the dental services. You say that you did not go to the emergency 
room because your sister made you an appointment with her dentist and he was kind enough to see you the next 
morning. 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. 
 The record shows you received the requested dental services from an out-of-network provider. 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 reimburse you for limited oral evaluation (D0140), intraoral - periapical first radiographic image (D0220), 
pulp vitality test (D0460), and root canal (D3310) provided from November 22, 2021, to November 29, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the assistant at surgery services provided on November 23, 
2021. 
 
You asked the Plan to pay for the assistant at surgery services. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as 
billed. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of 
practitioners. Therefore, we decided that the Plan does not have to pay for the assistant at surgery services 
provided on November 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cooling vest. 
 
You asked the Plan to pre-approve a cooling vest. You say that the item is necessary. The Plan denied your 
request. The Plan says the requested item is not primarily medical in nature. 
 
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 cooling vest.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on July 15, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the services should be covered as you disagree with 
the denial. The Plan denied your request. The Plan says the services denied correctly as they were non-
emergent and prior authorization was not obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 
  The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on July 15, 2021 by an 
out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on September 27, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that these services were medically necessary. 
The Plan denied your request. The Plan says these services are not covered because they were provided OON 
without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the laboratory services provided on September 27, 
2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete denture - mandibular (D5120) and complete 
denture - maxillary (D5110) provided on April 11, 2022. 
 
You asked the Plan to pay for the complete denture - mandibular (D5120) and complete denture - maxillary 
(D5110). You say that you were under the impression that the annual maximum would take care of the portion 
of the charges. The Plan denied your request. The Plan says these services are not covered by the Plan's dental 
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 pay for complete 
denture - mandibular (D5120) and complete denture - maxillary (D5110) provided on April 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for panoramic x-ray (D0330) provided on April 26, 2022. 
 
You asked the Plan to pay for panoramic x-ray (D0330). You say that you have not had a panoramic x-ray in 
many years. The Plan denied your request. The Plan says the service is covered but limitations apply. 
 
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. Panoramic x-ray, once every 
36 months. 
 
We looked at the file, the Plans rules, and Medicares rules. You previously received covered panoramic x-ray 
on July 15, 2021, and April 26, 2022.  Therefore, we decided that the Plan does not have to pay for panoramic 
x-ray (D0330) provided on April 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on February 22, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for home health services. You say that the patient is homebound because of the 
patients medical condition and health. The member was unable to be moved and be treated by a network 
provider. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for home health services provided on February 22, 
2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for application of caries arresting medicament (D1354) provided 
on May 16, 2022. 
 
You asked the Plan to pay for application of caries. The Plan denied your request. The Plan says this service is 
not covered under your 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 pay for 
application of caries arresting medicament (D1354) provided on May 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the expandable controller (E2377) harness (E2313) and 
electronic connection between wheelchair controller and two or more power seating system motors (E2311). 
 
You asked the Plan to pre-approve the upgraded electronics. You say that the enrollee is in need of a group 3 
power wheelchair in order to live a more independent life. The Plan denied your request. The Plan says the 
upgraded electronics are not medically necessary for the enrollee to safely operate the approved wheelchair. 
 
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 upgraded electronics. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found in this case the enrollee has a neurologic disorder with functional deficits. The 
criteria for a power wheelchair are met. The requested electrical accessories are not medically necessary as the 
enrollee does have use of the upper extremity and can operate and control the power options using the switches 
that are included in the basic wheelchair. 
 
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 upgraded electronics have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the expandable controller (E2377) harness (E2313) and electronic connection 
between wheelchair controller and two or more power seating system motors (E2311).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve deep sedation/general anesthesiafirst 15 minutes 
(D9222) and deep sedation/general anesthesiaeach subsequent 15 minute increment (D9223). 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says these services are not covered under your 
contractual policy. 
 
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 services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve deep 
sedation/general anesthesiafirst 15 minutes (D9222) and deep sedation/general anesthesiaeach subsequent 15 
minute increment (D9223).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided by an out-of-
network provider on April 6, 2022. 
 
You asked the Plan to pay for the dental services. You say that these services are medically necessary. 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. 
 
The record shows you received the requested dental services from an out-of-network provider. 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 a limited oral evaluation (D0140) provided by an out-of-network provider on April 6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mass spectrometry and tandem mass spectrometry coded 
83789 provided on October 25, 2021. 
 
You asked the Plan to pay for the mass spectrometry and tandem mass spectrometry. You say that you disagree 
with the Plan's denial. The Plan denied your request. The Plan says the services billed are not supported by the 
documentation. 
 
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 83789 is mass spectrometry and tandem mass 
spectrometry (eg, MS, MS/MS, MALDI, MS-TOF, QTOF), non-drug analyte(s) not elsewhere specified, 
qualitative or quantitative, each specimen. 
 
We find that CPT code 83789 is not supported in the medical record. Specifically, this code is not separately 
reimbursed when billed for specimen validity testing on urine specimens utilized for drug testing. Furthermore, 
this code represents a not elsewhere specified code. However, a complete description of the not elsewhere 
specified code was not included. Based on this information, we decided that Medicare rules for coverage of the 
mass spectrometry and tandem mass spectrometry have not been met. Therefore, we decided that the Plan does 
not have to pay for the mass spectrometry and tandem mass spectrometry coded 83789 provided on October 
25, 2021.