Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on December 
15, 2021 by a Medicare opt out provider. 
 
You asked the Plan to pay for the periodontal maintenance. You say that the treating provider was advised to 
opt out of Medicare because they had absolutely no interaction with Medicare at all since the practice started in 
2007. You also say that had the provider been informed it would affect dental reimbursements for patients 
down the road, they would have reconsidered their choice to opt out. The Plan denied your request. The Plan 
says this service was rendered by a provider who chose not to receive Medicare funds.  
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 when they are rendered by a provider who has opted out of Medicare. Therefore, we decided that the 
Plan does not have to pay for the periodontal maintenance (D4910) provided on December 15, 2021 by a 
Medicare opt out provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve four surgical placements of implant bodies: endosteal 
implants (D6010 x4) and four abutment supported porcelain/ceramic crowns (D6058 x4). 
 
You asked the Plan to pre-approve the endosteal implants and abutment supported porcelain/ceramic crowns. 
You say that you need these services but cannot pay for them. The Plan denied your request. The Plan says 
these services are not covered under your benefit plan. 
 
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 four 
surgical placements of implant bodies: endosteal implants (D6010 x4) and four abutment supported 
porcelain/ceramic crowns (D6058 x4).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 15 abutment supported cast metal crowns (D6063 x15) 
and 15 implant supported porcelain/ceramic crowns (D6065 x15). 
 
You asked the Plan to pre-approve the abutment supported cast metal crowns and implant supported 
porcelain/ceramic crowns. You say that you need support for the implants and cannot hold them. You also say 
that you suffer with a lot of pain with the implants, and you would like metal support. The Plan denied your 
request. The Plan says these services are not covered under your benefit plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 15 
abutment supported cast metal crowns (D6063 x15) and 15 implant supported porcelain/ceramic crowns 
(D6065 x15).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided by a 
participating provider on September 8, 2021. 
 
You asked the Plan to pay for a comprehensive oral evaluation. You say that you needed this evaluation done. 
The Plan denied your request. The Plan says the benefit limit of D0150 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 Plan's coverage rules apply in this case. The Plan covers one 
comprehensive oral evaluation every three years. 
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of a comprehensive oral evaluation have already been met. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided by a participating provider on September 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pre-diagnostic test (D0431), scaling in presence of gingival 
inflammation (D4346), gingival irrigation (D4821), and dental drugs (D9630) provided by a participating 
provider on April 23, 2021, to May 25, 2021. 
 
You asked the Plan to pay for a pre-diagnostic test, scaling in presence of gingival inflammation, gingival 
irrigation, and dental drugs. You say that you would like the Plan to pay for this. The Plan denied your request. 
The Plan says the rendered dental services that were provided 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 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 a pre-diagnostic test (D0431), scaling in presence of gingival inflammation (D4346), gingival irrigation (D4821), and dental drugs (D9630) provided by an out-of-network provider on April 23, 2021, to May 25, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on July 26, 2021. 
 
You asked the Plan to pay for the laboratory 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 must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the laboratory services provided on July 26, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to be improving but is still somewhat unstable (TPN) and 
requires short-term additional acute care services that can safely be administered at the current facility until 
more stable and appropriate for a lower level of care. There are no services at the LTACH that the enrollee 
requires that are not already available and covered at the current facility. Transfer may be considered when 
treatment has completed and the enrollee is more stable. 
 
 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the acute inpatient hospital care from April 17, 2022, 
through April 22, 2022. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the stay was necessary. The Plan 
denied your request. The Plan says your request is not medically necessary because your records show you do 
not have abnormal blood pressure or heartbeats that do not get better with treatment (hemodynamic instability). 
 
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 pre-approve 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 you were not expected to require hospital services that were likely to cross 
two (2) midnights as you were stable, and a lower level of care would have been more appropriate for physical 
therapy (PT) and continued treatment. The Plan stated in their documentation that you (the enrollee) are not to 
be held liable for inpatient services. 
 
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 pre-approve the acute inpatient hospital care from April 17, 2022, through April 22, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a skilled nursing facility (SNF) stay 
provided from July 1, 2021, to July 4, 2021. 
 
You asked the Plan to waive the copayment for a SNF stay. You say that you did not receive the notice of 
Medicare non-coverage till July 2, 2021. You also say that you could not get a bed delivered since it was a 
holiday weekend. 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 $0 
copayment per day for days 1-20 for an in-network skilled nursing facility stay. The contract also says there is 
a $187 copayment per day for days 21-47. The contract also says there is a $0 copayment for additional days 
after day 47, up to 100 days. The Plan contract also says that enrollees must pay a $4,900 maximum out-of-
pocket (MOOP) per calendar year. 
 
You are not being charged for the first 20 days you were in the SNF, from May 17, 2021, to June 9, 2021. The 
record shows you met your MOOP during the processing of this claim. You have been asked to pay the total 
amount of $360.27, which is less than the $187 copayment per day, for days 21-47, from July 1, 2021, to July 
4, 2021. A skilled nursing facility stay falls within the Skilled Nursing Facility (SNF) Care benefit category. 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for a skilled nursing facility (SNF) stay provided from July 1, 
2021, to July 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital discharge day management (99239) provided on 
September 4, 2021. 
 
You asked the Plan to pay for the hospital discharge day management (99239). You say that the services 
provided to the patient were reasonable and necessary for the treatment of this condition and CPT code 99239 
accurately reflects the treatment provided. The Plan denied your request. The Plan says the initial hospital care 
(99223) was overturned. The Plan also says that hospital discharge day management (99239) remains denied as 
the documents don't support the level of care. 
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 99239 is hospital discharge day management; more than 
30 minutes. 
 
We find that CPT code 99239 is not supported in the medical record. Specifically, the records do not support 
discharge management services of more than 30 minutes as required. Based on this information, we decided 
that Medicare rules for coverage of the hospital discharge day management (99239) have not been met. 
Therefore, we decided that the Plan does not have to pay for the hospital discharge day management (99239) 
provided on September 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a powered pressure-reducing air mattress (E0277). 
 
You asked the Plan to pre-approve a powered pressure-reducing air mattress. You say that you have difficulty 
with moving around frequently, so you can easily get bed sores. You also say that you have sciatica nerve pain. 
The Plan denied your request. The Plan says the special mattress is covered only when you already have ulcers 
on the skin or have a skin flap. 
 The Plan must follow Medicare rules. The rules say that a group 2 support surface is covered if the beneficiary 
meets at least one of the three criteria.   
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a powered pressure-reducing air mattress have not been met. Specifically, the records show that 
there is no evidence that you have multiple stage 2 pressure ulcers, large or multiple stage 3 or 4 pressure ulcers 
or a myocutaneous flap or skin graft for a pressure ulcer on the trunk or pelvis within the last 60 days. 
Therefore, we decided that the Plan does not have to pre-approve a powered pressure-reducing air mattress 
(E0277).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
January 1, 2021, to January 4, 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 provider has reported inpatient hospital services with the incorrect DRG. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 291 (HEART FAILURE AND SHOCK 
WITH MCC). 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 services at issue in this case were not supported by the medical records. Our physician reviewer 
found DRG 191: CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC is more appropriate. 
J96.00 and I50.33 were not appropriate diagnoses for this claim.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided to the enrollee from January 1, 2021, to January 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay the in network rate for the bitewings - three radiographic images 
(D0273) provided on October 14, 2021. 
 
You asked the Plan to pay the in network rate for the bitewing x-rays. You say that the list of in network 
providers you obtained from the plan included the practice location. You also say that the provider's office 
confirmed the provider is in network with your plan. The Plan denied your request. The Plan says bitewing x-
ray is not listed and therefore is not a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the bitewing x-ray is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay the in network rate for the 
bitewings - three radiographic images (D0273) provided on October 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for neuromuscular reeducation of movement, balance, 
coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities, 
Transcutaneous Electrical Nerve Stimulation (TENS), vasopneumatic device, Prolotherapy and vitamin 
injections provided on June 22, 2021. 
 
You asked the Plan to pay for neuromuscular reeducation of movement, balance, coordination, kinesthetic 
sense, posture, and/or proprioception for sitting and/or standing activities, Transcutaneous Electrical Nerve 
Stimulation (TENS), vasopneumatic device, Prolotherapy and vitamin injections. The Plan denied your request. 
The Plan says multivitamin injections (compounded Nutria), prolotherapy/acupuncture\, into the nerve and 
musculoskeletal structures are not a Medicare covered benefit. Its billing under the trigger point injection code 
is a misrepresentation of the actual service rendered. The Transcutaneous Electrical Nerve Stimulation (TENS) 
device, including supplies, for neuromuscular reconditioning is not a Medicare covered benefit. Pneumatic / 
vasopneumatic devices can be covered only for the treatment of chronic venous insufficiency with venous 
stasis ulcers, and refractory lymphedema. 
 
The Plan must follow Medicare rules. Medicare rules say that documentation must clearly support the medical 
necessity of unattended electrical stimulation used for control of pain and swelling, with objective and/or 
subjective changes noted in swelling and/or pain within 12 visits. The rules says that the use of vasopneumatic 
devices may be considered reasonable and necessary for the application of pressure to an extremity for the 
purpose of reducing edema or lymphedema. The rules say that beginning in July 2015, claims for compounded 
drugs shall be submitted using a compounded drug, not otherwise classified (NOC) code. Medicare rules say 
claims for Prolotherapy must not be reported with the trigger point codes or other injection codes.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or 
proprioception for sitting and/or standing activities, Transcutaneous Electrical Nerve Stimulation (TENS), 
vasopneumatic device, Prolotherapy and vitamin injections have not been met. Therefore, we decided that the 
Plan does not have to pay for neuromuscular reeducation of movement, balance, coordination, kinesthetic 
sense, posture, and/or proprioception for sitting and/or standing activities, Transcutaneous Electrical Nerve 
Stimulation (TENS), vasopneumatic device, Prolotherapy and vitamin injections provided on June 22, 2021.
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 August 12, 2021. 
 
You asked the Plan to pay for the mass spectrometry and tandem mass spectrometry. You say that you would 
like this claim reprocessed based on the modifier billed. The Plan denied your request. The Plan says the use of 
the modifier to specify separate payment is 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 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 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 mass spectrometry and tandem mass spectrometry. Our 
reviewer says that the requested services have not been billed correctly. Our reviewer found per Medicare 
regulations, validity testing is not separately reported from drug testing services. 
 
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 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 August 12, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the acute inpatient hospital care for the left reverse total 
shoulder arthroplasty (CPT code 23472). 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the service is medically 
necessary. The Plan denied your request. The Plan says the planned procedure listed under CPT codes 23472 is 
NOT listed on the CMS Inpatient Only List. The Plan states the procedure is currently approved as an 
ambulatory procedure and there is no documentation provided to support the expectation the enrollee will 
require a greater than two (2) midnight stay. 
 
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 pre-approve 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 the provided documentation does not reveal any unstable condition or other 
high-risk factors that would suggest a need for extraordinary care related to this surgery. It was not suggested in 
the records that you would require hospital services that would likely cross two (2) midnights for this typically 
ambulatory procedure. 
 
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 pre-approve the acute inpatient hospital care for the left reverse total shoulder 
arthroplasty (CPT code 23472).