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

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration because the services 
are medically necessary. The Plan denied your request. The Plan says an IRF admission is not medically 
necessary, and your needs can be provided safely in other settings. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
   
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on February 10, 2023. 
 
You asked the Plan to pay for the lab services. You say that you are dependent on receiving information from 
the ordering provider. The Plan denied your request. The Plan says information to consider the charges was not 
received. 
 
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. In this case, there are no medical records from the enrollees treating 
physician to show the intent for the services to be provided. There are no records indicating how the results of 
testing will impact clinical management, or that the testing was ordered for a specific medical problem.  Based on this information, we decided that the Medicare rules for coverage have not been met. Therefore, we 
decided that the Plan does not have to pay for the lab services provided on February 10, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is medically stable and ready 
for LTACH care. The Plan denied your request. The Plan says the enrollee does not meet Medicare guidelines 
for care in an LTACH. 
 
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 that the requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only 
on an inpatient basis. 
 
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 the LTACH services.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 80048 and J8499 billed for date of service 
September 8, 2022. 
 
You asked the Plan to pay for procedure codes 80048 and J8499. You say that you were diagnosed with Covid-
19. The Plan denied your request. The Plan says payment for code 80048 is bundled into payment for code 
80053. 
 
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 80048 
is a column II code to column I code 80053 with a modifier indicator of 0. The column II code, 80048, is 
therefore not payable. Based on this information, we decided that the Medicare rules for coverage have not 
been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The records show that code J8499 was billed for drugs Lisinopril and Clonidine 
Hydrochloride. These drugs, which are usually self-administered, are not among the types which are covered 
by Medicare Part B. Based on this information, we decided that the Medicare rules for coverage have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes 80048 and J8499 billed for 
date of service September 8, 2022.  
 
Benefits for procedure code J8499 may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the therapeutic continuous glucose monitor (CGM). You say that the 
enrollee does not like to prick her finger and that she prefers the Dexcom machine like her spouse has used. 
The Plan denied your request. The Plan says the enrollee does not require insulin three or more times daily. 
 
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 indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
the therapeutic continuous glucose monitor (CGM)  have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a therapeutic continuous glucose monitor (CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal scaling and root planning (D4341 x 4) 
provided from September 27, 2022, to October 19, 2022. 
 
You asked the Plan to pay for the dental services. You say that this service should be covered because it was 
medically necessary. The Plan denied your request. The Plan says this service is not a covered benefit under 
your dental 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 pay for the 
periodontal scaling and root planning (D4341 x 4) provided from September 27, 2022, to October 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on September 28, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says your benefit for the requested item or service 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 the requested item or service was exhausted on date of service September 28, 2022. 
Therefore, we decided that the Plan does not have to pay for the dental services on September 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the compression wrap (A6197) purchased 
on September 19, 2022. 
 
You asked the Plan to issue reimbursement for this item. You say that you are requesting a reconsideration of 
the Plan's denial for payment. The Plan denied your request. The Plan says this item is not payable as the 
provider is not enrolled in the Medicare program. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
A review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to issue reimbursement for the compression wrap 
(A6197) purchased on September 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an assisted living visit provided on July 11, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for an assisted living visit. You say that the services were medically necessary. The 
Plan denied your request. The Plan says there is no authorization on file for the services provided. 
 
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 assisted living visit provided on July 11, 2022, 
by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided from August 17, 2022, to 
September 13, 2022. 
 
You asked the Plan to pay for physical therapy services. You say that you were unaware you would be required 
to pay a $750 deductible before there would be a $0 copayment. The Plan denied your request. The Plan says 
this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $750 deductible which applies to each rehabilitation therapy service.  
 
The item or service you asked the Plan to pay for falls within the Outpatient Rehabilitation Services benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 
deductible which applies to each rehabilitation therapy service. This cost sharing is a contractual obligation that 
had not been met at the time physical therapy services was received on August 17, 2022, to September 13, 
2022. Therefore, we decided that the Plan does not have to pay for physical therapy services provided from 
August 17, 2022, to September 13, 2022.  
 
Your complaint about being misinformed regarding the cost share for physical therapy services is not a valid 
appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. 
Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the upper partial denture (D5211) provided on August 15, 
2022. 
 
You asked the Plan to pay for this item. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says this item 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 item provided is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the upper partial 
denture (D5211) provided on August 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the photochromatic tint (V2744), polycarbonate or equal 
lenses (V2784), anti-reflective coating (V2750), and progressive lenses (V2781) provided on August 11, 2022. 
 
You asked the Plan to pay for the photochromatic tint, polycarbonate or equal lenses, anti-reflective coating, 
and progressive lenses. You say that you used your credit cards to pay the $408.99, as you could barely afford 
it. You also say that you were under the impression that the rest would be covered. The Plan denied your 
request. The Plan says these items exceed the maximum benefit per period. The Plan also says that you are 
responsible for this purchase in its entirety. 
 Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers 1 pair of standard lenses and frames every 2 years. 
 
We looked at the file and the Plan's rules. The record shows that you received frames and lenses which were 
covered by the Plan on July 16, 2021, and your eyewear allowance has been exhausted. Based on this 
information, we decided that the Plan's rules for coverage of the photochromatic tint, polycarbonate or equal 
lenses, anti-reflective coating, and progressive lenses have not been met. Therefore, we decided that the Plan 
does not have to pay for the photochromatic tint (V2744), polycarbonate or equal lenses (V2784), anti-
reflective coating (V2750), and progressive lenses (V2781) provided on August 11, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an out-of-network, home health services 
facility from August 1, 2022, to August 15, 2022. 
 
You asked the Plan to waive the coinsurance for home health services. You say that you should not have to pay 
anything for this service, as it should be fully covered. The provider also did not understand this. The Plan 
denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 50% 
coinsurance for home health agency care. The allowed amount of this stay is $1012.08, resulting in a 
coinsurance amount of $506.04.74 ($1012.08 x 50% = $506.04). 
 
You have been asked to pay a $506.04 coinsurance for home health services. This item/service falls within the 
home health agency 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 coinsurance for an out-of-
network, home health services facility from August 1, 2022, to August 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93040 billed for date of service September 
21, 2022. You asked the Plan to pay for procedure code 93040. You say that you needed the testing before surgery. The 
Plan denied your request. The Plan says payment for code 93040 is bundled into payment for code 93000. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code.  
 
In this case, we have confirmed that code 93040 is a column II code to column I code 93000. We find that code 
93040 was not billed with an appropriate modifier to bypass the edit. There are no medical records to show that 
the service billed with the -59 modifier is a distinct procedural service. 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 
93040 billed for date of service September 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation, bitewings x-ray, and a cleaning 
(D0272, D1110, D0120) provided on July 18, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. 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 periodic oral evaluation, bitewings x-ray, and a cleaning (D0272, D1110, D0120) provided on July 
18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), bitewing x-rays- 
four radiographic images (D0274), dental cleaning (D1110), and the dental crowns (D2750 x 2) provided on  
July 29, 2022. 
 
You asked the Plan to pay for these dental items/services. You say that you are requesting a reconsideration of 
the Plan's denial for payment. The Plan denied your request. The Plan says your dental benefit 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 the services provided was exhausted on date of service March 8, 2022.   
Specifically, the Plan contract states that your yearly dental allowance is $1,000. You previously received 
dental services on February 11, 2022 and March 8, 2022 accordingly. The Plan issued payment to the provider 
for these services in the amount of $1,000. Therefore, you have exhausted the allowable dental benefit for this 
calendar year. The Plan contract says that after the annual maximum is exhausted, any remaining charges are 
your responsibility. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation 
(D0120), bitewing x-rays-four radiographic images (D0274), dental cleaning (D1110), and the dental crowns 
(D2750 x 2) provided on July 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation, crown, and core buildup services 
(D2950, D0140, D2740) provided on September 27, 2022. 
 
You asked the Plan to pay for the dental services. 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 do not fall 
within your 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 limited 
oral evaluation, crown, and core buildup services (D2950, D0140, D2740) provided on September 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on October 13, 
2022. 
 
You asked the Plan to pay for the dental services. 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 do not fall 
within your 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 limited 
oral evaluation (D0140) provided on October 13, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from May 
15, 2022, to May 17, 2022. 
 
You asked the Plan to waive the copayment for the inpatient care. You say that you cannot afford the 
copayment, and you did not receive a bill until recently. The Plan denied your request. The Plan says this cost 
sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a $325 
copayment per day for days 1-5 for inpatient hospital care.  
 
 
  The file shows that you were in the hospital from May 15, 2022, to May 17, 2022. Since there is no copayment 
for the discharge date, you have been asked to pay a $325 copayment per day for days 1-2 for the inpatient 
care, for a total of $650. This item/service falls within the inpatient hospital 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 inpatient hospital care provided from May 15, 2022, to May 17, 
2022.