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

 
We decided that the Plan does not have to pre-approve D6245 (pontic) for teeth #9 and 11 and D6740 
(abutment crown) for teeth #10 and 12. 
 
You asked the Plan to pre-approve the dental services. You say that this should be covered. The Plan denied 
your request. The Plan says you have already been approved for this service for teeth 6-8 so anything more 
than this would not be covered. 
 
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 will be exhausted once tooth 6-8 is complete. Therefore, 
we decided that the Plan does not have to pre-approve D6245 (pontic) for teeth #9 and 11 and D6740 
(abutment crown) for teeth #10 and 12.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on February 10, 2022. 
 
You asked the Plan to pay for lab testing. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for lab testing provided on 
February 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic care provided on December 21, 2022. 
 
You asked the Plan to pay for chiropractic care. You say that you are requesting reconsideration. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for chiropractic care 
provided on December 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and related 
supplies. 
 
You asked the Plan to pre-approve the CGM and related supplies. You say that it is medically necessary for 
constant monitoring with the CGM. The Plan denied your request. The Plan says the Medicare criteria was not 
met. 
 
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 you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of the CGM and 
related supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
continuous glucose monitor (CGM) and related supplies.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9500 billed for date of service October 26, 
2022, to November 1, 2022. 
 
You asked the Plan to pay for procedure code S9500. You say that the code was denied in error. The Plan 
denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
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 S9500 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9500 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for procedure 
code S9500 billed for date of service October 26, 2022, to November 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot inserts (L3000). 
 
You asked the Plan to pre-approve the foot inserts. You say that the cost of the inserts is too expensive and you 
cannot afford it. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot inserts (L3000).
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 need rehab to learn how to properly walk on 
your own and perform daily activities. The Plan denied your request. The Plan says an IRF admission is not 
medically necessary, and your needs can be met at a lower level of care. 
 
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 you do not need physician supervision 3 times a week or intensive therapy 3 
hours a day and 5 days per week with a multidisciplinary approach in an IRF. While you may benefit from 
physical and occupational therapy your needs can be provided in an alternate setting such as skilled nursing 
facility. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Kate Farms Standard 1.0 vanilla plant-based formula. 
 
You asked the Plan to pre-approve Kate Farms Standard 1.0 vanilla plant-based formula. You say that you feel 
the formula should be covered because purchasing it is causing financial hardship. The Plan denied your 
request. The Plan says orally administered enteral nutrition products are not covered under your Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. 
 
The items you asked the Plan to pre-approve are considered nutritional supplements. Although these may be 
appropriate, neither Medicare nor the Plan provides coverage for them. Therefore, we decided that the Plan 
does not have to pre-approve Kate Farms Standard 1.0 vanilla plant-based formula.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 27275 billed for date of service October 14, 
2022. 
 
You asked the Plan to pay for the billed services. You say that the documentation supports payment. The Plan 
denied your request. The Plan says the code is not separately reportable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 27275 is not supported. Code 27275 is not separately reportable. Based on this 
information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 27275 billed for date of service October 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6530. 
 
You asked the Plan to pre-approve the compression stockings. You say that the services should not be rejected. 
You also say that you would like the services to be paid and covered as you feel this is a medically necessary. 
The Plan denied your request. The Plan says you do not have a qualifying wound for coverage of compression 
stockings. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
  
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6530.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bitewings x-rays-four radiographic images (D0274) and 
the intraoral-periapical additional radiographic image (D0230) provided on November 16, 2022. 
 
You asked the Plan to pay for the dental 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 benefit for the services provided 
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 November 16, 2022. 
Specifically, the Plan contract states that two dental x-rays are covered per year. You previously received an 
intraoral-periapical first radiographic image on November 14, 2022 that was paid for by the Plan. Additionally, 
you received an intraoral-periapical radiographic image on November 16, 2022 that has been approved for 
payment by the Plan. Therefore, you have exhausted the allowable benefit for these services. Therefore, we 
decided that the Plan does not have to pay for the bitewings x-rays-four radiographic images (D0274) and the 
intraoral-periapical additional radiographic image (D0230) provided on November 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist visit provided on November 
14, 2022. 
 
You asked the Plan to waive the copayment for the specialist visit. You say that you think that the cost sharing 
for this service should be lower. 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 $15 
copayment for in and out-of-network services obtained from a specialist, or under certain circumstances, 
treatment by a nurse practitioner or physicians assistant or other non-physician health care professionals in a 
specialists office. 
 
 You have been asked to pay a $15 copayment for the specialist visit. This item/service falls within the 
physician/practitioner services, including doctors office visits benefit category. This means that you have been 
asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to 
waive the copayment for the specialist visit provided on November 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gingivectomy or gingivoplasty to allow access for 
restorative procedure, per tooth (D4212) and unspecified oral surgery (D7999) for tooth #2. 
 
You asked the Plan to pre-approve the dental services. You say that you are requesting reconsideration for the 
denial of the dental services. The Plan denied your request. The Plan says these are non-covered codes per your 
Evidence of Coverage. 
 
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 
gingivectomy or gingivoplasty to allow access for restorative procedure, per tooth (D4212) and unspecified 
oral surgery (D7999) for tooth #2.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on October 1, 2021, to 
October 13, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
claim was billed correctly and should be paid. The Plan denied your request. The Plan says documentation does 
not support the billed code. 
 
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 principal diagnosis A41.9, described as sepsis, 
unspecified organism. 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 inpatient hospital 
services at the DRG originally billed. Our reviewer says that documentation does not support the billed code. 
Our physician reviewer found that the enrollee was diagnosed and treated with infection of the sacral wound 
and was treated accordingly. There was no evidence of life-threatening organ dysfunction due to dysregulated 
host response to an infection or persistent hemodynamic instability.  
 
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 on October 1, 2021, to October 13, 2021, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for the surgery services provided on October 5, 2022. 
 
You asked the Plan to pay for the billed services. You say that the surgical assistant assists the surgeon in 
performing a safe operation. The Plan denied your request. The Plan says that nurse practitioners are not 
allowed to do surgeries. 
 
The Plan follows Medicare rules. Medicare rules say that for procedures with an assistant surgery indicator of 
2, the payment restriction for assistants at surgery does not apply and the assistant surgeon services will be 
paid.  
 
In this case, assistant surgery services, indicated by the AS modifier, for CPT code 27447 was billed. The 
Medicare Fee Schedule Database contains a surgical indicator of 2 for this procedure. Based on this 
information, we decided that Medicare rules for coverage of the billed services have been met. Therefore, we 
decided that the Plan has to pay for the surgery services provided on October 5, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on May 11, 2022. 
 
You asked the Plan to pay for laboratory services. You say that the records attached support the services 
provided. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for laboratory services 
provided on May 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for pontic-porcelain fused to high noble metal (D6240) 
Tooth #12, retainer crown-porcelain fused to high noble (D6750) Tooth #11, 13, retainer crown  porcelain 
used to high noble (D6751) Tooth #11, 13, and extraction, erupted tooth or exposed root (D7140) Tooth #12 
provided on October 13, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you always pay a certain amount for 
services, and you had to pay more, but do not know why. The Plan denied your request. The Plan says you 
have reached the $1,000 benefit program maximum for the 2022 benefit year. 
  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 plan pays up to the 
Calendar Year Maximum of $1,000. All covered services are subject to the Calendar Year Maximum. Services 
received from a dentist in an emergency situation are subject to plan rules and cost-sharing. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows you have reached the $1,000 benefit program maximum for the 2022 benefit year. Any amount over the 
$1,000 limit is your responsibility. Therefore, we decided that the Plan does not have to pay more for pontic-
porcelain fused to high noble metal (D6240) Tooth #12, retainer crown-porcelain fused to high noble (D6750) 
Tooth #11, 13, retainer crown  porcelain used to high noble (D6751) Tooth #11, 13, and extraction, erupted 
tooth or exposed root (D7140) Tooth #12 provided on October 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pain management provided on October 27, 2022. 
 
You asked the Plan to pay for pain management. You say that you are requesting reconsideration. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for pain management 
provided on October 27, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate for transforaminal lumbar 
interbody fusion (TLIF) surgery. 
 
You asked the Plan to pre-approve bone marrow aspirate. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says studies have not proven that this is helpful for treatment 
of the enrollee's problem. 
 
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 bone marrow aspirate. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found bone marrow aspirate is experimental for use as bone graft extender in spine surgery. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bone marrow aspirate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone marrow aspirate for transforaminal lumbar interbody fusion (TLIF) surgery.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for computed tomography (CT) scan provided 
on August 04, 2022. 
 
You asked the Plan to waive the copayment for computed tomography (CT) scan. You say that you disagree 
with the 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $350 
copayment for outpatient diagnostic tests/computed tomography (CT). 
 
You have been asked to pay a $350 copayment for computed tomography (CT) scan. This item/service falls 
within the outpatient diagnostic tests/computed tomography (CT) 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 computed tomography (CT) scan provided on August 04, 2022.