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

 
We decided that the Plan does not have to waive the copayment for an endoscopy provided on June 20, 2022. 
 
You asked the Plan to waive the copayment for an endoscopy. You say that you thought you were getting a 
colonoscopy. 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 $250 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers. 
 
You have been asked to pay a $250 copayment for an endoscopy. This item/service falls within the outpatient 
surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 an endoscopy provided on June 20, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient care provided on May 22, 
2022, to May 26, 2022. 
 
You asked the Plan to waive the copayment for the inpatient care. You say that you are on a fixed income and 
cannot afford 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 $825 
copayment for inpatient hospital care. 
 
You have been asked to pay a $825 copayment for the inpatient care. 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. Per the EOC, there is a $275 copayment per day for days 1-5 of inpatient care. Your stay 
lasted 4 days from May 22, 2022, to May 26, 2022. However, you were only charged for 3 days, for a total of 
$825. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient care provided 
on May 22, 2022, to May 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a porcelain/ceramic crown. 
 
You asked the Plan to pre-approve a porcelain/ceramic crown. You say that the services requested are 
medically necessary. The Plan denied your request. The Plan says we denied the CDT ITEMS because the x-
ray for tooth #3 shows enough tooth remaining that can be filled with a multi-surface filling. Also, there is no 
decay under the existing filling which is part of the criteria for a crown. 
 
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 covers a 
porcelain/ceramic crown when the services are medically necessary and reasonable.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of a porcelain/ceramic crown have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a porcelain/ceramic crown.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve posterior tibial neurostimulation, percutaneous needle 
electrode, single treatment, includes programming (CPT code 64566). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says your request is not medically necessary because the enrollee's records do not show they 
have had improvement with the multiple PTNS sessions already approved (16 sessions). 
 
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 services. Our physician reviewer 
found posterior tibial neurostimulation is not medically necessary because the enrollee's records do not show 
that they have had improvement with the multiple prior PTNS sessions (16 sessions). 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve posterior tibial neurostimulation, percutaneous needle electrode, single treatment, includes 
programming (CPT code 64566).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the acute inpatient hospital care for the knee 
arthroplasty (CPT code 27447). 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the stay is necessary. The Plan 
denied your request. The Plan says the stay is not necessary. 
 
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 there was no reported unstable condition or high-risk condition that would 
warrant a prolonged inpatient stay following this procedure. There is no indication that the enrollee would 
require hospital services that would likely cross two (2) midnights for this typically ambulatory procedure. 
Consideration for inpatient services can be made during or following the procedure if appropriate. 
 
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 knee arthroplasty (CPT code 27447).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on February 15, 2022, by an 
OON provider. 
 
You asked the Plan to pay for laboratory services. The Plan denied your request. The Plan says the out-of-
network services were not authorized. 
 
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 laboratory services provided on February 15, 
2022, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve guided tissue regeneration (D4266) of tooth #15 and a 
bone replacement graft for ridge preservation (D7953) of tooth #15. 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered. The Plan 
denied your request. The Plan says the requested services are not listed in the table of covered supplemental 
dental services. Therefore, the Plan denied the claim because these services are excluded from coverage. 
 
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 
guided tissue regeneration (D4266) of tooth #15 and a bone replacement graft for ridge preservation (D7953) 
of tooth #15.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on February 9, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says you billed with an 
incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for the lab services provided on February 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 25, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that this was medically necessary, and you are appealing 
with supporting records. The Plan denied your request. The Plan says enrollees must receive care from a 
network provider. 
 
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 an office visit 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 an office visit these 
items/services. Therefore, we decided that the Plan does not have to pay for an office visit provided on May 25, 
2022 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuation of partial hospitalization services. 
 
You asked the Plan to pre-approve partial hospitalization services. You say that you have benefited from this 
treatment and recommends that you continue these services. The Plan denied your request. The Plan says these 
services are not medically necessary. 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 partial hospitalization services. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that the records provided for the dates in question indicate that you were 
showing some psychological or psychiatric impairment, but this impairment is not documented. You have not 
been showing any moderate dysfunction in your family, social environment or performance of daily living 
skills. You were not showing any dangerousness to self or others and were not showing any perceptual 
disturbance, psychosis or aggressive behaviors. It did not appear medically necessary and reasonable to have 
psychiatric care provided at the partial hospitalization level of care rather than a lower level of care beyond the 
dates in question as you did not have any suicidal or homicidal thoughts or behavioral disturbance. Based upon 
review the records provided, this you do not meet the criteria for treatment at partial hospitalization level of 
care and could have been treated in a lesser restrictive setting after the date in question. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of partial hospitalization services have not been met. Therefore, we decided that 
the Plan does not have to pre-approve continuation of partial hospitalization services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removal of an impacted tooth - partially bony (D7230). 
 
You asked the Plan to pre-approve the dental services. You say that you feel this service should be covered and 
you had an appointment scheduled for the tooth extraction. The Plan denied your request. The Plan says this 
service is not covered under the benefit package. 
 
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 removal of an impacted tooth - 
partially bony (D7230) is not among those covered under this benefit. Therefore, we decided that the Plan does 
not have to pre-approve removal of impacted tooth - partially bony (D7230).  The Plan agreed to pre-approve 
the deep sedation/general anesthesia  first 15 minutes (D9222), and deep sedation/general anesthesia  each 
subsequent 15 minute increment (D9223x2).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve expandable controller (E2377) harness (E2311) 
electronic connection (E2311) push handles (K0108) and power seat elevation system (E2300). 
 
You asked the Plan to pre-approve the upgraded electronics, push handles and power seat elevation system. 
You say that the medical records provided support the necessity of the services in dispute. The Plan denied 
your request. The Plan says the upgraded electronics are not medically necessary. The seat elevator and push 
handles do not serve a medical purpose and cannot be covered. 
 
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 and power seat 
elevation system. Our reviewer says that the requested items/services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found the enrollee does not require non-proportional input 
devices (e.g., sip and puff, head array, etc.). The enrollee does not require a separate display (i.e., for alternate 
control devices), other electronic devices (e.g., control of an augmentative speech device or computer through 
the chair's drive control), or an attendant control. The documentation does not support that it is medically 
necessary to control the requested power options through the joystick (drive interface). The enrollees upper 
extremity strength and function should be sufficient to control any power options through their own switches. 
The documentation does not reveal that the E2377 expandable controller, E2313 expandable controller harness 
and E2311 electronic connection between 2 systems are medically necessary per Local Coverage Article: 
Wheelchair Options/Accessories - Policy Article (A52504). 
 
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, push handles and power seat elevation system have 
not been met. Therefore, we decided that the Plan does not have to pre-approve expandable controller (E2377) 
harness (E2311) electronic connection (E2311) push handles (K0108) and power seat elevation system 
(E2300).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wheelchair ramp. 
 
You asked the Plan to pre-approve the ramp. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a wheelchair ramp.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0480 billed for date of service March 11, 
2022. You asked the Plan to pay for procedure code G0480. The Plan denied your request. The Plan says the number 
of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code G0480 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. 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 G0480 billed for date of 
service March 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (81479) provided on November 10, 2021. 
 
You asked the Plan to pay for the genetic testing. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the records do not support the billed service. 
 
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. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of genetic testing (81479) provided on 
November 10, 2021. have been met. No clinical records were provided to show that this service was medically necessary. Only lab results were provided. Therefore, we decided that the Plan does not have to pay for genetic 
testing (81479) provided on November 10, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an x-ray on June 6, 2022. 
 
You asked the Plan to waive the copayment for an x-ray. You say that you would like to appeal the cost share. 
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 
copayment for an x-ray.  
 
You have been asked to pay a $50 copayment for an x-ray. This item/service falls 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 
copayment for an x-ray on June 6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on April 27, 2022. 
 You asked the Plan to pay for the laboratory services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says screening services with no relation to a medical diagnosis of disease 
for the health of the patient are not a benefit. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The laboratory testing at issue in this appeal was requested solely for screening purposes. Medicare does not 
cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the 
laboratory services provided on April 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prefabricated abutments on tooth #21 and 28 (D6056) 
and implant supported crowns on tooth #21 and 28 (D6065). 
 
You asked the Plan to pre-approve the implant services. You say that you disagree with the denial of dental 
services. The Plan denied your request. The Plan says dental implants and all associated services are not 
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, 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 
prefabricated abutments on tooth #21 and 28 (D6056) and implant supported crowns on tooth #21 and 28 
(D6065).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hospital outpatient clinic visit provided on May 3, 2022. 
 
You asked the Plan to pay for the hospital outpatient clinic visit. The Plan denied your request. The Plan says 
non-emergent, non-urgent services with out-of-network providers require 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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for a hospital outpatient clinic visit provided on May 3, 2022.