Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dermatology services provided on November 3, 2021, by 
an OON provider. 
 
You asked the Plan to pay for the dermatology services. You say that the skin growth was causing issues under 
the clothes. The Plan denied your request. The Plan says the services were provided out-of-network and were 
not approved in advance. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the dermatology services provided on November 
3, 2021, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the scaling in presence of generalized moderate or severe 
gingival inflammation (D4346) provided on January 7, 2022. 
 
You asked the Plan to pay for the dental service. You say that you were advised prior to the service that you did 
not have a copayment for this procedure. You also say that all of the services were covered by your insurance. 
The Plan denied your request. The Plan says scaling in presence of generalized moderate or severe gingival 
inflammation 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the scaling in presence of generalized moderate or severe gingival inflammation is not among those covered under this benefit. Therefore, we decided 
that the Plan does not have to pay for the scaling in presence of generalized moderate or severe gingival 
inflammation (D4346) provided on January 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the antimicrobial agents (D4381) and the adjunctive pre-
diagnostic test (D0431) provided on November 5, 2021. 
 
You asked the Plan to pay for the dental services. You say that you feel you were given services which are not 
necessary and the cost for this care is too high. The Plan denied your request. The Plan says these services are 
not covered by your dental benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 the 
antimicrobial agents (D4381) and the adjunctive pre-diagnostic test (D0431) provided on November 5, 2021.
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 May 
26, 2021, to May 30, 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 DRG was updated. 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 190. 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 the patient only required up to 1-2L oxygen 
for a brief period, inconsistent with acute respiratory failure. Although the provider documented acute 
respiratory failure, reasonable support within the health record must be present for that diagnosis. It is 
appropriate for facilities to ensure that documentation is complete, accurate and appropriately reflects the 
patient's clinical conditions. DRG 192 (CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT 
CC/MCC) is more appropriate.  
 
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 May 26, 2021, to May 30, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for individual psychotherapy services (90837) provided on 
September 17, 2021 to December 8, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for psychotherapy services. You say that the medical records provided support the 
necessity of the services in dispute. The Plan denied your request. The Plan says enrollees must receive their 
medical services from an in-network provider with the exception being urgent or emergent services. Non-
emergent services with non-contracted providers require prior authorization before services being rendered. 
 
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 individual psychotherapy services (90837) 
provided on September 17, 2021 to December 8, 2021 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI) of 
the brain (70551) provided on October 20, 2021. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
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 $150 
copayment for advanced imaging services.  
 
You have been asked to pay a $150 copayment for the advanced imaging service provided. 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 the magnetic resonance imaging (MRI) of the 
brain (70551) provided on October 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for moderate sedation services provided to the enrollee on 
January 8, 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 CPT code 99153 may not be paid if furnished to a hospital inpatients or patients in a hospital 
outpatient department. 
 
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 99153 is "Moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; each additional 15 minutes intraservice time (List 
separately in addition to code for primary service)." 
 
 
 We find that CPT code 99153 is not supported in the medical record. Specifically, this code cannot be paid to 
hospital inpatients or patients in a hospital outpatient department, as it has a Professional Component 
(PC)/Technical Component (TC) indicator of 3. 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 pay for 
moderate sedation services provided to the enrollee on January 8, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a colonoscopy with resection performed on 
December 8, 2021. 
 
You asked the Plan to waive the copayment for the colonoscopy. You say that you cannot afford the 
copayment. You say that you would not have had it done if you knew the cost. 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 $250 
copayment per day, per provider, for surgery performed in an outpatient hospital.  
 
 You have been asked to pay a $250 copayment for the colonoscopy. The colonoscopy 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 a colonoscopy with 
resection performed on December 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for eyeglasses provided on  
January 30, 2021. 
 
You asked the Plan to pay an additional amount for eyeglasses. The Plan denied your request. The Plan says 
does not cover lens upgrades, including but not limited to transition, progressive, polish, scratch-resistant or 
tinted lenses, or insurance. Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear 
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  
 
We looked at the file and the Plan's rules. The file shows that the Plans vision benefit does not provide 
coverage for lens upgrades. Based on this information, we decided that the Plan's rules for coverage of 
eyeglasses have not been met. Therefore, we decided that the Plan does not have to pay an additional amount 
for eyeglasses provided on January 30, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from November 2, 2021, to November 6, 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 while on hospice, skilled nursing facility level services are not covered. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from November 2, 2021, to November 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral x-rays (D0220, D0230), eight simple extractions 
(D7140) and an unspecified preventative procedure (D1999) provided on November 11, 2021. 
 
You asked the Plan to pay for the dental services. You say that your provider told you they accept your 
insurance, and you did not realize they were out-of-network. You live on a fixed income and this bill is costly. 
The Plan denied your request. The Plan says this claim was processed in accordance with your dental benefits. 
When you use an out-of-network provider, you may be billed for any amount greater than what the Plan pays 
for covered services. In addition, the unspecified preventative procedure is not a covered service under your 
dental benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan does not cover 
services which are not listed in the dental benefits chart section of the contract. 
 
The rules also 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 states that all eligible 
services require a $0 copayment; however, if you choose to see an out-of-network dentist, you might be billed 
for charges above what the Plan pays, even for services listed as a $0 copayment. For services obtained out-of-
network, the Plan only pays up to a certain amount. If you choose to see an out-of-network dentist, you might 
be billed for any amount greater than what the Plan pays. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested unspecified preventative 
procedure is not among those covered under this benefit. Therefore, you are responsible for the charges for this 
service, which in this case amounts to $20. 
 
The documentation shows that the provider billed the Plan of $2,549.72 for the eligible services provided on 
November 11, 2021. The Plans total allowed cost for these services is $540. This is the amount an in-network 
provider would accept as full payment for these services; however, out-of-network providers do not have this 
agreement with the Plan and are allowed to bill you the difference between the charged amount and the amount 
the Plan pays ($2549.72 - $542 = $2,007.72). The Plan has paid the full allowed cost in this case, as you are 
responsible for a $0 copayment for these services. Cost sharing is always calculated from the Plans price. This 
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to pay for the intraoral x-rays (D0220, D0230), eight simple extractions (D7140) and an 
unspecified preventative procedure (D1999) provided on November 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve extraction of tooth #7 plus bone grafting and implant 
placement. 
 
You asked the Plan to pre-approve the extraction, bone grafting, and implant placement. You say that you feel 
that the services are necessary. The Plan denied your request. The Plan says there is no documented need for 
extraction, and the other requested 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. The Plan covers the extraction, 
bone grafting, and implant placement when the services are medically necessary and reasonable.  
 
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 extraction, bone grafting, and 
implant placement. Our reviewer says that the requested extraction is not shown to be reasonable and 
necessary. Our physician reviewer found a review of the documentation indicates that tooth #8 was lost and tooth #7 was loosened due to a traumatic event in 2021. At this time the patient has a pontic replacing #8 
attached to tooth #7. There was no indication as to why tooth #7 was to be extracted. The documentation 
provided does not address the reason for the extraction of tooth #7. 
 
The requested bone grafting and implant are not covered under your dental benefit. 
 
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 the extraction, bone grafting, and implant placement have not been met. 
Therefore, we decided that the Plan does not have to pre-approve extraction of tooth #7 plus bone grafting and 
implant placement.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for guided tissue regeneration (D4266) provided on November 
18, 2021. 
 
You asked the Plan to pay for guided tissue regeneration. You say that this service is necessary. The Plan 
denied your request. The Plan says this service is not covered by your dental benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 guided 
tissue regeneration (D4266) provided on November 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral exam (D0150) provided on January 
18, 2022. 
 
You asked the Plan to pay for the comprehensive exam. You say that you were not aware this service would 
not be covered. The Plan denied your request. The Plan says you previously had a comprehensive oral exam in 
September of 2020, which was covered by the Plan at that time. This service is covered once every three plan 
years. 
 
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 can cover one 
comprehensive oral exam (D0150) every three plan years. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the comprehensive exam is requested 
in a frequency that is not covered under this benefit. The documentation shows you had a previous 
comprehensive oral exam which was covered for you less than three plan years before the date in question. Therefore, we decided that the Plan does not have to pay for the comprehensive oral exam (D0150) provided on January 18, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve inpatient psychiatric care from April 22, 2022, forward. 
 
You asked the Plan to pre-approve inpatient psychiatric hospital services from April 22, 2022, forward. You 
say that the services at issue are medically necessary. The Plan denied your request. The Plan says that the 
services at issue are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric hospital services 
from April 22, 2022, forward. Our reviewer says that you meet the criteria for acute inpatient mental health 
treatment beyond the date in question of April 22, 2022, forward. Our physician reviewer found you did appear 
to require inpatient mental health treatment beyond the date in question as you were a danger to yourself or 
others. It did appear that active treatment was taking place beyond the date in question. It did appear that the 
services were reasonably expected to improve your condition, or for the purpose of diagnosis beyond the date 
in question. It did appear that the records were supervised and evaluated by a physician. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric hospital services from April 22, 2022, forward have been 
met. Therefore, we decided that the Plan has to pre-approve inpatient psychiatric care from April 22, 2022, 
forward.  
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction, erupted tooth or exposed root (elevation 
and/or forceps removal) (D7140), periodic oral evaluation - established patient (D0120), intraoral - periapical 
first radiographic image (D0220) and prophylaxis - adult (D1110) provided October 4, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the tooth extraction, periodic oral exam, intraoral x-ray and dental cleaning. You 
say that the dental office is in-network and you do not get to choose which dentist you see. The Plan denied 
your request. The Plan says these services are not covered because they were provided OON. 
 
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 the requested 
services when they are provided in-network. 
We looked at the file and Medicare rules. The services in this case were rendered by an out-of-network 
provider. Based on this information, we decided that the Plan's rules for coverage of the tooth extraction, 
periodic oral exam, intraoral x-ray and dental cleaning have not been met. Therefore, we decided that the Plan 
does not have to pay for the extraction, erupted tooth or exposed root (elevation and/or forceps removal) 
(D7140), periodic oral evaluation - established patient (D0120), intraoral - periapical first radiographic image 
(D0220) and prophylaxis - adult (D1110) provided October 4, 2021, by an out-of-network (OON) provider.