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

 
We decided that the Plan has to pay for the destruction of internal hemorrhoid(s) by thermal energy (46930) 
provided on September 17, 2020. 
 
You asked the Plan to pay for the destruction of internal hemorrhoid(s) by thermal energy. You say that the 
services at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says that 
rules for payment have not been met because the procedure at issue is outside the scope of practice of a 
physical therapist. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan has not provided a Medicare rule that would disallow payment for the 
services at issue when rendered by a physical therapist in a state that includes these services in the scope of 
practice for physical therapy. Therefore, we decided that the Plan has to pay for the destruction of internal 
hemorrhoid(s) by thermal energy (46930) provided on September 17, 2020.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for treatment with Methylprednisolone acetate (J1040) provided 
on March 13, 2021, by an out-of-network provider. 
 
You asked the Plan to pay for treatment with Methylprednisolone acetate. You say that the services at issue 
were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for out-of-network 
care have not been met. 
 
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 treatment with Methylprednisolone acetate 
(J1040) provided on March 13, 2021, by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a resin-based composite - two surfaces (D2392) provided by 
a participating provider on July 12, 2021. 
 
You asked the Plan to pay for a resin-based composite - two surfaces. You say that you were given 
misinformation. You say that you thought that this would be covered completely. The Plan denied your request. 
The Plan says they have already issued reimbursement for two fillings. 
 
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 two resin-
based composite fillings a year.  
 
We looked at the file and Medicare rules. Evidence was provided to show that resin-based composite fillings 
were provided for tooth #31 and #29. Based on this information, we decided that the Plan's rules for coverage 
of a resin-based composite - two surfaces have not been met. Therefore, we decided that the Plan does not have to pay for a resin-based composite - two surfaces (D2392) 
provided by a participating provider on July 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic X-ray (D0330), an oral/facial photographic 
image (D0350), and oral hygiene instructions (D1330) provided on June 25, 2021. 
 
You asked the Plan to pay for a panoramic X-ray, an oral/facial photographic image, and oral hygiene 
instructions. You say that your new dental provider needed to perform the services at issue for your care. The 
Plan denied your request. The Plan says rules for payment have not been met. 
 
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 panoramic X-rays or full mouth X-rays at the rate of one procedure code every five years. 
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of panoramic X-rays have not been met. The Plan has provided coverage for full mouth X-rays on the 
same date of service. The benefit for panoramic X-rays has been exhausted. Though the Plan offers a dental 
benefit in excess of Medicare coverage, an oral/facial photographic image and oral hygiene instructions are not 
among those services covered under this benefit. Therefore, we decided that the Plan does not have to pay for a 
panoramic X-ray (D0330), an oral/facial photographic image (D0350), and oral hygiene instructions (D1330) 
provided on June 25, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH care is medically necessary for 
the enrollee's condition. The Plan denied your request. The Plan says LTACH care is not medically necessary, 
and you are receiving appropriate care in the current acute care hospital. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was admitted to an acute care hospital with bacteremia from abdominal 
infection. The record indicates that the enrollee still requires dialysis. The enrollee continues to receive acute 
care services and these have not been denied. The medical record does not indicate that the enrollee requires 
services that he is not currently receiving but that would be available at the LTACH facility. The elements of 
the coverage rules are not satisfied. The requested service cannot be recommended. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital services (procedure code 99233) provided to the 
enrollee on June 8, 2021. 
 
You asked the Plan to pay for the services. You say that the enrollee saw multiple providers with different 
specialties on the same date of service. The Plan denied your request. The Plan says this was denied with 
another evaluation and management service on the same day. 
 
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 99233 is "Subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed 
interval history; A detailed examination; Medical decision making of high complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is 
unstable or has developed a significant complication or a significant new problem. Typically, 35 minutes are 
spent at the bedside and on the patient's hospital floor or unit." 
 We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found two evaluation and management visits 
were performed on the same day, by the same specialty. Either visit supports being unrelated of the primary 
service provided, and therefore both services would not be covered. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for hospital services (procedure code 99233) provided to the enrollee on June 8, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SNF services provided from December 5, 2020, through 
December 23, 2020. 
 
You asked the Plan to pay for SNF services. The Plan denied your request. The Plan says the services were 
custodial in nature. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SNF services have not been met. Specifically, we find that the services at issue in this case are 
considered custodial in nature. Therefore, we decided that the Plan does not have to pay for SNF services 
provided from December 5, 2020, through December 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established 
patient (D0150) provided June 28, 2021. 
 
You asked the Plan to pay for the comprehensive oral exam. You say that you would like the service to be 
covered. The Plan denied your request. The Plan says you have exceeded frequency limits for this service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. The Plan covers the 
comprehensive oral exam when the services are medically necessary and reasonable.  
 
 
 
 We looked at the file and Medicare rules. The Plan provided documentation showing that a comprehensive oral 
exam was previously covered on December 14, 2020. Based on this information, we decided that the Plan's 
frequency limit for coverage of the comprehensive oral exam has been exceeded. Therefore, we decided that 
the Plan does not have to pay for the comprehensive oral evaluation - new or established patient (D0150) 
provided June 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete upper denture (D5110) provided on June 23, 
2021. 
 
You asked the Plan to pay for a complete upper denture. You say that your previous provider did not fit you 
correctly for a partial upper denture. You decided to visit another provider closer to your home and you would 
like reconsideration on payment for this claim. The Plan denied your request. The Plan says this service has a 
plan limit of one procedure every five-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 covers a complete 
upper denture once every five years.  
 
We looked at the file and Medicare rules. The records show that you had a complete upper denture provided to 
you on December 30, 2019. The EOC confirms you are allowed a complete upper denture once every five plan 
years. Based on this information, we decided that the Plan's rules for coverage of a complete upper denture 
have not been met. Therefore, we decided that the Plan does not have to pay for a complete upper denture 
(D5110) provided on June 23, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (88264, 88271, 88275, 88237) provided on 
February 8, 2021, by an out-of-network provider. 
 
You asked the Plan to pay for genetic testing. You say that the services at issue were a medical necessity for 
the enrollee. The Plan denied your request. The Plan says rules for out-of-network care have not been met. 
 
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 
items/services 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 genetic testing (88264, 88271, 88275, 88237) 
provided on February 8, 2021, by an out-of-network provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional supplies, materials, and clinical staff time 
provided from June 4, 2021, through July 2, 2021. 
 
You asked the Plan to pay for the additional supplies, materials, and clinical staff time. You say that the 
medical records fully support and justify the code billed. You say that the notes clearly show what kind of 
precautions were taken prior to treating the patient and the claims should be reprocessed for prompt payment. 
The Plan denied your request. The Plan says bundled services are not eligible for separate reimbursement. 
 
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 99072 is additional supplies, materials, and clinical staff 
time over and above those usually included in an office visit or other non-facility service(s), when performed 
during a Public Health Emergency, as defined by law, due to respiratory-transmitted infectious disease.  We find that CPT code 99072 is not supported in the medical record. Specifically, CPT code 99072 has a status 
indicator of B. This means that CPT code 99072 is considered bundled and not separately payable. Based on 
this information, we decided that Medicare rules for coverage of the additional supplies, materials, and clinical 
staff time have not been met. Therefore, we decided that the Plan does not have to pay for the additional 
supplies, materials, and clinical staff time provided from June 4, 2021, through July 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for retreatment of previous root canal therapy (D3346) provided 
on December 3, 2020. 
 
You asked the Plan to pay for retreatment of previous root canal therapy. You say that the services at issue 
were a medical necessity for you. The Plan denied your request. The Plan says rules for payment have not been 
met because the services at issue are 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 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 
retreatment of previous root canal therapy (D3346) provided on December 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the telehealth visit you had with an 
infectious disease specialist on June 1, 2021. 
 
You asked the Plan to waive the copayment for the telehealth visit with an infectious disease specialist. You 
say that you do not know why this claim was rejected. The Plan denied your request. The Plan says this claim 
was not denied.  Rather, the allowed amount for this service ($25.75) is less than your copayment obligation.  
Therefore, the Plan says you are responsible for the full allowed 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 $40 
copayment for visits (including telehealth visits) with a specialist.  
 You have been asked to pay a $40 copayment for the telehealth visit with an infectious disease specialist. The 
telehealth visit with an infectious disease specialist falls within the visits with a specialist 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 the telehealth visit you had with an infectious disease 
specialist on June 1, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response without transport provided on 
August 24, 2021. 
 
You asked the Plan to pay for the ambulance response. You say that you feel that this should be paid because 
you passed out for a few moments, and someone called an ambulance. The ambulance staff checked your vitals 
which were normal, and you did not require transportation to the emergency room. You feel this should be a 
covered service. The Plan denied your request. The Plan says Medicare does not cover ambulance services 
when no transportation occurs. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on August 24, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response without transport 
provided on August 24, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary or rest home visit (99336) rendered by the 
out-of-network (OON) provider on June 11, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without 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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the domiciliary or rest home visit (99336) rendered by the out-of-network (OON) 
provider on June 11, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital services you received 
from March 22, 2021, to March 25, 2021. 
 
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you should not owe 
anything because you were hospitalized for COVID-19. The Plan denied your request. The Plan says the 
COVID-19 copayment waiver program was only in effect from February 3, 2020, to February 15, 2021.  These 
services occurred after the copayment waiver program ended, so you were charged this copayment 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 $225 
copayment per day for days 1-7 for inpatient hospital care.  
 
  
Records show you were in the hospital for three days. You have been asked to pay a $225 copayment per day 
for three days, for a total of $675. The COVID-19 copayment waiver program was not in effect on the dates of 
these services. 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 services you received 
from March 22, 2021, to March 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a standard weight motorized wheelchair with 
programmable control parameters for speed adjustment, tremor dampening, acceleration control, and braking. 
 
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient?s condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 wheelchair. Our reviewer says that 
the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found the mobility 
deficit does not significantly impair MRADLs in the home. The deficit can be ameliorated by a walker.  
 
  
The documentation indicates that you have dementia, therefore it is not clear that you can safely operate the 
requested power wheelchair. The documentation does not support that this power wheelchair will significantly 
improve MRADLs in the home. 
 
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 wheelchair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a standard weight motorized wheelchair with programmable control parameters for speed 
adjustment, tremor dampening, acceleration control, and braking.