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

 
We decided that the Plan has to pay for the office visit coded 99213 provided on August 12, 2022. 
 
You asked the Plan to pay for the office visit. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says that the payment for this service is included in the fee for the procedure. 
 
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. Review of the file shows that the Plan has denied this code due to the payment 
for this service being included in the fee for the procedure. This code was billed with 72110 (spine x-ray). The 
documentation does not show why separate payment cannot be made for this code. No medicare rules were 
provided to support why code 99213 cannot be separately paid. The Plan did not substantiate their denial. 
Therefore, we decided that the Plan has to pay for the office visit coded 99213 provided on August 12, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on February 7, 2021, through 
February 8, 2021. 
 
You asked the Plan to pay for the medical services. You say that you submitted a corrected claim on January 
28, 2022, which was within the time limits for filing. The Plan denied your request. The Plan says your 
corrected claim was not submitted within the 365-day deadline. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the medical services was not filed until April 12, 2022. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for medical services provided on February 7, 2021, through February 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the core build-up (D2950) provided on September 21, 
2022. 
 
You asked the Plan to pre-approve the core build-up (D2950). You say that you were told this would be paid 
for. You say you want to be reimbursed. The Plan denied your request. The Plan says the service is not a 
covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the core build-up is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the core build-up 
(D2950) provided on September 21, 2022.  
 
Your complaint about the provider group is not a valid appeal for medical coverage. This part of your 
complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision 
about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia (D9222 and D9223) and therapeutic parenteral 
drugs (D9612) provided on September 26, 2022. 
 
You asked the Plan to pay for anesthesia and therapeutic parenteral drugs. You say that you would like the Plan 
to pay for this. The Plan denied your request. The Plan says the rendered dental services are not covered 
benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for anesthesia 
(D9222 and D9223) and therapeutic parenteral drugs (D9612) provided on September 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a consultation - diagnostic service provided by dentist or 
physician (D9310), cone beam CT capture and interpretation with field of view of both jaws (D0367), 
coronectomy  intentional partial tooth removal (D7251), deep sedation/general anesthesia  first 15 minutes 
(D9222), and deep sedation/general anesthesia  each subsequent 15 minute increment (D9223), provided on 
October 4, 2022, and October 5, 2022. 
 
You asked the Plan to pay for the dental services. You say that you called the Plan to obtain insurance and was 
assured the dental coverage would be in effect immediately. You also say that the insurance then advised you 
that the policy went into effect on November 1, 2022. The Plan denied your request. The Plan says these 
services are 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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a 
consultation - diagnostic service provided by dentist or physician (D9310), cone beam CT capture and 
interpretation with field of view of both jaws (D0367), coronectomy  intentional partial tooth removal 
(D7251), deep sedation/general anesthesia  first 15 minutes (D9222), and deep sedation/general anesthesia  
each subsequent 15 minute increment (D9223), provided on October 4, 2022, and October 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bone replacement graft (D7953) provided on October 6, 
2022. 
 
You asked the Plan to pay for the dental service. You say that although the code D7953 is not covered, it does 
not make sense for you to not use your dental coverage for your needs. The Plan denied your request. The Plan 
says dental code D7953 is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a bone 
replacement graft (D7953) provided on October 6, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the radiology services (71045), provided on August 28, 2022. 
 
You asked the Plan to pay for the radiology services. You say that the service should be covered. The Plan 
denied your request. The Plan says that this claim is a duplicate. 
 
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 didnt include any evidence showing that they previously received and 
paid a duplicate claim in the case file. Therefore, we decided that the Plan has to pay for the radiology services 
(71045), provided on August 28, 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: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the Electrical stimulator supplies (A4595), provided on July 6, 2022. 
 
You asked the Plan to pay for the Electrical stimulator supplies. You say that the item was medically necessary. 
The Plan denied your request. The Plan says that there is no evidence to support the ordering provider ordered 
the service. 
 
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 hasnt provided sufficient evidence or reasoning that the order on file is 
invalid. Therefore, we decided that the Plan has to pay for the Electrical stimulator supplies (A4595), provided 
on July 6, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93971-LT billed for date of service July 12, 
2022. 
 
You asked the Plan to pay for procedure code 93971-LT. You say that this service is supported as billed. The 
Plan denied your request. The Plan says this service is not supported in the medical record. 
 
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 93971 is duplex scan of extremity veins including 
responses to compression and other maneuvers; unilateral or limited study. 
 
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 procedure code 93971-LT. Our reviewer says that this code 
is not supported in the medical record. Our reviewer found that the medical records provided do not include 
sufficient documentation to validate that a Duplex scan of extremity veins including responses to compression and other maneuvers; unilateral or limited study was performed on July 12, 2022; therefore, this procedure 
cannot be verified, and no additional payment is allowed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 93971-LT have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 93971-LT billed for date of service July 12, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on May 17, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the provider relies on other staff to 
obtain authorizations. The Plan denied your request. The Plan says services obtained out-of-network are 
excluded from coverage. 
 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 subsequent nursing facility care provided on May 
17, 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 LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the request is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. All medically necessary care is being provided in 
the current acute care setting. 
 
 
 
 
 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 LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a panoramic x-ray (D0330) provided on 
February 2, 2022. 
 
You asked the Plan to waive the deductible for a panoramic x-ray (D0330). You say that you called and 
complained about the $79 bill for an x-ray, and was told that they would take care of it. The Plan denied your 
request. The Plan says this cost sharing was charged correctly. 
 
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 rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $100 deductible which applies to class 2 basic dental services.   
You have been asked to pay $79.72. The item or service you asked the Plan to waive the deductible for falls 
within the class 2 basic dental services benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $100 deductible which applies to class 2 basic dental services. This cost 
sharing is a contractual obligation that had not been met at the time a panoramic x-ray (D0330) was received on 
February 2, 2022. Therefore, we decided that the Plan does not have to waive the deductible for a panoramic x-
ray (D0330) provided on February 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids (V5298) purchased on September 28, 2022, 
from an out-of-network (OON) provider. 
 
You asked the Plan to pay for the hearing aids. You say that nothing in the documentation you received 
requires you to purchase hearing aids from a Plan-approved hearing aid vendor. You also say that you chose to 
purchase hearing aids from this OON provider based on the selection of products and price. The Plan denied 
your request. The Plan says you did not contact the Plan's hearing department prior to receiving the hearing 
aids. The Plan also says that you self-referred to an OON provider. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when you use the Plan's approved hearing aid vendor for your hearing aid benefits. 
 
We looked at the file and the Plan's rules. Specifically, the record shows that you received these hearing aids 
from an OON provider. Based on this information, we decided that the Plan's rules for coverage of the hearing 
aids have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aids (V5298) 
purchased on September 28, 2022, from an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visits provided on August 
31, 2022. 
 
You asked the Plan to waive the copayment for specialist office visits. You say that you disagree with the 
copayments. 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 per visit for physician/practitioner Services/services obtained from a Tier 2 specialist.  
 
You have been asked to pay a $50 copayment per visit for specialist office visits. The total amount you are 
being asked to pay $100 ($50 + $50 = $100). This item/service falls within the physician/practitioner 
Services/services obtained from a Tier 2 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 specialist office visits provided on August 31, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee has severe visual impairments and is 
very confused. You say you hope the enrollee will be provided care at a SNF because it would not be safe to 
return home. The Plan denied your request. The Plan says based on Medicare guidelines, the SNF services you 
are requesting do not meet the requirements for approval. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does have skilled therapy needs 
that require the specialized skill, knowledge, and judgment of a skilled professional therapist however, 
provided records do not document a significant decline in the patients functional status to necessitate daily 
inpatient skilled therapy services. The enrollee does not require daily skilled nursing and/or skilled therapy on 
an inpatient basis in a skilled nursing facility (SNF) setting. Records support that services in the home or an 
assisted living facility with home health care or in a long-term care facility on a part time basis are appropriate 
in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on May 10, 2022. 
 
You asked the Plan to pay for ambulance services. The Plan denied your request. The Plan says Original 
Medicare is responsible for payment. 
 
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 ambulance services provided on May 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Hereditary Cardio Screen Panel (81479) provided on 
August 26, 2021. 
 
You asked the Plan to pre-approve the Hereditary Cardio Screen Panel. You say that this testing was medically 
necessary. The Plan denied your request. The Plan says this service is not covered for suspected or documented 
cardiovascular disease. 
 
The Plan follows Medicare rules. The rules say that Medicare denies coverage for all cardiovascular risk 
assessment panels for patients with suspected or documented cardiovascular disease. 
 
We reviewed the file and Medicare rules. In this case the enrollee has suspected or documented cardiovascular 
disease. Therefore, we decided that the Plan does not have to pre-approve the Hereditary Cardio Screen Panel 
(81479) provided on August 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the meningococcal vaccine (90620) and administration 
(90471) provided on September 2, 2022. 
 
You asked the Plan to pay for the immunization services. You say that the services should be paid. The Plan 
denied your request. The Plan says the vaccine in this case is not covered by Medicare or the Plan. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the immunization 
services. The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the immunization 
services. Therefore, we decided that the Plan does not have to pay for the meningococcal vaccine (90620) and 
administration (90471) provided on September 2, 2022.