Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Fluid Administration set w/ vented, 4 FR Powerpicc 
Single Lumen, Radiology TR, Decal, Olcott Torque Device, Presto Inflation Device, Sodium Hypochlorite 
0.125%, Venipuncture, 1.25MM Solid, 145CM Diamondback 360 Peri and 4FR x 135CM Rubicon 18 Support 
Catheter which were included on the inpatient bill for services provided on June 10, 2021, through July 17, 
2021. 
 
You asked the Plan to pay for the routine items and services. You say that you would like reconsideration 
based on the records submitted. The Plan denied your request. The Plan says these services are considered 
routine or not supported by the documentation submitted. 
 
The Plan must follow Medicare rules. Medicare rules say that inpatient routine services in a hospital or skilled 
nursing facility generally are those services included in by the provider in a daily service charge--sometimes 
referred to as the "room and board" charge. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the routine items and services have not been met. Specifically, the documentation does not support 
that 1.25MM Solid was used on the billed date of service. Additionally, the remaining supplies at issue are 
considered routine items and services and payment for these items is included in the room and board charge. 
Therefore, we decided that the Plan does not have to pay for the Fluid Administration set w/ vented, 4 FR 
Powerpicc Single Lumen, Radiology TR, Decal, Olcott Torque Device, Presto Inflation Device, Sodium 
Hypochlorite 0.125%, Venipuncture, 1.25MM Solid, 145CM Diamondback 360 Peri and 4FR x 135CM 
Rubicon 18 Support Catheter which were included on the inpatient bill for services provided on June 10, 2021, 
through July 17, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an electroencephalogram (95822) provided on October 10,
2021.

You asked the Plan to pay for the electroencephalogram. You say that this service was medically necessary.
The Plan denied your request. The Plan says the documentation does not support the billed services.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.

We find that CPT code 95822 is not supported in the medical record. Specifically, the records do not support
the code billed. Documentation provided supports code 95955. Based on this information, we decided that
Medicare rules for coverage of the electroencephalogram have not been met. Therefore, we decided that the
Plan does not have to pay for an electroencephalogram (95822) provided on October 10, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for SNF care provided from January 14, 2022, to 
February 28, 2022.

You asked the Plan to pay for SNF care. You say that the SNF care was medically necessary. The Plan denied your request. The Plan says the SNF care does not meet Medicare coverage criteria.

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 pay for 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 from a nursing perspective, the enrollee received oral and inhaled medications. The enrollee had stable vital signs. She had a wound vac to her abdomen and she was treated for pain. Regarding rehabilitation services, there are no identified therapy notes in the medical records to document the need for skilled therapy. There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. As a practical matter, this enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pay for SNF care provided from January 14, 2022, to February 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on May 
31, 2022. 
 
You asked the Plan to pay for the comprehensive oral evaluation. You say that you believe this service should 
be covered. The Plan denied your request. The Plan says your benefit for the requested service has already been 
exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested service was exhausted on date of service January 12, 2022. Therefore, we 
decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on May 31, 
2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided June 11, 2020.

You asked the Plan to pay for the lab services. You say that you would like the Plan to reconsider their denial
of payment. The Plan denied your request. The Plan says the services are not covered as billed.

The Plan must follow Medicare rules. Medicare rules say that the DOS of the test/service must be the date the
specimen was collected.

We looked at the file and Medicare rules. There is no documentation describing genetic testing on a sample
collected on the date of service at issue. Based on this information, we decided that Medicare rules for
coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the
lab services provided June 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the sales tax provided on November 23, 2021. 
 
You asked the Plan to pay for the sales tax. You say that you would like to appeal your right to reimbursement. 
The Plan denied your request. The Plan says sales tax is not a covered service, and the charge cannot be 
reimbursed. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare does not make separate payment for 
sales tax.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the sales tax have not been met. Therefore, we decided that the Plan does not have to pay for the 
sales tax provided on November 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), bitewing x-rays 
(D0274), and prophylaxis (D1110) provided on May 16, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the dental services. You say that you started seeing this provider about two years 
ago, and the provider was in-network. You also say that this is the closest provider to you that is in-network, 
and the next closest provider is over 25 miles away. The Plan denied your request. The Plan says the dental 
services were received from an OON provider and are not covered by your supplemental 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. 
 
The record shows you received the requested dental services from an OON provider. Though the Plan offers a 
dental benefit in excess of Medicare coverage, the requested items or services are not covered under this 
benefit when received from an OON provider. Therefore, we decided that the Plan does not have to pay for the 
periodic oral evaluation (D0120), bitewing x-rays (D0274), and prophylaxis (D1110) provided on May 16, 
2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (14301) provided on October 14, 2021.
You asked the Plan to pay for the surgical services. You say that this service was medically necessary. The
Plan denied your request. The Plan says the documentation does not support the billed service.

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 14301 is Adjacent tissue transfer or rearrangement, any
area.

We find that CPT code 14301 is not supported in the medical record. Specifically, medical documentation does
not support the additional use of procedure code 14301. Based on this information, we decided that Medicare
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the arthroscopy services coded 29822-59 provided on 
January 31, 2022. 
 
You asked the Plan to pay for the arthroscopy services as billed. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says separate payment cannot 
be made as these services are considered inclusive to code 29827. 
 
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, we have confirmed that code 29822 is a column II code to column I code 29827; however, 29822 
was billed with a modifier.  
 
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 arthroscopy services as billed. Our reviewer says that the 
documentation does not support separate payment for the services as billed. Our reviewer found the operative 
report describes arthroscopic procedures performed on right shoulder, and in this case limited debridement is 
inclusive to the primary arthroscopic procedure. Per the National Comprehensive Coding Initiative Policy 
Manual Chapter 4 "7. Shoulder arthroscopy procedures include limited debridement (e.g., CPT code 29822) 
even if the limited debridement is performed in a different area of the same shoulder than the other procedure. 
With 3 exceptions, shoulder arthroscopy procedures include extensive debridement (e.g., CPT code 29823) 
even if the extensive debridement is performed in a different area of the same shoulder than the other 
procedure. CPT codes 29824 (Arthroscopy, shoulder, surgical; distal claviculectomy including distal articular 
surface (Mumford procedure)), 29827 (Arthroscopy, shoulder, surgical; rotator cuff repair), and 29828 
(Arthroscopy, shoulder, surgical; biceps tenodesis) may be reported separately with CPT code 29823 if the 
extensive debridement is performed in a different area of the same shoulder".  In this case, the documentation 
supports that the service service was unbundled. 
 
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 arthroscopy services as billed have not been met. Therefore, we decided that 
the Plan does not have to pay for the arthroscopy services coded 29822-59 provided on January 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), topical application of 
fluoride varnish (D1206), and periodontal maintenance (D4910) provided on May 3, 2022. 
 
You asked the Plan to pay for the dental services. You say that the contract provides benefits for periodontal 
maintenance twice in a benefit period. You also say that this was the first procedure you had in 2022, and 
should be covered. The Plan denied your request. The Plan says your annual dental benefit has already been 
exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your annual dental benefit was exhausted on date of service February 4, 2022. Therefore, we decided 
that the Plan does not have to pay for the periodic oral evaluation (D0120), topical application of fluoride 
varnish (D1206), and periodontal maintenance (D4910) provided on May 3, 2022.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (20660, 20938, 22554, 22830, 22845,
22853, 63081) provided on October 6, 2021.

You asked the Plan to pay for the surgical services. You say that the services were medically necessary. The
Plan denied your request. The Plan says the documentation does not support the billed services.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.

We find that CPT code 20660, 20938, 22554, 22830, 22845, 22853 and 63081 is not supported in the medical
record. Specifically, there are multiple Column 2 NCCI edits with procedure code 20660 being unable to be
billed with approved procedure codes. Approved code 22855 is clearly documented in the records without the
need for additional codes. Based on this information, we decided that Medicare rules for coverage of the
surgical services have not been met. Therefore, we decided that the Plan does not have to pay for surgical
services (20660, 20938, 22554, 22830, 22845, 22853, 63081) provided on October 6, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for full mouth debridement (D4355) provided on March 29, 
2022. 
 
You asked the Plan to pay for full mouth debridement. You say that this procedure was medically necessary 
due to the amount of buildup. The Plan denied your request. The Plan says that the coverage criteria has 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 Plans coverage rules apply in this case. The Plan covers full mouth 
debridement 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 pay for full mouth debridement. Our reviewer says 
that the coverage criteria has not been met. Our physician reviewer found that the documentation does not 
support that the enrollee had tarter build-up which did not allow the provider to fully assess decay or the condition of the teeth. 
 
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 full mouth debridement have not been met. Therefore, we decided that the Plan 
does not have to pay for full mouth debridement (D4355) provided on March 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia complicated by emergency conditions (specify) 
(List separately in addition to code for primary anesthesia procedure) (99140) and anesthesia for patient of 
extreme age, younger than 1 year and older than 70 (List separately in addition to code for primary anesthesia 
procedure (99100) provided April 7, 2022. 
 
You asked the Plan to pay for the anesthesia services. You say that the medical records provided support the 
necessity of the services in dispute. The Plan denied your request. The Plan says these procedure codes has a 
status indicator of "B" and is always bundled into payment for other services not specified and no separate 
payment is made. 
 
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, we have confirmed that code the 
anesthesia services is an add-on code and has not been billed with an appropriate primary procedure code. 
Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan 
does not have to pay for anesthesia complicated by emergency conditions (specify) (List separately in addition 
to code for primary anesthesia procedure) (99140) and anesthesia for patient of extreme age, younger than 1 
year and older than 70 (List separately in addition to code for primary anesthesia procedure (99100) provided 
April 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2750) for tooth #30. 
 
You asked the Plan to pre-approve a crown. The Plan denied your request. The Plan says is not medically 
necessary to replace the cap on your tooth. 
 
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 crown 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 a crown. Our reviewer says that the 
documentation provided does not meet the criteria for coverage for a replacement crown (D2750) for tooth #30. 
Our physician reviewer found tooth #30 has a crown restoration in place. Our reviewer also found that there 
was no narrative indicating why the crown needed replacement and the x-ray provided was not diagnostically 
adequate to determine if a replacement is warranted. 
 
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 crown have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a crown (D2750) for tooth #30.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2750) for tooth #7. 
 
You asked the Plan to pre-approve a crown. The Plan denied your request. The Plan says a crown is not needed 
to fix your tooth. 
 
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 crown 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 a crown. Our reviewer says that the 
documentation provided was inadequate to determine if the criteria for coverage for a crown (D2750) for tooth 
#7 have been met. Our physician reviewer found the x-rays submitted were not of diagnostic quality to 
determine if the criteria for coverage have been met.  
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 crown have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a crown (D2750) for tooth #7.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the custom fabricated abutment (D6057) and abutment 
supported porcelain/ceramic crown (D6058) provided on May 18, 2022. 
 
You asked the Plan to pay for the custom fabricated abutment and abutment supported crown. You say that this 
was not a cosmetic procedure, and not replacing this tooth could have caused other problems. The Plan denied 
your request. The Plan says these services are not covered benefits under your dental plan. 
 
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 the 
custom fabricated abutment (D6057) and abutment supported porcelain/ceramic crown (D6058) provided on 
May 18, 2022.
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 this is medically necessary. The Plan
denied your request. The Plan says this is not medically necessary, and continued acute hospital stay was
offered, until the member could discharge to a lower level of care.

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 there are no services at the LTACH that the patient requires that are not already
available and covered at the current facility.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve LTACH services.