Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral surgery services provided on September 9, 2021, 
billed with codes 21210, 21026, 10120, 21248, 21208, and 21298. 
 
You asked the Plan to pay for the oral surgery services. You say that this should be covered as medical care. 
The Plan denied your request. The Plan says this was correctly denied. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. Medicare also excludes services which are dental in nature. 
 
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 oral surgery services. Our reviewer says 
that the requested services are considered dental in nature and are not medically reasonable and necessary. Our 
physician reviewer found the enrollee is a 69-year-old woman with pain in her left lower jaw due to an abscess 
and fracture. The documentation is insufficient to support that the services provided were medical in nature, as 
the case file does not contain clinical notes supporting the two operative reports. The available clinical 
documentation does not support that the items/services at issue in this case were medically reasonable and 
necessary for the enrollee. 
 
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 oral surgery services have not been met. Therefore, we decided that the Plan 
does not have to pay for the oral surgery services provided on September 9, 2021, billed with codes 21210, 
21026, 10120, 21248, 21208, and 21298.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services you received from an out-of-network dentist 
on November 30, 2021. 
 
You asked the Plan to pay for the out-of-network dental services. You say that you have moved and you could 
not find a plan dentist in your area.  You asked for assistance with this bill. The Plan denied your request. The 
Plan says out-of-network dental care is not covered.  The Plan says that there are 51 network dentists within a 
30-mile radius of your home address and the Plan has provided this list to you. 
 
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 dental services you received from an out-of-network dentist on November 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services you received from an out-of-network dentist 
on October 7, 2021. 
 
You asked the Plan to pay for the out-of-network dental services. You say that you were given several dentists 
in your plan, but when you called them, they all advised you that they no longer accepted your plan. You said 
that you were in paid from a broken tooth, so you went to the first dentist who could treat you.  You believe 
this should be covered because you were not able to locate an in-network dentist. The Plan denied your request. 
The Plan says out-of-network dental care is not covered. 
 
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 dental 
services you received from an out-of-network dentist on October 7, 2021.  
Your complaint about the Plan having an outdated provider directory 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an extracapsular cataract removal. 
 
You asked the Plan to pre-approve the requested services. You say that laser surgery will not provide a 
permanent solution. The Plan denied your request. The Plan says the request is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that micro-invasive glaucoma surgery is only covered 
under certain medical indications.  
 
 We looked at the file and Medicare rules. The records provided in the case file does not show that the enrollee 
is being treated with an ocular hypotensive medication. Based on this information, we decided that Medicare 
rules for coverage of the requested services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an extracapsular cataract removal.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF services. 
 
You asked the Plan to pre-approve SNF services. You say that SNF care is medically necessary. The Plan 
denied your request. The Plan says a SNF admission is not medically necessary. 
 
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 services. Our reviewer says that 
daily skilled services are not medically necessary. Our physician reviewer found that based on the 
documentation provided, the enrollee does not qualify for SNF coverage. The enrollee does not have 
documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee 
is walking household distances and tending to activities of daily living with minimal supervision. Daily skilled 
services are not required to establish a maintenance program or to prevent deterioration of the enrollees 
condition. The enrollees care needs, custodial and intermittent, can as a practical matter, be provided at a 
lower level of care (ex. home, assisted living, long term care). 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve SNF services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied 
your request. The Plan says the enrollee can be managed at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. 
 Our physician reviewer found the enrollee is medically stable and does not need physician supervision 3 times 
per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical 
conditions. At the current functional level, the enrollee does not need intensive therapies, consisting of at least 
3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy in an IRF. 
IRF admission is not medically necessary based on lack of medical complexity and lack of acute rehab nursing 
needs and high functional level. The enrollee's rehab needs can be met at a lower intensity 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the esophagogastroduodenoscopy (43235) provided on April 
19, 2021. 
 
You asked the Plan to pay for the esophagogastroduodenoscopy. You say that you would like reconsideration 
based on the records submitted. The Plan denied your request. The Plan says CPT code 43235 is included in 
39541. 
 
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 43235 is  esophagogastroduodenoscopy, flexible, 
transoral; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate 
procedure). 
 
 
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 esophagogastroduodenoscopy. Our reviewer says that 
CPT code 43235 does not meet criteria for billing or reimbursement consideration. Our reviewer found the 
operative report describes an endoscopic hernia repair, and diagnostic Esophagogastroduodenoscopy during the 
same session.  In this case service was unbundled from the hernia repair. Per the CPT Manual instructions, 
surgical endoscopy includes diagnostic endoscopy. A diagnostic endoscopy HCPCS/CPT code shall not be 
reported with a surgical endoscopy code. 2. If multiple endoscopic services are performed, the most 
comprehensive code describing the service(s) rendered shall be reported. If multiple services are performed and 
not adequately described by a single HCPCS/CPT code, more than one code may be reported. The multiple 
procedure modifier 51 should be appended to the secondary HCPCS/CPT code. 
 
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 esophagogastroduodenoscopy have not been met. Therefore, we decided 
that the Plan does not have to pay for the esophagogastroduodenoscopy (43235) provided on April 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraspinal chiropractic services (98943), therapeutic 
procedures (97110), and office visit (99213) provided on June 11, 2021. 
 
You asked the Plan to pay for the services rendered by a chiropractor. You say that you would like this claim 
reprocessed based on the medical documentation. The Plan denied your request. The Plan says these services 
are not covered by Medicare when rendered by a chiropractor. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not for manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the extraspinal chiropractic services (98943), therapeutic procedures 
(97110), and office visit (99213) provided on June 11, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department visit and rhythm ECG (99285, 
93042) provided on July 28, 2021. 
 
 
You asked the Plan to pay for the emergency department visit and rhythm ECG. You say that you would like 
reconsideration because this claim denied as a duplicate in error. The Plan denied your request. The Plan says 
this claim is a duplicate.  
The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined 
to be an exact duplicate are rejected.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the emergency department visit and rhythm ECG have not been met. Specifically, the record 
indicates that the Plan previously processed and paid the claim for these services. There is no evidence to 
support that this claim is not a duplicate to the claim that has been paid by the Plan. Therefore, we decided that 
the Plan does not have to pay for the emergency department visit and rhythm ECG (99285, 93042) provided on 
July 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the clinic visit services provided on September 10, 2021, 
September 17, 2021, and September 24, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the clinic visit services. You say that you provided medically necessary services 
and the claim should be paid. The Plan denied your request. The Plan says the rendering provider is an out-of-
network provider and there was no referral from the enrollee's primary care physician or an approved 
authorization. Also, services rendered was not urgent or emergent. 
 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 clinic visit services provided on September 10, 
2021, September 17, 2021, and September 24, 2021, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home sleep study to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve a home sleep study. You say that you are requesting the enrollee to get a 
home sleep study from an out-of-network provider. The Plan denied your request. The Plan says there are in-
network providers that provide the same quality of service. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a home sleep study to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve replacement mandibular oral appliance (E0486 x1). 
 
You asked the Plan to pre-approve replacement mandibular oral appliance. You say that the item is medically 
necessary. The Plan denied your request. The Plan says records indicate the damage to the oral appliance is 
from wear-and-tear. 
 
The Plan must follow Medicare rules. Medicare rules say that replacement due to wear-and-tear as the result of 
everyday use will be denied as statutorily non-covered prior to the expiration of the 5-year RUL.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of replacement mandibular oral appliance have not been met. Therefore, we decided that the Plan 
does not have to pre-approve replacement mandibular oral appliance (E0486 x1).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for durable medical equipment (DME) provided on September 
28, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the DME. You say that the claim should be paid because you did not know prior 
authorization was required. The Plan denied your request. The Plan says the rendering provider is an out-of-
network provider with no in-network referring provider or no approved authorization. Also, the services 
rendered was not urgent or emergent. 
 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 durable medical equipment (DME) provided on 
September 28, 2021, by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for chiropractic services and outpatient mental 
health services provided to the enrollee from April 5, 2021, to July 12, 2021. 
 
You asked the Plan to waive the copayments for the services. You say that you were advised that you would 
not be responsible for this. The Plan denied your request. The Plan says the claim processed correctly per your 
plan's policy.  
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 $20 
copayment for chiropractic services.  
 
You have been asked to pay a $40 copayment for each of the eight outpatient mental health care sessions. 
These services fall under the outpatient mental health care benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. 
 
You have been asked to pay $16.53 instead of the full $20 copayment for chiropractic services for the services 
received on June 2, 2021 and June 4, 2021. The plan's allowed amount for these services was only $16.53, so 
you don't have to pay the full $20 copayment. the services falls within the chiropractic services 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. Additionally, you 
received services on these dates that are not considered manual manipulation of the spine - procedure codes 
99203 and 97140. These codes were correctly denied and you are responsible for these charges.  
 
Therefore, we decided that the Plan does not have to waive the copayments for chiropractic services and 
outpatient mental health services provided to the enrollee from April 5, 2021, to July 12, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
   
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, at an intensive rehabilitation therapy program. It is not clear that the enrollee is reasonably expected to 
fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Therapy 
services may be provided at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to adjust the copayment for the prostate biopsy (55700) provided on 
October 12, 2021. 
 
You asked the Plan to adjust 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 $250 
copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including 
but not limited to hospital or other facility charges and physician or surgical charges.  You have been asked to pay a $250 copayment for the Medicare-covered surgery provided at an outpatient 
hospital. 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 adjust the copayment for the prostate biopsy (55700) provided on 
October 12, 2021.