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

 
We decided that the Plan does not have to pay for the opioid injections provided on November 15, 2021. 
 
You asked the Plan to pay for the services provided. You say that subarachnoid opioids are very effective. The 
Plan denied your request. The Plan says there is insufficient documentation of response to prior injections. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We looked at the file and the rules. The medical records provided are invalid. The records do not indicate the 
date the services were provided. Based on this information, we decided that Medicare rules for coverage of the 
billed services have not been met. Therefore, we decided that the Plan does not have to pay for the opioid 
injections provided on November 15, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the total shoulder arthroplasty (23472). 
 
You asked the Plan to pre-approve the total shoulder arthroplasty. You say that the requested shoulder surgery 
is medically reasonable and necessary. The Plan denied your request. The Plan says the requested surgery 
services are not medically reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 the total shoulder arthroplasty. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that the enrollee is a 67-year-old female being treated for pain in the left 
shoulder. She presented with left shoulder pain for 8+ years. The pain is rated 7 out of 10. The pain is constant, 
stiff, throbbing, and worse at night. The exam reveals normal strength with discomfort on resistance testing. 
Range of motion is forward flexion 65, abduction 45, and with little to no internal or external rotation. X-rays 
are noted to show bone-on-bone severe, end-stage glenohumeral arthritis with multiple osteophyte formation. 
However, detailed documentation is not evident regarding trial and failure/outcomes of recent, reasonable, and 
comprehensive less invasive conservative care measures.  She was noted to have started therapy in March 2022 as well as having undergone a cortisone injection on 
March 11, 2022. There are limited large-scale, long-term references showing the safety and efficacy of the 
requested surgery in this clinical setting. There is no compelling rationale presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, 
the requested shoulder arthroplasty services are not medically reasonable or necessary. 
 
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 total shoulder arthroplasty have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the total shoulder arthroplasty (23472).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal scaling and root planing - one to three teeth 
per quadrant (D4342) and periodic oral evaluation - established patient (D0120) provided December 23, 2021. 
 
You asked the Plan to pay for the periodontal scaling and root planing and periodic oral exam. You say that 
you would like these services covered. The Plan denied your request. The Plan says you have exhausted your 
dental benefits for 2021. 
 
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 
periodontal scaling and root planing and periodic oral exam up to $1,000 every year for non-Medicare covered 
preventative dental services and non-Medicare covered comprehensive dental services combined. 
We looked at the file and Medicare rules. The Plan provided documentation showing that your full $1,000 
dental allowance has been applied to dental service provided January 4, 2021, and December 23, 2021. 
Therefore, we decided that the Plan does not have to pay for the periodontal scaling and root planing - one to 
three teeth per quadrant (D4342) and periodic oral evaluation - established patient (D0120) provided December 
23, 2021.  
 
Your complaint about the medical jargon used by the Plan which you feel is not consumer-friendly 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 the intraoral - periapical first radiographic image (D0220) 
provided November 29, 2021. 
 
You asked the Plan to pay for the periapical x-ray. You say that this service was necessary, and you feel it 
should be covered. The Plan denied your request. The Plan says this service is not covered under your 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 the 
intraoral - periapical first radiographic image (D0220) provided November 29, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient services provided on December 30, 2019. 
 
You asked the Plan to pay for the acute inpatient services. You say that the acute inpatient services provided 
were emergent and medically necessary. The Plan denied your request. The Plan says medical necessity was 
not established. 
 The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient services. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the enrollee presented with a syncopal episode lasting a few seconds. Our reviewer 
found that there was no cause for syncope found in initial workup in the emergency department and the patient 
was hemodynamically stable at the time of admission. Our physician reviewer also found that based on the 
provided documentation, it was not expected that the patient would require hospital services that would likely 
cross 2 midnights. 
 
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 acute inpatient services have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient services provided on December 30, 2019.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for the emergency ambulance transportation services (A0427-DH, A0425-
DH) provided on December 22, 2021. 
 
You asked the Plan to pay for the ambulance transport. You say that emergency services are separately payable 
in this instance. The Plan denied your request. The Plan says that this is not a separately payable service in this 
case, as payment for this transportation would be included in the facility fees where the enrollee was 
institutionalized during transport. 
 
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. 
 
In this case, the documentation suggests that the enrollee was transported from a rehab facility to a hospital 
after experiencing fever and confusion following a urinary tract infection. The Plan argues that the payment for 
this service is included in the payment for the facility. The Plan has not made reasonable and diligent efforts to 
gather and forward to us information regarding their decision to deny your request. Specifically, the 
documentation does not show that the enrollee was inpatient at any facility prior to transport on the date in 
question. The Plan submitted a claim from a hospital for the same date, but there is no other evidence to show 
that the inpatient claim was accurate or billed correctly. The National Provider Identifier (NPI) we found for 
the facility the enrollee was transported from indicates that this facility is a Comprehensive Outpatient 
Rehabilitation Facility (CORF) and not an inpatient facility. If this facility were a skilled nursing facility or an 
inpatient rehabilitation facility, modifiers H or N would have been more appropriate. The Plans denial is not 
substantiated in this case. Therefore, we decided that the Plan has to pay for the emergency ambulance 
transportation services (A0427-DH, A0425-DH) provided on December 22, 2021.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81479) provided on September 17, 2021. 
 
You asked the Plan to pay for the laboratory 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. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, code 81479, was requested solely for screening purposes. Medicare does not 
cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the 
laboratory services (81479) provided on September 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hearing aid services provided on June 4, 2018, and October 
28, 2020. 
 
You asked the Plan to pay for hearing aid services. You say that you were just told these services are covered 
by your Plan and you feel they should not be denied. The Plan denied your request. The Plan says your Plan did 
not cover hearing aids in 2018, and hearing aids in 2020 were only covered when they are purchased through 
the specified hearing vendor. 
 
Medicare does not pay for hearing aids or related services. Though the hearing aids may have been appropriate 
in this case, neither Medicare nor the Plan covered or paid for these types of items and services in 2018. 
Therefore, we decided that the Plan does not have to pay for the hearing aid services provided on June 4, 2018. In 2020, the Plan offered a hearing aid benefit that exceeded Medicare coverage. For that reason, the Plans 
coverage rules apply in this case. The Plan paid for hearing aids in 2020 only when they were purchased 
through the specified hearing vendor. 
 
We looked at the file and the Plan's rules. The hearing aids in this case were purchased from an out-of-network 
vendor. Based on this information, we decided that the Plan's rules for coverage of hearing aid services have 
not been met. Therefore, we decided that the Plan does not have to pay for hearing aid services provided on 
October 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete 
series of intraoral x-rays (D0210) provided on January 6, 2022. 
 
You asked the Plan to pay for the comprehensive oral evaluation and complete series of intraoral x-rays. You 
say that you tried to get your records from the other provider, but you were not successful. You also say that 
you would like these services to be covered. The Plan denied your request. The Plan says these services exceed 
the maximum counts allowed per period. 
 
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, comprehensive oral evaluation 
(D0150) and complete series of intraoral x-rays (D0210) are each limited to one procedure every three plan 
years. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) 
and complete series of intraoral x-rays (D0210) provided on January 6, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy (PT) and occupational therapy (OT) 
services provided on July 21, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the PT and OT services. You say that these services were medically necessary, 
and you would like this claim to be reprocessed for payment. The Plan denied your request. The Plan says this 
service requires prior authorization. The Plan also says that no prior authorization for the service was obtained 
and there is no documentation that this procedure was part of an emergency 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 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 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 physical therapy (PT) and occupational 
therapy (OT) services provided on July 21, 2021 by 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 a skilled nursing facility (SNF) stay and 
outpatient rehabilitation services provided from June 1, 2021, to June 18, 2021. 
 
You asked the Plan to waive the copayment for the SNF stay and outpatient rehabilitation services. You say 
that the services should be covered as you disagree with the charges. The Plan denied your request. The Plan 
says the cost-sharing applied correctly based on the services 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 $170 
copayment per day for days 21-100 of Skilled nursing facility (SNF) care and a $20 copayment for Outpatient 
rehabilitation services.  
 You have been asked to pay a $850 copayment for 5 days of SNF care ($170 x 5 = $850) and a $20 copayment 
for outpatient rehabilitation 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 a skilled nursing 
facility (SNF) stay and outpatient rehabilitation services provided from June 1, 2021, to June 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bitewings (D0272) provided on February 11, 2022. 
 
You asked the Plan to pay for the bitewings. You say that this was your first visit to the dentist for the 2022 
plan year. The Plan denied your request. The Plan says this service is allowed two times per calendar year. The 
Plan also says that you have reached this limit 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, you are limited to two of either codes 
D0220, D0230, D0270, D0272, D0273 or D0274 per 1 Calendar year(s). The record shows that you received a 
first intraoral periapical x-ray (D0220) and an additional intraoral periapical x-ray (D0230) on February 11, 
2022 which was covered by the Plan, and your intraoral x-rays and bitewing x-rays benefits have been 
exhausted. Therefore, we decided that the Plan does not have to pay for the bitewings (D0272) provided on 
February 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the consultation (D9310) provided on January 21, 2022. 
 
You asked the Plan to pay for the consultation. You say that the treating provider accepted your insurance card, 
and you believe the Plan should pay for this service. The Plan denied your request. The Plan says this service is 
not a covered expense under your dental plan. The Plan also says that you did not contact the Plan prior to the 
date of service to verify 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 the 
consultation (D9310) provided on January 21, 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 the admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH 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 there are no services available at the LTACH that you require that are not available 
and being provided at the health care setting being offered by the health plan. 
 
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 the spinal injection provided on November 8, 2021. 
 
You asked the Plan to pay for the spinal injection. You say that this was denied using epidural injection rules, 
and the injection provided is subarachnoid. This treatment was necessary for the enrollee's condition. The Plan 
denied your request. The Plan says the records provided do not support medical necessity. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare requires that services 
provided/ordered/certified be authenticated by the persons responsible for the care of the beneficiary in 
accordance with Medicare's policies. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the spinal injection have not been met. Specifically, the documentation submitted does not include 
a valid signature from the persons responsible for the care of the beneficiary.  Review of the progress note shows that the field for electronic signature is blank, and the only potential 
signature is typed and undated. In addition, the progress note does not have a date of service specified, meaning 
it cannot be confirmed that this note is for the services provided on the date of service at issue. Therefore, we 
decided that the Plan does not have to pay for the spinal injection provided on November 8, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital outpatient clinic visit provided on February 7, 2022. 
 
You asked the Plan to pay for hospital outpatient clinic visit. The Plan denied your request. The Plan says the 
rendering provider is non-par and there is no referring provider. There is no evidence that this is 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 did not pre-approve the 
service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for hospital outpatient clinic visit provided on February 7, 2022.