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

 
We decided that the Plan does not have to pay for the gingival irrigation  per quadrant (D4921) provided April 
6, 2022. 
 
You asked the Plan to pay for the gingival irrigation. You say that you want your dental expenses 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 
gingival irrigation  per quadrant (D4921) provided April 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive orthodontic treatment of the adult 
dentition (D8090). 
 
You asked the Plan to pre-approve the comprehensive orthodontic treatment. You say that you would like this 
service to correct your sleep apnea and narrow nasal passages. The Plan denied your request. The Plan says this 
service is not covered under your 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 pre-approve a 
comprehensive orthodontic treatment of the adult dentition (D8090).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete denture - maxillary (D5110) and immediate 
denture - mandibular (D5140). 
 
You asked the Plan to pre-approve the dental services. You say that the enrollee is unable to use his current 
dentures without using a lot of adhesives. The Plan denied your request. The Plan says the enrollees benefit for 
the requested item or 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 the enrollees benefit for the complete denture (D5110) was exhausted on date of service February 6, 
2019, and the enrollees benefit for the immediate denture (D5140) was exhausted on April 4, 2019. Therefore, 
we decided that the Plan does not have to pre-approve a complete denture - maxillary (D5110) and immediate 
denture - mandibular (D5140).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture (D5213) provided by a 
participating provider. 
 
You asked the Plan to pre-approve the dental services. You say that you need these dentures. The Plan denied 
your request. The Plan says your benefit for the requested item or 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 item or service was exhausted on date of service January 14, 2019. 
Therefore, we decided that the Plan does not have to pre-approve a maxillary partial denture (D5213) provided 
by a participating provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system identified with code 
E2300, expandable controller identified with code E2377, harness for upgrade to expandable controller 
identified with code E2313, electronic connection between wheelchair controller and two or more power 
seating system motors identified with code E2311, and active reach seating system identified with code K0108. 
 
You asked the Plan to pre-approve a power seat elevation system, expandable controller, harness for upgrade to 
expandable controller, electronic connection between wheelchair controller and two or more power seating 
system motors, and active reach seating system. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the requested items are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that power wheelchair accessories are only covered 
for certain indications. A power seat elevation feature is non-covered. 
 
The request for the active reach seating system is only available with a power adjustable seat height. As noted, 
the power seat elevation system feature is non covered. This means this item is not covered as well. 
 
We looked at the file and Medicare rules. The requested power seat elevation system and active reach seating 
system are specifically not covered. The documentation shows that the enrollee has right upper limb strength 
and function adequate to be able to control the approved power options using their own switches which are 
included in the allowance of the power options. 
 
Based on this information, we decided that Medicare rules for coverage of a power seat elevation system, 
expandable controller, harness for upgrade to expandable controller, electronic connection between wheelchair 
controller and two or more power seating system motors, and active reach seating system have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system identified with 
code E2300, expandable controller identified with code E2377, harness for upgrade to expandable controller 
identified with code E2313, electronic connection between wheelchair controller and two or more power 
seating system motors identified with code E2311, and active reach seating system identified with code K0108.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient services provided May 9, 2021, to May 16, 
2021. 
 
You asked the Plan to pay for the inpatient services. You say that you disagree with the Plan's decision. The 
Plan denied your request. The Plan says the services billed are not supported by the documentation.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with primary diagnosis of J96.91, defined as respiratory 
failure, unspecified with hypoxia. 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 inpatient 
services. Our reviewer says that the documentation does not support the DRG billed. Our physician reviewer 
found the enrollee was admitted to the hospital with shortness of breath and cough due to pneumonia. An 
arterial blood gas was not performed. It is noted that the oxygen saturation was 91-95 percent in the emergency 
department; the oxygen saturation was between 91-99 percent on 0-2 liters of oxygen during the hospital stay. 
However, there was no documentation of persistent respiratory distress/increased work of breathing, persistent 
tachypnea, cyanosis, or persistent or progressive dyspnea over the member's baseline. The physician 
documented in the history and physical and progress notes "no acute distress". Listing of acute respiratory 
failure in the medical record was not substantiated by the documentation. In summary, J96.91 (respiratory 
failure, unspecified with hypoxia) was not substantiated as a valid diagnosis. Therefore, the DRG billed is not 
supported by the documentation.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for the inpatient services provided May 9, 2021, to May 16, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Calcitriol capsules you received from March 4, 2022, to 
March 30, 2022. 
 
You asked the Plan to pay for the Calcitriol tablets. You say that Medicare coverage was ignored, and your 
plan should pay 10% of what Medicare pays. The Plan denied your request. The Plan says self-administered 
drugs are not covered under your medical benefits. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the Calcitriol capsules you 
received from March 4, 2022, to March 30, 2022.   
Benefits for the Calcitriol tablets may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic services provided on April 13, 2022, by an 
out-of-network chiropractor. 
 
You asked the Plan to pay for the chiropractic services. You say that the patient is enrolled in a Dual plan and 
is entitled to coverage of all Medicare services. The Plan denied your request. The Plan says codes 97530-59 
and 98943 are not covered chiropractic services under any circumstance.  The Plan also says that the manual manipulation of the spine (code 98941) is not covered in this instance because it was provided by an out-of-
network provider without authorization. 
 
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.  In addition, the rules say that Plans can restrict 
members to using network providers in most instances.  
 
The records show that codes 97530-59 and 98943 are not manual manipulation of the spine. In addition, the 
chiropractor who provided these services is not a network provider with the Plan and did not have authorization 
to provide this care. Therefore, we decided that the Plan does not have to pay for the chiropractic services 
provided on April 13, 2022, by an out-of-network chiropractor.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an inpatient hospital stay for an approved shoulder 
surgery. 
 
You asked the Plan to pre-approve the inpatient stay. You say that the inpatient stay is medically necessary. 
The Plan denied your request. The Plan says this procedure can be performed in an outpatient setting. 
 
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 inpatient stay. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no indication from recent notes that the enrollee has an unstable condition that might 
warrant inpatient treatment following this procedure, which is typically performed in an ambulatory 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 inpatient stay have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an inpatient hospital stay for an approved shoulder surgery.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for urology surgical services provided to the enrollee on March 
18, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services billed. 
 
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 55650 is Vesiculectomy, any approach. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found that the records do not support that 
CPT 55650 - vesiculectomy, any approach - was separate and distinct from the surgical laparoscopic retropubic 
radical prostatectomy (represented by CPT 55866) in this case. Bilateral vesiculectomy is/was considered to be 
a component of radical prostatectomy.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for urology surgical services provided to the enrollee on March 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 9, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the services should be covered as you disagree with 
the denial. The Plan denied your request. The Plan says the services denied correctly as they were non-
emergent and prior authorization was not obtained. 
 
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 an office visit provided on February 9, 2022 by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lodging services (procedure code 99070) provided to the 
enrollee on January 28, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99070 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99070 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for 
lodging services (procedure code 99070) provided to the enrollee on January 28, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from March 10, 2021, to April 1, 2021. 
 
You asked the Plan to pay for the services. You say that you have submitted supporting documentation for 
reconsideration of this adjustment. The Plan denied your request. The Plan says the provider has reported 
skilled services with the incorrect PDPM Health Insurance Prospective Payment System (HIPPS) score. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
The provider has billed PDPM score NJCE1. The plan disagrees with "C" which requires documentation of 
extensive services for coding of isolation while a resident, and a nursing function score of 0-14. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that a review of Resident Assessment 
and Care Screening dated 3/1021 does not document extensive services for coding of isolation while a resident. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for skilled nursing facility (SNF) services provided to the enrollee from March 10, 2021, to April 1, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a primary care office visit provided on 
March 2, 2022. 
 
You asked the Plan to waive the copayment for a primary care office visit. You say that you should not have to 
pay a copayment for this visit. The Plan denied your request. The Plan says the copayment applied was correct. 
 
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 $25 
copayment for physician/practitioner services.  
 
You have been asked to pay a $25 copayment for a primary care office visit. a primary care office visit falls 
within the Physician/Practitioner 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. Therefore, we decided that the Plan does not have to waive the copayment 
for a primary care office visit provided on March 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wheelchair ramp. 
 
You asked the Plan to pre-approve a wheelchair ramp. You say that you do not want to stay inside the house 
for the rest of your life. You also say that you cannot get out of your house without this wheelchair ramp. The 
Plan denied your request. The Plan says the requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a wheelchair ramp.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical techniques requiring use of robotic surgical 
system identified with code S2900. 
 
You asked the Plan to pre-approve surgical techniques requiring use of robotic surgical system. You say that 
you disagree with the Plan's denial. The Plan denied your request. The Plan says the requested services are 
specifically not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code S2900 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S2900 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of surgical techniques requiring use of robotic surgical system have not been met. Therefore, 
we decided that the Plan does not have to pre-approve surgical techniques requiring use of robotic surgical 
system identified with code S2900.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wrist arthroplasty (25447, 25310). 
 
You asked the Plan to pre-approve the procedure. You say that this service is medically necessary. The Plan 
denied your request. The Plan says the requested procedure is not medically 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 procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found records do not show comprehensive less invasive conservative care measures (including formal 
physical therapy). Additionally, the x-rays demonstrate mild to moderate degenerative joint disease. There are 
limited studies showing the safety and efficacy of the requested surgery in this clinical 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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a wrist arthroplasty (25447, 25310).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the health club membership (S9970) 
purchased on March 1, 2022. 
 
You asked the Plan to issue reimbursement for this service. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says the health club membership is not 
payable as it was purchased from an out-of-network provider. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers a fitness 
membership when purchased from the Plans select provider. 
 
We reviewed the case file and the Plans rules. Based on this information we have decided that the Plans rules 
for coverage of this service have not been met. Specifically, the Plan contract states that a fitness membership 
is offered as a supplemental benefit with the Plans select provider at participating locations. The membership 
in this case was purchased from an out-of-network provider. Therefore, we decided that the Plan does not have 
to issue reimbursement for the health club membership (S9970) purchased on March 1, 2022.