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

 
We decided that the Plan does not have to pre-approve inpatient hospital services for the enrollee. 
 
You asked the Plan to pre-approve inpatient hospital services. You say that these services are medically 
necessary. The Plan denied your request. The Plan says that there is no documentation provided to support the 
expectation the enrollee will require a greater than 2 midnight stay. 
 
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 pre-approve inpatient hospital services. Our 
reviewer says that inpatient hospital services are not medically reasonable and necessary. The patient has 
cervical spinal stenosis with radiculopathy. This is a request for inpatient care associated with elective spinal 
surgery (hybrid total disc arthroplasty/ACDF). The provided records did not reveal an unstable condition, high 
risk medical history, or expectation that this patient would require hospital services that would likely cross 2 
midnights associated with this nonemergent surgery. Our physician reviewer found that the enrollee's condition 
does not meet criteria for coverage of inpatient hospital services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient hospital services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve inpatient hospital services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scaling and root planing - four or more teeth 
per quadrant (D4341) and extractions, erupted tooth requiring removal of bone and/or sectioning of tooth, and 
including elevation of mucoperiosteal flap if indicated (D7210). 
 
You asked the Plan to pre-approve periodontal scaling and root planing and surgical tooth extractions. You say 
that you need these services. The Plan denied your request. The Plan says these services are 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 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 pre-approve 
periodontal scaling and root planing - four or more teeth per quadrant (D4341) and extractions, erupted tooth 
requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for fishing reels an ice fishing auger provided on December 8, 
2021. 
 
You asked the Plan to pay for fishing equipment. You say that you are requesting reimbursement for this 
equipment. The Plan denied your request. The Plan says the denial of payment for this equipment is correct, 
because this equipment is not covered by Medicare and does not fall within the Plan's Wellness Wallet 
reimbursement benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose. The Plan contract says that the Wellness Wallet reimbursement program may cover fitness 
expenses, including fitness membership fees and personal trainer fees.  
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Although fishing 
is a fitness activity, the fishing equipment that you are requesting payment for is not eligible for reimbursement 
under the Plans Wellness Wallet program because it is not a fitness membership or personal trainer fee 
expense. Therefore, we decided that the Plan does not have to pay for fishing reels an ice fishing auger 
provided on December 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient hospital services provided on October 13, 
2021, billed with multiple codes including G0463 and 96377. 
 
You asked the Plan to pay for the outpatient hospital services. You say that this is billed correctly and should 
be paid. The Plan denied your request. The Plan says a Column 2 code was billed on this claim without a 
modifier. This caused an OCE edit which returned the claim to provider to be corrected. 
 
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 G0463 
is a column II code to column I code 96377. This claim has not been billed with an appropriate modifier to 
bypass the edit. This edit causes OPPS claims to be denied in full and returned to the provider. Based on the 
claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have 
to pay for the outpatient hospital services provided on October 13, 2021, billed with multiple codes including 
G0463 and 96377.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 92921 billed for date of service September 
15, 2021. 
 
You asked the Plan to pay for procedure code 92921. You say that you have submitted medical records to 
support payment. The Plan denied your request. The Plan says no separate payment is made for this code. 
 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 92921 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 92921 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of procedure code 92921 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 92921 billed for date of service September 15, 2021.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for the emergency room services provided on October 16, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says that the 
charge is incidental to another service. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
We looked at the file and the rules. The services denied as incident to another service. The Plan did not provide 
any information regarding the service it is incident to. The Plan has not made reasonable and diligent efforts to 
gather and forward to us information regarding their decision to deny your request. Therefore, we decided that 
the Plan has to pay for the emergency room services provided on October 16, 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sleep study. 
 
You asked the Plan to pre-approve the study. You say that this is medically necessary. The Plan denied your 
request. The Plan says the notes must shows signs or symptoms of temporary stoppage of breathing during 
sleep (sleep apnea). 
 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 study. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found a home sleep test is not medically necessary, due to a lack of information. The information provided 
does not include any medical records or reports of a clinical evaluation. There is no documentation of a sleep 
history, examination, or reason for this test. 
 
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 study have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a sleep study.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for biologic materials to aid in soft and osseous tissue 
regeneration (D4265), intravenous (IV) moderate (conscious) sedation/analgesia- first 15 minutes (D9239) and 
intravenous moderate (conscious) sedation/analgesia - each subsequent 15-minute increment (D9243). 
 
You asked the Plan to pay for biologic materials to aid in soft and osseous tissue regeneration and IV sedation. 
You say that extractions are medically necessary due to an infection, and you do not want to be awake for the 
procedure. The Plan denied your request. The Plan says these services are 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 biologic 
materials to aid in soft and osseous tissue regeneration (D4265), intravenous (IV) moderate (conscious) sedation/analgesia- first 15 minutes (D9239) and intravenous moderate (conscious) sedation/analgesia - each 
subsequent 15-minute increment (D9243).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on May 29, 2021. 
 
You asked the Plan to pay for the ambulance services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment is included in the inpatient facility 
payment. 
 The Plan must follow Medicare rules. The rules say that the applicable payments made under the prospective 
payment systems are payment in full for all inpatient hospital services. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the ambulance services have not been met. Specifically, the record shows that the enrollee was 
admitted as inpatient to the origin location provider. The record did not include adequate documentation 
showing that the enrollee was discharged from the original provider when transported to another provider. This 
means that the ambulance service appears to be covered as an inpatient hospital service and is not separately 
billable. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on May 
29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custom abutment (D6057) and abutment supported 
crowns (D6058). 
 
You asked the Plan to pre-approve abutment and supported crowns. You say that you cannot eat properly due 
the pain because the screws have been implanted and you need to finish the dental work. The Plan denied your 
request. The Plan says that custom abutment (D6057) and abutment supported crowns (D6058) are not covered 
by your Plans dental 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 pre-approve 
custom abutment (D6057) and abutment supported crowns (D6058).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the full cost for cone beam CT image capture (code 
D0383), occlusal orthotic device (code D7880), maxillofacial prosthesis (code D5999) and occlusal adjustment 
(code D9951). 
 
You asked the Plan to pre-approve the full cost for cone beam CT image capture, occlusal orthotic device, 
maxillofacial prosthesis, and occlusal adjustment. You say that you were told procedure code D7880 would be 
covered. The Plan denied your request. The Plan says the requested service is not covered by Medicare or the 
Health Plan. 
 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, there is an annual maximum benefit 
amount of $1,500.  The Explanation of Dental Plan Reimbursement shows the Plan agreed to apply the full 
$1,500 benefit to the occlusal device, which would exhaust your annual dental benefit. Additionally, the cone 
beam CT image, prosthesis, and occlusal adjustment are not covered under your dental benefit. Therefore, we 
decided that the Plan does not have to pre-approve the full cost for cone beam CT image capture (code D0383), 
occlusal orthotic device (code D7880), maxillofacial prosthesis (code D5999) and occlusal adjustment (code D9951).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140), an intraoral periapical x-
ray (D0220), and a crown (D2920) provided on February 4, 2022. 
 
You asked the Plan to pay for evaluation, x-ray, and crown.. You say that the provider is an in-network 
provider. The Plan denied your request. The Plan says that a limited oral evaluation (D0140) and an intraoral x-
ray (D0220) are covered once per year, but the coverage benefit has been exhausted. The Plan also says that a 
crown (D2920) is not covered by your Plan's supplemental dental 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 Plan covers a limited oral 
evaluation (D0140) and an intraoral x-ray (D0220) once per year. The Plan does not cover a crown (D2920). 
 
We looked at the case file, the Plans rules, and Medicare rules. The record shows the Plan paid for a limited 
oral evaluation (D0140) and an intraoral x-ray (D0220) on March 15, 2022, from a different provider. 
Therefore, the benefits for these services are exhausted. Though the Plan offers a dental benefit in excess of Medicare coverage, a crown (D2920) is not among those covered under this benefit. Therefore, we decided that 
the Plan does not have to pay for a limited oral evaluation (D0140), an intraoral periapical x-ray (D0220), and a 
crown (D2920) provided on February 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided to the enrollee on February 16, 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 was denied due to documentation stating a specifc laterality for the hip osteoarthritis. 
 
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 99213 is "Office or other outpatient visit for the 
evaluation and management of an established patient, which requires a medically appropriate history and/or 
examination and low level of medical decision making. When using time for code selection, 20-29 minutes of 
total time is spent on the date of the encounter." 
 
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 the service were billed with an 
unspecified laterality code. The documentation supports a higher specificity code, and should be reported. 
 
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 an office visit provided to the enrollee on February 16, 2022.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for emergency room services provided to the enrollee on October 19, 2021. 
 
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 that evaluation and management codes are not covered for this specialty or provider type. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The plan has not provided a valid rationale for why the rendering provider type 
is not appropriate for emergency services. The provider at issue in this case is an MD - doctor of medicine. 
This would be a valid provider of emergency services. Therefore, we decided that the Plan has to pay for 
emergency room services provided to the enrollee on October 19, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Endobronchial Valve (EBV) placement (31647, 31651). 
 
You asked the Plan to pre-approve EBV placement. You say that the requested service is medically necessary. 
The Plan denied your request. The Plan says the service at issue 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 EBV placement. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee appears to be a good candidate for this procedure, but there is no arterial blood gas 
demonstrating a partial pressure of carbon dioxide of 60 or less, no 6-min walk test, and the enrollee has not 
participated in pulmonary rehabilitation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of EBV placement have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Endobronchial Valve (EBV) placement (31647, 31651).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the Transcutaneous Electrical Nerve Stimulators (TENS) supply 
(A4595), provided on January 27, 2022. 
 
You asked the Plan to pay for the TENS supply. You say that the service is medically necessary. The Plan 
denied your request. The Plan says that the service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 TENS supply. Our reviewer says that the 
requested items are considered medically reasonable and necessary in this case. Our physician reviewer found 
this member does meet LCD criteria for coverage of this item. 
 
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 TENS supply have been met. Therefore, we decided that the Plan has to pay 
for the Transcutaneous Electrical Nerve Stimulators (TENS) supply (A4595), provided on January 27, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the Transcutaneous Electrical Nerve Stimulators (TENS) supply 
(A4595), provided on January 23, 2022. 
 
You asked the Plan to pay for the TENS supply. You say that the item is medically necessary. The Plan denied 
your request. The Plan says that the item is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 TENS supply. Our reviewer says that the 
requested items are considered medically reasonable and necessary in this case. Our physician reviewer found 
the member does meet LCD criteria for coverage of this item. 
 
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 TENS supply have been met. Therefore, we decided that the Plan has to pay 
for the Transcutaneous Electrical Nerve Stimulators (TENS) supply (A4595), provided on January 23, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.