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

 
We decided that the Plan does not have to pre-approve an additional endodontic therapy (D3320) 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says your benefit for the requested item or 
service has already been exhausted. The plan will only cover one of these codes per year and so the additional 
procedure cannot be approved at this time. 
 
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 10/23/2022 through 
01/21/2023. Therefore, we decided that the Plan does not have to pre-approve an additional endodontic therapy 
(D3320)
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is experiencing significant decline, is not 
able to discharge without proper physical therapy. The Plan denied your request. The Plan says that based on 
Medicare guidelines the inpatient rehabilitation facility services you are requesting do not meet the 
requirements for approval. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the clinical documentation shows the enrollee has active medical conditions thus the enrollee would be 
expected to require continued inpatient hospitalization during rehabilitation with an interdisciplinary approach 
to care. The documentation also shows that the enrollee has complex functional impairments including 
neurological weakness related to post-ictal state in addition to self-care and mobility deficits. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute IRF admission and services.  
 
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: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair (K0857) and related 
accessories (E2361, E1028, E1002, E2300, K0108, and E2311). 
 
You asked the Plan to pre-approve a group 3 power wheelchair and related accessories. You say that Hurricane 
Ian caused irreparable damages to the enrollee's existing power wheelchair. You say that the enrollee's needs 
remain the same and there is no other insurance responsible for replacement of this equipment. The Plan denied 
your request. The Plan says the enrollee does not have a qualifying diagnosis causing mobility limitation for 
which a group 3 power wheelchair is medically needed. 
 
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for 
enrollees who have a mobility limitation that is due to: 
 
1. A neurological condition; 
 
2. Myopathy; or 
 3. Congenital skeletal deformity. 
 
The records indicate the enrollee has two amputations. The file does not show that the enrollee has a mobility 
limitation that is due to a neurological condition, myopathy or congenital skeletal deformity. Therefore, we 
decided that the Plan does not have to pre-approve a group 3 power wheelchair (K0857) and related accessories 
(E2361, E1028, E1002, E2300, K0108, and E2311).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for computed tomography (CT scan) provided 
on August 01, 2022. 
 
You asked the Plan to waive the copayment for computed tomography (CT scan). You say that you shouldnt 
have to pay for this. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 $75 
copayment for Diagnostic procedures and tests. 
 
You have been asked to pay a $75 copayment for computed tomography (CT scan). This item/service falls 
within the Diagnostic procedures and tests 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 computed tomography (CT scan) provided on August 01, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient mental health visits provided 
from July 7, 2022, to August 8, 2022. 
 
You asked the Plan to waive the copayment for outpatient mental health visits. You say that you disagree with 
the copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 per visit for outpatient mental health care.  
 
You have been asked to pay a $25 copayment per visit for outpatient mental health visits. The total amount you 
are being asked to pay is $70 ($25 x 7 visits = $70). 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 
outpatient mental health visits provided from July 7, 2022, to August 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation services (99153) provided on June 2, 
2022. 
 
You asked the Plan to pay for the moderate sedation services. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says sedation is not separately 
payable when performed by a physician in a facility setting. 
 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 99153 is moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; each additional 15 minutes intraservice time (List 
separately in addition to code for primary service). 
 
We looked at the file and Medicare rules. In this case, all items and non-physician services furnished to 
inpatients must be furnished directly by the hospital or billed through the hospital. Based on this information, 
we decided that Medicare rules for coverage of the moderate sedation services have not been met. Therefore, 
we decided that the Plan does not have to pay for the moderate sedation services (99153) provided on June 2, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to more pay for dental services you received on July 5, 2022. 
 
You asked the Plan to more pay for the dental services. You say that you were not told that there were 
limitations to your tooth cleaning benefits. The Plan denied your request. The Plan says your benefit for the 
requested item or service has already been exhausted. Specifically, it has paid a total of $544 towards the dental 
services you received on July 5, 2022.  This amount, plus the amounts that the Plan has paid for other dental 
services you received in 2022, equal your $1000 benefit. 
 
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. Your dental 
benefit only covers dental services up to $1000 per year. According to your records, the Plan has already paid 
out $1000 towards your dental claims for 2022, so the Plan is not required to pay any more towards the dental 
services you received on July 5, 2022. Therefore, we decided that the Plan does not have to more pay for dental 
services you received on July 5, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued SNF care. 
 
You asked the Plan to pre-approve continued SNF care. You say that you still need the rehabilitation services. 
 The Plan denied your request. The Plan says your needs can be continued with home health services. 
 
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 care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found your endurance with walking requires exercise with support from non-skilled 
personnel. Daily skilled physical therapy is not medically necessary. You have reached a level of function with 
occupational therapy with good capacity for dressing and bathing but had not responded to therapy with 
toileting. You do not have daily skilled nursing needs that require the specialized skill, knowledge, and 
judgment of a skilled professional nurse. You do not have daily skilled therapy needs that require the 
specialized skill, knowledge, and judgment of a skilled professional therapist. Our reviewer also found that you 
do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility 
(SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve continued SNF care.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost share for an injection and a myocardial perfusion 
imaging provided on July 26, 2022. 
 
You asked the Plan to reduce the cost share for an injection and a myocardial perfusion imaging. You say that 
an additional copayment was billed for date of service July 26, 2022, and you would like the claim to be 
reviewed for reconsideration. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
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 20% 
coinsurance for Medicare-covered Part B drugs and a $50 copayment for advanced imaging services when 
provided in a physician's office.  
 You have been asked to pay a total cost share of $103.24 for an injection and a myocardial perfusion imaging. 
This total includes a coinsurance of $53.24, which is 20% of the allowed amount for an injection ($266.18 
allowed x 20% = $53.24) and a $50 copayment for a myocardial perfusion imaging. An injection falls within 
the Medicare Part B Prescription Drugs benefit category. A myocardial perfusion imaging falls within the 
Outpatient Diagnostic Tests 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 reduce the cost share for an injection 
and a myocardial perfusion imaging provided on July 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone replacement graft (D7953) 
 
You asked the Plan to pre-approve the dental services. 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 do 
not fall within your 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 a 
bone replacement graft (D7953)
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services coded G0483 provided on 
December 8, 2021. 
 
You asked the Plan to pay for the drug testing services coded G0483. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says the service coded G0483 
is redundant to services already paid. 
 
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 G0483 is drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, the documentation indicates 
CPT code G0480 was already paid on the date of service in question. It is inappropriate to bill two drug testing 
services with different drug classes measured. Based on this information, we decided that Medicare rules for 
coverage of the drug testing services coded G0483 have not been met. Therefore, we decided that the Plan does 
not have to pay for the drug testing services coded G0483 provided on December 8, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that admission is medically necessary. The 
Plan denied your request. The Plan says based on Medicare guidelines and the information we have about your 
condition you do not meet all the requirements. 
 
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 is no documentation provided indicating medical necessity for admission to a 
LTACH. You are receiving appropriate care at the present setting. You do not require services at the LTACH 
that are not available at the acute care hospital where you are receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services denied with code B provided to 
the enrollee from July 15, 2021, to July 31, 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 the facility has recently provided the itemized bill allowing the plan to identify and validate the 
charges. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
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 services provided was 
"Ferangio software PAT Chrgable" and "Hemapro".  After careful review of the medical record these items 
were not provided, and therefore cannot be verified.  
 
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 inpatient hospital services denied with code B provided to the enrollee from July 15, 2021, to 
July 31, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says 
admission 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 the record indicates that the enrollee remains critically ill requiring vasopressor 
support and other acute critical care services. The medical record does not indicate that the enrollee requires 
services that they are not currently receiving but that would be available at the LTACH facility. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay on August 30, 2022, 
to September 01, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that you want to appeal the 
amount being charged. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
 
 
 
 
 
 The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay a $310 copayment per day for days 1 -6 for each Medicare-covered hospital stay, you are required to 
pay the applicable cost sharing, starting with day 1 each time you are admitted. Includes inpatient acute, 
inpatient rehabilitation, long-term care hospitals and other types of inpatient hospital services. Inpatient 
hospital care starts the day you are formally admitted to the hospital with a doctors order. The day before you 
are discharged is your last inpatient day. There were 2 days. 2 x $310 = $620. Therefore, results in the total cost 
sharing amount of $620.  
 
The enrollee has been asked to pay a $310 copayment per day for inpatient hospital stay. This item/service falls 
within the Inpatient hospital care benefit category. This means that the enrollee has been asked to pay the 
correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee 
agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for inpatient hospital stay on August 30, 2022, to September 01, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance service provided on June 1, 
2022. 
 
You asked the Plan to waive the copayment for ambulance service. You say that you are disputing the share 
cost. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 $250 
copayment for ambulance services.  
 
You have been asked to pay $250 copayment for ambulance service. This item/service falls within the 
ambulance 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 ambulance service 
provided on June 1, 2022.