Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided on January 28, 2022, 
through February 2, 2022. 
 
You asked the Plan to pay for the self-administered drugs. You say that the items are medically necessary. The 
Plan denied your request. The Plan says self-administered drugs are not covered. 
 
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 self-administered drugs 
provided on January 28, 2022, through February 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pontic (D6245) or pay more for one retainer crown 
(D6740) provided on November 29, 2021. 
 
You asked the Plan to pay for the pontic and to pay more for the one retainer crown. You say that you have a 
$2,000 dental benefit which should have been used to cover these services. The Plan denied your request. The 
Plan says pontic is not a covered expense under your dental plan. The Plan also says that your dental maximum 
has been met. 
 
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, pontic (D6245) is not among those 
covered under this benefit. The contract says that the Plan offers a $2,000 annual dental benefit maximum. The 
record shows that you met the annual maximum benefit when this claim for the November 29, 2021 date of 
service was reprocessed and your annual maximum benefit has been exhausted. Therefore, we decided that the 
Plan does not have to pay for the pontic (D6245) or pay more for one retainer crown (D6740) provided on 
November 29, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the Urovysion Bladder cancer testing provided on August 30, 2021. 
 
You asked the Plan to pay for the Urovysion Bladder cancer testing. You say that this testing was medically 
necessary. The Plan denied your request. The Plan says that this is noncovered screening testing that cannot be 
covered even if ordered by a network provider. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules.  
 
The enrollee was referred for the Urovysion Bladder cancer testing by a contract provider. The file does not 
show that the plan provided notice that the Urovysion Bladder cancer testing would not be covered. In fact, the 
local Medicare contractor specifically allows coverage for this testing. Under Medicare rules, this means the 
Urovysion Bladder cancer testing is considered approved by the plan. Therefore, we decided that the Plan has 
to pay for the Urovysion Bladder cancer testing provided on August 30, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the interpretation of diagnostic image (code D0391) and the 
cone beam computed tomography (CT) image of the jaws (code D0383) you received on January 7, 2022. 
 
You asked the Plan to pay for the interpretation of diagnostic image and the cone beam CT image of the jaws. 
You say that these services were performed by a maxillofacial surgeon, not a dentist.  You said that these 
services were for spots on your gums. The Plan denied your request. The Plan says these services are not 
covered. 
 
Medicare generally does not cover dental services. This includes treatment and care of the gums. However, the 
Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The two codes billed by this provider are dental codes, not medical codes.  Your Plan only covers 
those dental codes explicitly listed in your benefits chart.  The two codes in dispute are not listed in your 
benefits chart, so they would not be covered for any reason. 
 
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 
interpretation of diagnostic image (code D0391) and the cone beam computed tomography (CT) image of the 
jaws (code D0383) you received on January 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the cleaning (D1110), bitewing x-rays (D0274), and periodic 
evaluation (D0120) provided by an out-of-network provider on January 18, 2021, and February 7, 2022. 
 
You asked the Plan to pay for the cleaning (D1110), the bitewing x-rays (D0274), and the periodic evaluation 
(D0120). You say that you are only being reimbursed $20.09 for the services when you paid $218 out-of-
pocket. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount. 
 
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 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 80% 
coinsurance for out-of-network for exams, cleanings, and dental x-rays. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the cleaning (D1110), the bitewing x-
rays (D0274), and the periodic evaluation (D0120) are among those covered under this benefit. You have been 
asked to pay a total of $197.73 for the services. See chart below. 
 
Date of 
Service 
Service Provider 
Charge 
Allowed 
Amount 
Coinsurance Coinsurance 
Responsibility 
Difference 
of Provider 
Charge 
and 
Allowed 
Amount 
Member 
Liability 
February 
7, 2022 
D1110 $100.00 $47.19 80% $37.75 $52.81 $90.56 
February 
7, 2022 
D0274 $66.00 $28.98 80%  
$23.18 
$37.02 $60.02 
February 
7, 2022 
D0120 $52.00 $27.75 80% $19.40 $27.75 $47.15 
Total       $197.73 
 
Therefore, we decided that the Plan does not have to pay for the porcelain ceramic crown (D2740), the cleaning 
(D1110), bitewing x-rays (D0274), and periodic evaluation (D0120) provided by an out-of-network provider on 
January 18, 2021, and February 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial observation care services coded 99220 provided on 
October 5, 2021. 
 
You asked the Plan to pay for the initial observation care services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable. 
 
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 99220 is initial observation care, per day, for the 
evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission to outpatient hospital "observation status" are of high severity. Typically, 70 minutes are spent at the 
bedside and on the patient's hospital floor or unit. 
 
 We find that CPT code 99220 is not supported in the medical record. Specifically, this service was previously 
billed and processed/paid by the Plan. This means this service has been previously billed the maximum number 
of times allowed. Based on this information, we decided that Medicare rules for coverage of the initial 
observation care services have not been met. Therefore, we decided that the Plan does not have to pay for the 
initial observation care services coded 99220 provided on October 5, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT) of the heart with contrast 
material (75573). 
 
You asked the Plan to pre-approve a CT of the coronary arteries. You say that this scan is medically necessary. 
The Plan denied your request. The Plan says the provider confirmed that after your hospital admission, the CT 
of the heart is no longer necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 pre-approve a CT of the coronary arteries. Our 
reviewer says that the requested imaging service is not medically necessary in this case. Our physician reviewer 
found the records indicate that there are plans for cardiac catheterization to investigate your coronary disease 
and aortic valve dysfunction. As a result, at this time CT imaging would not be considered medically necessary 
and reasonable in your clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a CT of the coronary arteries have not been met.  
 
 
 Therefore, we decided that the Plan does not have to pre-approve computed tomography (CT) of the heart with 
contrast material (75573).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from June 20, 2022, forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from June 20, 2022, forward. You say that the 
services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue are 
not medically necessary. 
 The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 psychiatric care from June 20, 
2022, forward. Our reviewer says that you do not meet the criteria for acute inpatient mental health treatment 
beyond the date in question of June 20, 2022, forward. Our physician reviewer found you did not require 
inpatient mental health treatment beyond June 20, 2022, as you were not a danger to yourself or others and did 
not have any delusions, auditory or visual hallucinations. It did not appear that active treatment was taking 
place beyond the date in question. It did not appear that the services for the dates in question were reasonably 
expected or medically necessary to improve your condition or for the purpose of diagnosis. 
 
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 psychiatric care from June 20, 2022, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from June 20, 2022, 
forward.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for resin fillings you received on November 23, 2021. 
 
You asked the Plan to pay for the resin fillings. You say that you believe these services should be covered at 
50%. The Plan denied your request. The Plan says fillings are not covered under your dental 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, 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 resin 
fillings you received on November 23, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomographic angiography (CTA) (71275) 
provided on October 28, 2021. 
 
You asked the Plan to pay for the CTA. You say that the date of service is not within hospice dates. The Plan 
denied your request. The Plan says the claim processed correctly. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on October 1, 2021. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the computed 
tomographic angiography (CTA) (71275) provided on October 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics (L3215). 
 
You asked the Plan to pay for foot orthotics. You say that the items are medically necessary. The Plan denied 
your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. 
Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of 
orthotics for the enrollee's condition.  
 
 
 
 
 
  
Therefore, we decided that the Plan does not have to pay for foot orthotics (L3215).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for the filling (D2331) for the incisal and 
buccal surfaces of tooth # 25 provided on February 1, 2022 by the out of network dentist. 
 
You asked the Plan to pay an additional amount for the dental service. You say that you do not understand the 
reduced payment. You say that you had a recent cracked tooth. You also say that this had not occurred before. 
The Plan denied your request. The Plan says the claim processed correctly. 
 
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 and fillings are listed as covered, they 
are limited to the same surface and tooth once every 2 years. The record shows that the plan paid for the incisal 
and buccal surfaces of tooth # 25 that you received on November 23, 2020. As a result, the frequency limit has 
been exhausted. Therefore, we decided that the Plan does not have to pay an additional amount for the filling 
(D2331) for the incisal and buccal surfaces of tooth # 25 provided on February 1, 2022 by the out of network dentist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gingival irrigation (D4921 x 2) provided on January 19, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were only expecting services necessary for 
a 6-month check up to be performed. The Plan denied your request. The Plan says gingival irrigation is not 
listed as a covered service. 
 
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 gingival irrigation are not among 
those covered under this benefit regardless of the dentist's network status. Therefore, we decided that the Plan 
does not have to pay for the gingival irrigation (D4921 x 2) provided on January 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on 
February 2, 2022. 
 
You asked the Plan to pay for the comprehensive oral evaluation. You say that you want this service to be 
covered in full according to your plan benefit. The Plan denied your request. The Plan says this service exceeds 
the frequency limitation in your benefit 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, comprehensive oral evaluation 
(D0150) is limited to one procedure every three plan years. The record shows that you received a 
comprehensive oral evaluation (D0150) on November 15, 2021 and your comprehensive oral evaluation 
(D0150) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the 
comprehensive oral evaluation (D0150) provided on February 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81355, 81230, 81240, 81241, 81291, 
and 81335) provided on October 5, 2021. 
 
You asked the Plan to pay for codes 81355, 81230, 81240, 81241, 81291, and 81335. 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 as 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. 
 
We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT code 81479. Therefore, we decided that the Plan does not have 
to pay for the laboratory services (81355, 81230, 81240, 81241, 81291, and 81335) provided on October 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the at home covid-19 test, purchased on January 4, 2022. 
 
You asked the Plan to pay for the at home covid-19 test. You say that the item was medically necessary. The 
Plan denied your request. The Plan says you obtained this item through a provider that is not enrolled in 
Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the at home covid-19 test, purchased on 
January 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shingles vaccine (97050), provided on February 24, 
2022. 
 
You asked the Plan to pay for the shingles vaccine. You say that the service should be covered. The Plan 
denied your request. The Plan says the Shingrix (Zoster) vaccine is a Medicare Part D (prescription coverage) 
vaccine and is not eligible for coverage under Medicare Part B. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the shingles vaccine. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the shingles 
vaccine. Therefore, we decided that the Plan does not have to pay for the shingles vaccine (97050), provided on 
February 24, 2022.  
 
Benefits for the shingles vaccine 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from June 10, 2021, to 
July 12, 2021. 
 
You asked the Plan to pay for the home health care. You say that you contacted the enrollee's plan on 3 
different occasions. You say that you were advised all 3 times that only final claims were needed. You also say 
that you should not be penalized because the representative misspoke. The Plan denied your request. The Plan 
says there was no request for an exception to be made for the 5-day 
 
The Plan must follow Medicare rules. Medicare rules say that all Home Health Agencies (HHAs) must submit 
a request for anticipated payment (RAP) within 5 calendar days after the start of care date for initial 30-day 
periods and within 5 calendar days after the from date for each subsequent 30-day period of care, which is set 
at 0 percent at the beginning of every 30-day period.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health care have not been met. Specifically, the record indicates the RAP was not 
submitted within 5 days of the from the start of care date, June 10, 2021. Therefore, we decided that the Plan 
does not have to pay for the home health services provided from June 10, 2021, to July 12, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT) of the abdomen and pelvis 
without contrast (74178). 
 
You asked the Plan to pre-approve a CT scan of the abdomen. You say that this scan is medically necessary. 
The Plan denied your request. The Plan says the requested scan is not medically necessary as there is no 
documentation that you have had further abdominal symptoms since the visit to your primary care provider on 
April 11, 2022. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 pre-approve a CT scan of the abdomen. Our 
reviewer says that the requested imaging service is not medically necessary. Our physician reviewer found the 
record indicates that you had a colonoscopy in 2019 with a single polyp removed. The plain film of the 
abdomen results are not in the records, and there are no recent repeat labs to show any change in status since 
April. Your symptoms and physical exams have not been updated in two and a half months. The medical 
necessity of going forward with a CT scan at this point in time has not been established in the records provided. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a CT scan of the abdomen have not been met. Therefore, we decided that the Plan does not have to pre-approve computed tomography (CT) of the abdomen 
and pelvis without contrast (74178).