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

 
We decided that the Plan does not have to pay for implant placement (D6010) provided on February 23, 2021. 
 
You asked the Plan to pay for implant placement. You say that you have not used your dental benefits in 2021 
prior to having these services. The Plan denied your request. The Plan says implant placement (D6010) is not 
covered under 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 implant placement (D6010) is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for implant 
placement (D6010) provided on February 23, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve twelve (12) home health physical therapy visits. 
 
You asked the Plan to pre-approve the home health physical therapy visits. You say that you can barely walk 
with the prosthetic leg you have and still need assistance getting around you home. You state you are currently 
unable to leave the home. The Plan denied your request.  The Plan says there is no documentation to 
support that you are unable to leave your home. The Plan states you do not require physical assistance 
from another person to walk or transfer. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health physical therapy visits. 
Our physician reviewer found the documentation does not support that you require additional skilled 
rehabilitation services to provide treatment that is medically necessary. You do not require additional 
rehabilitation services to effectively provide treatment, care, and/or services in order to improve your condition, 
perform a maintenance program to maintain your condition and/or prevent deterioration. You have been 
medically stable without any recent exacerbations of chronic medical problems or hospitalizations. You have 
received skilled physical therapy in the home and are independent with a home exercise program that will 
improve his endurance. The requested home health services are not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the home health physical therapy visits have not been met. Therefore, we 
decided that the Plan does not have to pre-approve twelve (12) home health physical therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transversus abdominis plane (TAP) block (64488) 
provided on November 12, 2021. 
 
You asked the Plan to pay for the TAP block. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says this is a duplicate claim. 
 The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the transversus abdominis plane (TAP) 
block (64488) provided on November 12, 2021. have been met. Specifically, the documentation submitted 
shows that the Plan paid one unit of CPT code 64488-59 to this provider. The documentation does not show 
that this service was rendered more than once by this provider on the billed date of service. Therefore, we 
decided that the Plan does not have to pay for the transversus abdominis plane (TAP) block (64488) provided 
on November 12, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from 
November 27, 2021, to November 28, 2021. 
 
You asked the Plan to waive the copayment for the inpatient care. You say that you were instructed to send the 
bills to insurance for payment. The Plan denied your request. The Plan says you have been charged the correct 
cost sharing amount. 
 
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 $220 per 
day for days 1-7 for each inpatient admission.  
 
The file shows that you were in the hospital from November 27, 2021, to November 28, 2021, but there is no 
copayment for the discharge date. Therefore, you have been asked to pay $220 for the first day of inpatient 
care. The inpatient care falls within the Inpatient Hospital Care 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 inpatient hospital care provided from November 27, 2021, to November 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740) and build up (D2950) for tooth #3. 
 
You asked the Plan to pre-approve a crown and build up. You say that the enrollee meets criteria. The Plan 
denied your request. The Plan says this service is not medically necessary because there was no documented 
decay or missing tooth structure. 
 
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 crown and 
build up when the services are medically necessary and reasonable.  
 
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 crown and build up. Our reviewer 
says that the enrollee does not meet medical criteria for a crown and build up of tooth #3. Our physician 
reviewer found the documentation does not support that the enrollee had cracked-tooth syndrome, as she had 
no reported complaints, with no indication of pain. There is no documentation of missing tooth structure. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of a crown and build up have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a crown (D2740) and build up (D2950) for tooth #3.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from January 13, 2022, 
through January 24, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient services were medically 
necessary. The Plan denied your request. The Plan says that the inpatient services are not covered. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that the record showed that at the time of inpatient admission the admitting physician 
reasonably expected that the enrollees necessary hospital care (including earlier emergency department and/or 
observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from January 13, 2022, through January 24, 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
January 15, 2022. 
 
You asked the Plan to waive the copayment for the ER visit. You say that you should not be charged due to 
someone else's carelessness. The Plan denied your request. The Plan says you have been charged the correct 
cost sharing amount. 
 
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 $90 
copayment for each emergency room visit.  
 
You have been asked to pay a $90 copayment for the ER visit. The ER visit falls within the Emergency Care 
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 an emergency room (ER) visit 
provided on January 15, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay provided from July 
31, 2021, to August 8, 2021. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that this charge should be 
covered. The Plan denied your request. The Plan says the copayment applied is 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 $100 
copayment each day for days 1 through 5 for Medicare covered hospital care. $0 copayment for additional 
Medicare covered days.  
 
 
 
 You have been asked to pay a total of $500($100.00 x 5= $500.00) copayment for the inpatient hospital stay. 
Inpatient hospital stay falls within the Inpatient Hospital Care 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 inpatient hospital stay provided from July 31, 2021, to August 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller with harness upgrade, safety 
belt, power seat elevation system, Accutrac Motor Tech connector, controller module with LCD display, 
occupied transit, Class X program unit, and foot plate/bracket assembly. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
We looked at the file and Medicare rules. The requested power seat elevation system, controller module with 
LCD display, and occupied transit do not serve a purpose that is primarily medical in nature and are not 
covered. The expandable controller with harness upgrade is not needed to control the approved power options. 
The Class X program unit is included in the expandable controller and cannot be requested separately. 
The Accutrac Motor Tech connector exceeds your needs and is not needed over the approved standard motor. 
The safety belt is not covered with the approved Group 3 PWC base. The foot plates were requested with the 
incorrect procedure code (K0108) and have already been approved with the Group 3 PWC. 
 
Therefore, we decided that the Plan does not have to pre-approve an expandable controller with harness 
upgrade, safety belt, power seat elevation system, Accutrac Motor Tech connector, controller module with 
LCD display, occupied transit, Class X program unit, and foot plate/bracket assembly.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation provided on 
September 18, 2021. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that you did not ask for 
the ambulance service. The Plan denied your request. The Plan says you have been charged the correct cost 
sharing amount. 
 
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 $225 
copayment for each one-way ambulance trip.  
 
You have been asked to pay a $225 copayment for the ambulance transportation. The ambulance transportation 
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 transportation provided on September 18, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection rendered on June 17, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code J1030 is not supported. 
 
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 J1030 is injection, methylprednisolone acetate, 40 mg. 
 
We find that CPT code J1030 is not supported in the medical record. Specifically, there is no documentation of 
an injection of 40 mg of methylprednisolone acetate. Based on this information, we decided that Medicare rules 
for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for 
the injection rendered on June 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2740) provided by a participating provider on 
December 10, 2021. 
 
You asked the Plan to pay for a crown. You say that your dentist chose this procedure. You say that you had no 
choice. The Plan denied your request. The Plan says the service provide has been processed correctly. 
 
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. 
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of a crown have not been met. Therefore, we decided that the Plan does not have to pay for a crown 
(D2740) provided by a participating provider on December 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intravenous conscious sedation, initial 15 minutes, 
(D9239), and each additional 15 minutes of intravenous conscious sedation (D9243 x 2) provided on December 
13, 2021. 
 
You asked the Plan to pay for the dental services. You say that you had to have a couple of teeth pulled. You 
say that the sedation was medically necessary. You also say that you do not understand how you own $1,500 
for the sedation. The Plan denied your request. The Plan says intravenous conscious sedation services are not 
listed as covered. 
 
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 intravenous conscious sedation 
services are not among those covered under this benefit. The record shows that Therefore, we decided 
that the Plan does not have to pay for the intravenous conscious sedation, initial 15 minutes, (D9239), and each 
additional 15 minutes of intravenous conscious sedation (D9243 x 2) provided on December 13, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve remede phrenic nerve stimulation. 
 
You asked the Plan to pre-approve remede phrenic nerve stimulation. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the requested services are 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 remede phrenic nerve stimulation. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found you have central sleep apnea. The requested service is considered an 
experimental/ investigational procedure. Therefore, the request is considered not medically reasonable or 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of remede phrenic nerve stimulation have not been met. Therefore, we decided that 
the Plan does not have to pre-approve remede phrenic nerve stimulation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a resin-based composite (D2391) provided by a participating 
provider on March 7, 2022. 
 
You asked the Plan to pay for a resin-based composite. You say that you thought you were covered for this. 
The Plan denied your request. The Plan says that enrollee did not purchase the optional enhanced dental 
coverage. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for a resin-based composite (D2391) 
provided by a participating provider on March 7, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the drug testing provided on June 12, 2017. 
 
You asked the Plan to pay for the drug testing. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says that this service has been up coded. 
 
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 G0482 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; 15-21 drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0482 is supported in the medical record. Specifically, the lab report clearly shows that 
15-21 drug classes were tested in this case. Please note, we counted the classes based on the separately billable 
tests from the CPT Handbook. Additionally, the record indicates that this provider was directed by the Plan to 
not obtain records. With this direction, it is inappropriate for the Plan to deny these services based on the 
physician signature. Based on this information, we decided that Medicare rules for coverage of the drug testing 
have been met. Therefore, we decided that the Plan has to pay for the drug testing provided on June 12, 2017.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the x-ray to be performed by an out-of-network 
provider. 
 
You asked the Plan to pre-approve the out-of-network services. You say that the services are necessary. The 
Plan denied your request. The Plan says there are in-network providers that can render the services. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. The requested 
provider in this case is not a network provider with the Plan. The Plan has network providers available who can 
provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-
approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the x-ray to be 
performed by an out-of-network provider.