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

 
We decided that the Plan does not have to pay for periodic oral evaluation (D0120), limited oral evaluation - 
problem focused (D0140), bitewings - four radiographic images (D0274), prophylaxis (D1110) and extraction, 
erupted tooth or exposed root (elevation and/or forceps removal) (D7140) provided on June 24, 2022, to July 
28, 2022. 
 
You asked the Plan to pay for the dental services. You say that you tried to find an in-network provider but 
could not wait until they had an available appointment. The Plan denied your request. The Plan says the dental 
services were received from an out-of-network provider and are not covered by your supplemental 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. This benefit includes coverage 
for the requested items or services, but only when they are received from an in-network provider. Limited oral 
evaluation - problem focused (D0140) is not a covered benefit under you Plans dental benefit under any 
circumstance. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested oral evaluation (D0120), bitewings - four 
radiographic images (D0274), prophylaxis (D1110) and extraction, erupted tooth or exposed root (elevation 
and/or forceps removal) (D7140) are not covered under this benefit when received from an out-of-network 
provider. Limited oral evaluation - problem focused (D0140) is not covered under you Plans dental benefits. 
Therefore, we decided that the Plan does not have to pay for periodic oral evaluation (D0120), limited oral 
evaluation - problem focused (D0140), bitewings - four radiographic images (D0274), prophylaxis (D1110) 
and extraction, erupted tooth or exposed root (elevation and/or forceps removal) (D7140) provided on June 24, 
2022, to July 28, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ultrasound provided on June 30, 2022. 
 
You asked the Plan to waive the copayment for ultrasound. 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 $110 
copayment for outpatient diagnostic tests and therapeutic services and supplies.  
 
You have been asked to pay $104.31 which is less than the $110 copayment for ultrasound. This item/service 
falls within the outpatient diagnostic tests and therapeutic services and supplies 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 ultrasound provided on June 30, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care service provided on 
July 5, 2022, to July 9, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital care 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 $190 
copayment per day for days 1 to 5 for inpatient hospital care. This inpatient hospital stay lasted 4 days, 
resulting in a copayment amount of $760 ($190 per day for 4 days = $760). 
 
You have been asked to pay $190 copayment per day for days 1 to 5 for inpatient hospital care service. This 
item/service 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 service provided on July 5, 2022, to July 9, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided on April 11, 2022, to April 
12, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the admission was medically 
necessary. The Plan denied your request. The Plan says that the required services could have been provided at 
an observation level of care. 
 
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 the review has determined that the record showed that at the time of inpatient admission the 
admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier ED 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 on April 11, 2022, to April 12, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that enrollee is requesting LTACH due to 
complexity of medical needs and the need for a safe discharge plan. The Plan denied your request. The Plan 
says the request is not medically necessary, when the enrollee is ready to leave the hospital, they can safely 
receive this care in another setting, such as a Skilled Nursing Facility (SNF). 
 
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 transfer to the LTACH is not medically necessary as the patient is not yet stable, has 
not yet completed treatment, and as it would not be clinically advantageous. Completion of treatment at the 
current facility is recommended.  
 
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 LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a seat lift chair. 
 
You asked the Plan to pre-approve a seat lift chair. You say that you need a reclining chair where you do not 
need to use your weight to move it. The Plan denied your request. The Plan says the requested item is not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed in the Medicare rules section are met. 
 
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 seat lift chair. Our reviewer says that 
the documentation does not support that the requested device is medically reasonable or necessary. Our 
physician reviewer found you had an assessment by a physical therapist. The documentation shows that you are 
able to stand independently from a seated position. Therefore, you do not meet criteria for the requested 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 a seat lift chair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a seat lift chair.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from June 11, 2022, to 
July 10, 2022. 
 
You asked the Plan to pay for the billed services. You say that the notice of admission was billed and 
processed. The Plan denied your request. The Plan says the rules for payment have not been made. 
 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 looked at the file and the rules. The date of admission on the notice of admission is inconsistent with the 
date of admission on the final claim. Based on this information, we decided that Medicare rules for coverage of 
the billed services have not been met. Therefore, we decided that the Plan does not have to pay for the home 
health services provided from June 11, 2022, to July 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat lift chair. 
 
You asked the Plan to pre-approve a power seat lift chair. You say that you have to put clothes under your 
couch so you can sit. You also say that you are in constant pain. The Plan denied your request. The Plan says 
the requested device is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed in the Medicare rules section are met. 
 
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 power seat lift chair. Our reviewer 
says that the documentation does not support that the requested item is medically reasonable or necessary. Our 
physician reviewer found you had an occupational therapist evaluation in your home. The documentation 
shows that you are able to independently stand from a seated position from toilet couch and standard kitchen 
chairs. Therefore, you do not meet criteria for the requested device.  
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 power seat lift chair have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a power seat lift chair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs provided on 
January 21, 2021, to October 5, 2021. 
 
You asked the Plan to waive the coinsurance for Medicare Part B drugs. 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 20% 
coinsurance for Medicare part B prescription drugs.  
 
You have been asked to pay 20% coinsurance for Medicare Part B drugs. This item/service falls within the 
Medicare part B prescription drugs 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 coinsurance for 
Medicare Part B drugs provided on January 21, 2021, to October 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the house call (D9410) provided on April 30, 2022. 
 
You asked the Plan to pay for the house call (D9410). You say that the service should be covered. The Plan 
denied your request. The Plan says the service is not a covered 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 the house 
call (D9410) provided on April 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) and a periapical x-ray 
(D0220) provided on July 26, 2022, and a periodic oral evaluation (D0120) provided on August 4, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says your benefit for the requested items or services has already been 
exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for a limited oral evaluation and a periodic oral evaluation was exhausted on dates of 
service January 6, 2022, and February 3, 2022. The record also shows your benefit for a periapical x-ray was 
exhausted on date of service January 6, 2022. Therefore, we decided that the Plan does not have to pay for a 
limited oral evaluation (D0140) and a periapical x-ray (D0220) provided on July 26, 2022, and a periodic oral 
evaluation (D0120) provided on August 4, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve total hip arthroplasty (THA) surgery. 
 
You asked the Plan to pre-approve total hip arthroplasty. You say that the enrollee needs this surgery. The Plan 
denied your request. The Plan says the record does not support the medical necessity of this procedure. 
 
The Plan follows Medicare rules. Medicare rules state that total hip arthroplasty surgery is only covered under 
certain circumstances. 
 
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 total hip arthroplasty. Our reviewer 
says that the enrollee does not meet the criteria for the requested total hip arthroplasty. Our physician reviewer 
found a formal imaging study was not provided for review to corroborate the pathology of the right hip. 
Additionally, detailed documentation is not evidence regarding a trial and failure of recent, reasonable, and 
comprehensive less-invasive conservative care measures. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of total hip arthroplasty have not been met. Therefore, we decided that the Plan 
does not have to pre-approve total hip arthroplasty (THA) surgery.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve a Dexcom continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a Dexcom CGM. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says that the requested device does not meet step therapy criteria. 
 
The Plan must follow Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced in the Medicare rules section. The rules 
also say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The Plan contract does not say in clear and accurate terms how 
much enrollees should expect to pay for continuous glucose monitors or what specific brands are covered. 
 
We looked at the contract between the enrollee and the Plan. We did not see where the contract says that only 
specific brands of CGM are covered. The Plan contract does not clearly say that only FreeStyle Libre systems 
are covered. This means that the Plan did not follow Medicare rules for disclosure of cost sharing information. 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a Dexcom CGM have been met. Therefore, we decided that the Plan has to pre-approve a Dexcom 
continuous glucose monitor (CGM).  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 pay for inpatient hospital services provided on June 1, 2021, to June 
16, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the code 
assignments are in accordance with the documentation. The Plan denied your request. The Plan says there is 
lack of clinical evidence to support the diagnosis codes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services with diagnosis code J96.21, defined as acute and chronic 
respiratory failure with hypoxia, and J96.22, defined as acute and chronic respiratory failure with hypercapnia. 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the inpatient hospital services at the DRG 
originally billed. Our physician reviewer found that the enrollee has a history of chronic obstructive pulmonary 
disease (COPD) and chronic dyspnea with a baseline requirement for continuous supplemental oxygen. She 
was maintained on her baseline rate of supplemental oxygen with continuation of baseline nocturnal bilevel 
positive airway pressure (BiPAP) While experiencing persistent dyspnea, she did not exhibit documented 
hypoxia while receiving baseline supplemental oxygen. There was no clinical evidence of acute hypoxic 
respiratory failure. The review has determined that the records did not show that the diagnoses codes are 
supported.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on June 1, 2021, to June 16, 2021, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a nursing facility visit provided on April 21, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for a nursing facility visit. You say that medically necessary services were provided 
in good faith. The Plan denied your request. The Plan says the enrollee must receive care from a network 
provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a nursing facility visit provided on April 21, 2022, 
by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a guided tissue regeneration (D4266), debridement of a 
peri-implant defect or defects surrounding a single implant, and surface cleaning of the exposed implant 
surfaces, including flap entry and closure (D6101) and bone graft for repair of peri-implant defect (D6103). 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing the denial. The Plan 
denied your request. The Plan says these services are not covered by the Plan's 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 
guided tissue regeneration (D4266), debridement of a peri-implant defect or defects surrounding a single 
implant, and surface cleaning of the exposed implant surfaces, including flap entry and closure (D6101) and 
bone graft for repair of peri-implant defect (D6103).