Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a tie down kit for a power wheelchair. 
 
You asked the Plan to pre-approve tie down kit. You say that this is needed. The Plan denied your request. The 
Plan says a tie down is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a tie down kit for a power wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transit option, pneumatic propulsion tires, and wheel 
locks. 
 
You asked the Plan to pre-approve transit option, pneumatic propulsion tires, and wheel locks. You say that 
you disagree with the Plan's denial. The Plan denied your request. The Plan says the requested items are not a 
covered benefit.  
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose. The rules also state that for equipment to be covered, it must be appropriate and needed for 
use inside the home. 
 
The pneumatic propulsion tires are included in the initial of the manual wheelchair. The transit option at issue 
in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan 
covers equipment for use outside the home. The wheel locks at issue in this appeal does not serve a purpose 
that is primarily medical in nature. This item is available to the general public and would be helpful even to 
those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve transit 
option, pneumatic propulsion tires, and wheel locks.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional moderate sedation time provided on date of 
service May 2, 2022, billed with code 99153. 
 
You asked the Plan to pay for procedure code 99153. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says code 99153 is not payable in the facility 
setting. 
 
Medicare rules say that the OPPS recognizes that CPT code 99153 is a PE only code and that PE are not 
payable to the physician for services provided in the facility setting.  
 
We find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment to the 
physician for CPT code 99153 when performed in the facility setting. Therefore, we decided that the Plan does 
not have to pay for the additional moderate sedation time provided on date of service May 2, 2022, billed with 
code 99153.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from January 25, 2023, 
forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from January 25, 2023, 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 January 
25, 2023, forward. Our reviewer says that the enrollee does not meet the criteria for acute inpatient mental 
health treatment beyond the date in question of January 25, 2023, forward. Our physician reviewer found the 
enrollee did not require inpatient mental health treatment beyond January 25, 2023, as she was not a danger to 
herself 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 the enrollee's 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 January 25, 2023, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from January 25, 
2023, forward.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller with harness upgrade and 
electronic connection. 
 
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. Medicare rules say that an expandable controller is used to control 
multiple power options. 
 
We looked at the file and Medicare rules. The file shows that the expandable harness upgrade and electronic 
connection are not needed to control the approved power switches. 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 pre-approve an expandable controller with harness upgrade and electronic connection.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous vertebral augmentation, including cavity 
creation (fracture reduction and bone biopsy included when performed) using mechanical device (eg, 
kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance; lumbar 
(22514). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says your request is not medically necessary because the enrollee's records show 
they have severe spinal stenosis/canal compromise at the level of the compression fracture/fragment 
retropulsion. 
 
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 service. Our physician reviewer 
found imaging studies show severe neural compression which is a contraindication to kyphoplasty in this 
elderly enrollee. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve percutaneous vertebral augmentation, including cavity creation (fracture reduction and 
bone biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 vertebral body, unilateral 
or bilateral cannulation, inclusive of all imaging guidance; lumbar (22514).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an inpatient admission associated with an elective 
surgery. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the enrollee needs inpatient care. 
The Plan denied your request. The Plan says there is no documentation provided to support the expectation the 
enrollee will require a greater than a two midnight stay. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.   

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this 
case. Our physician reviewer found that detailed documentation is not evident regarding a significant past 
and/or current medical history that would place this enrollee at increased risk for peri-surgical complications 
requiring an inpatient stay. There is no compelling rationale presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception. Therefore, the record does not show that at the 
time of inpatient admission, the admitting physician reasonable expected that the enrollee's necessary hospital 
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 not been met. Therefore, we decided that the 
Plan does not have to pre-approve an inpatient admission associated with an elective surgery.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 0245U billed for date of service July 13, 
2022. 
 
You asked the Plan to pay for procedure code 0245U. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment for code 0245U is bundled into 
payment for code 0018U. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 0245U 
is a column II code to column I code 0018U. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 0245U billed for date of service July 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for endodontic therapy, molar tooth (excluding final restoration) 
(D3330) provided on October 10, 2022. 
 
You asked the Plan to pay for the endodontic therapy, molar tooth (excluding final restoration) (D3330). You 
say that you went to the dental service based on an emergency call per the Plan's representatives instructions. 
You also say that this visit was due to pain from an infection in your jawbone. The Plan denied your request. 
The Plan says this service is not covered under the benefit package. 
 
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 
endodontic therapy, molar tooth (excluding final restoration) (D3330) provided on October 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral - periapical first radiographic image (D0220) and 
limited oral evaluation - problem focused (D0140) provided on October 13, 2022. 
 
You asked the Plan to pay for the dental services. You say that you went to the dentist and received a filling. 
You also say that when you went home you started having a tooth ache and were scheduled for another 
appointment with an x-ray. The Plan denied your request. The Plan says your benefit for the requested item or 
service 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 the requested items or services was exhausted on date of service October 12, 2022. 
Therefore, we decided that the Plan does not have to pay for an intraoral - periapical first radiographic image 
(D0220) and limited oral evaluation - problem focused (D0140) provided on October 13, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infectious agent detection provided on August 31, 2022. 
 
You asked the Plan to pay for infectious agent detection. You say that you are requesting a review of medical 
records and a reconsideration of the denied payment. The Plan denied your request. The Plan says that 
unauthorized, out-of-network care is not covered. 
 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for infectious agent 
detection provided on August 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown and core buildup services (D2920, D2950) provided 
on September 15, 2022. 
 
You asked the Plan to pay for 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 pay for a crown 
and core buildup services (D2920, D2950) provided on September 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost-sharing for the transitional care management services 
provided on August 4, 2022. 
 
You asked the Plan to waive the cost-sharing for the transitional care management services. You say that you 
never had charges before for this service. 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 $150 
copayment for Medicare-covered outpatient hospital non-surgical services. 
 
 
 
 
 
 
 You have been asked to pay a cost-share of $58.41 for the transitional care management services. The Plan has 
chosen to charge only 50% of the allowed amount because the allowed amount is less than double your 
contractual copayment ($116.82 allowed amount x .50 = $58.41). This item/service falls within the outpatient 
hospital 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 cost-sharing for the transitional care 
management services provided on August 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hearing aids (V5140) provided on July 11, 2022. 
 
You asked the Plan to pay for hearing aids (V5140). You say that your policy does provide for hearing aids 
through your subsidiary vendor. You also say some compensation should be allowed for the purchase from 
your licensed provider. The Plan denied your request. The Plan says are care received from a non-participating 
provider will not be covered by the Plan.  
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when received by a specific Plan vendor provider. 
 
We looked at the file and the Plan's rules. The Plan rules say that basic hearing evaluations and hearing aids 
must be provided by a specific Plan vendor provider. The record shows that this service was not received by a 
Plan vendor provider. Based on this information, we decided that the Plan's rules for coverage of hearing aids 
(V5140) have not been met. Therefore, we decided that the Plan does not have to pay for hearing aids (V5140) 
provided on July 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist visit provided on March 01, 
2022. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that this should be a $0 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 $30 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $30 copayment for a specialist visit. This item/service falls within the 
physician/practitioner services, including doctors office visits 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 a specialist visit provided on March 01, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visit provided on August 8, 
2022. 
 
You asked the Plan to waive the copayment for specialist office visit. 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 $45 
copayment for physician/practitioner services/specialist.  
 
You have been asked to pay a $45 copayment for specialist office visit. This item/service falls within the 
physician/practitioner services/specialist 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 specialist office visit provided on August 8, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ambulance trip provided on September 
11, 2022. 
 
You asked the Plan to waive the copayment for an ambulance trip. You say that you do not agree with this 
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 $250 
copayment for ambulance services.  
 
You have been asked to pay $233.65 which is less than your copayment amount of $250 for an ambulance trip. 
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 an ambulance trip provided on September 11, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services provided on April 19, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the surgical services provided by an OON provider. You say that you would like 
the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services 
received were neither emergent nor urgent and prior authorization was not obtained to seek out-of-network 
care. The Plan says there were in-network providers available to you that could have provided the surgical 
services you received. 
 
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 the surgical services provided on April 19, 2022, 
by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) provided on 
September 3, 2022, to September 30, 2022. 
 
You asked the Plan to waive the copayment for SNF. 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 $20 per 
day for days 1-20 and $120 per day for days 21-44 for skilled nursing facility (SNF) care.  
 
You have been asked to pay $20 per day for days 1-20 and $120 per day for days 21-44 for SNF. This 
item/service falls within the skilled nursing facility (SNF) care benefit category. The total amount for the SNF 
is $1,240 ($20 x 20days =$400) and ($120 x 7 days = $840) ($400 + $840 = $1,240). 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 skilled nursing facility (SNF) provided on September 3, 2022, to September 30, 
2022.