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

 
We decided that the Plan does not have to pay for the surgical services rendered on August 24, 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 63047 is not separately payable. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
The provider submitted a claim for procedure codes 63047 (lumbar laminectomy, facetectomy and 
foraminotomy) and 22633 (lumbar arthrodesis). Code 63047 is a column II code with a modifier indicator of 1 
when billed with column I code 22633. Code 63047 was not billed with an appropriate modifier to allow for 
separate payment. The -59 modifier is not supported as a separate and distinct procedural service. Therefore, 
we decided that the Plan does not have to pay for the surgical services rendered on August 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete lower denture (D5120). 
 
You asked the Plan to pre-approve the denture. You say that you expected this would be covered by your Plan 
and this denture is essential for your health. The Plan denied your request. The Plan says dentures are not 
covered by 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 pre-approve a 
complete lower denture (D5120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral exam (D0150) and intraoral x-ray 
(D0220) provided on November 15, 2021. 
 
You asked the Plan to pay for the dental services. You say that you were referred to this provider by your 
primary dentist, and you were told by the Plan that this provider is in-network. The Plan denied your request. 
The Plan says this provider does not participate in Original Medicare, and therefore these services are not 
eligible for payment. 
 
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 Plans contract states that 
you may see any licensed dental provider who accepts Medicare patients in the United States and has not opted 
out of Medicare. If you use a provider that has opted out of Medicare, you will not receive reimbursement. Though the Plan offers a dental benefit in excess of Medicare coverage, items or services received from 
providers who have opted out of Medicare are not covered under this benefit. The provider in this case does not 
participate in Original Medicare. Therefore, we decided that the Plan does not have to pay for the 
comprehensive oral exam (D0150) and intraoral x-ray (D0220) provided on November 15, 2021.  
 
Your complaint about potential misinformation from a Plan representative is not a valid appeal for medical 
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not 
permit us to make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system. 
 
You asked the Plan to pre-approve the requested service. You say that you cannot move around without this 
chair. The Plan denied your request. The Plan says the system is not considered medical in nature. 
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 the rules. The item at issue does not serve a purpose that is primarily medical in 
nature. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implants (D6010 x 2), custom abutments (D6057 x 2), 
abutment supported crowns (D6060 x 2), bone graft at time of implant placement (D6104), and temporary 
upper denture (D5820). 
 
You asked the Plan to pre-approve the dental services. You say that you have supplemental dental coverage. 
You also say that the services should be covered. The Plan denied your request. The Plan says the services are 
not covered by your supplemental dental benefits. The Plan also says there is no documentation indicating that 
the services are being done for treatment of neoplastic disease of the jaw. 
 
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 implants and related 
services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pre-approve implants (D6010 x 2), custom abutments (D6057 x 2), abutment supported crowns (D6060 x 2), 
bone graft at time of implant placement (D6104), and temporary upper denture (D5820).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) spinal canal and 
contents (72146) magnetic resonance imaging (MRI) of the cervical spine without the use of a contrast dye 
(72141) 
 
You asked the Plan to pre-approve the diagnostic service. You say that the requested MRI services are covered 
benefits and should be approved. The Plan denied your request. The Plan says the medical necessity criteria has 
not been established as the results of the prior study is needed to show the need for repeat imaging. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 the diagnostic service. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is an MRI of the cervical spine noted from 6/2/21, and two MRIs of the thoracic 
spine from 10/7/21 and 11/3/21. Repeat imaging is not supported without emergence of a red flag, physiologic 
evidence of tissue insult or neurologic dysfunction, progressive neurologic symptoms, failure of conservative 
treatment, or clarification of anatomy prior to an invasive procedure. There is no compelling rationale 
presented or extenuating circumstances noted to support the medical necessity of this request as an exception to 
guidelines.  
 
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 diagnostic service have not been met.  Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) spinal 
canal and contents (72146) magnetic resonance imaging (MRI) of the cervical spine without the use of a 
contrast dye (72141)
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a debridement of subcutaneous tissue (11042) provided on 
November 5, 2021. 
 
You asked the Plan to pay for a debridement of subcutaneous tissue. You say that the service at issue was a 
medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not 
been met because the billed code is inclusive to another billed code. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
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 a debridement of subcutaneous tissue Our 
reviewer says that the billed code does not meet criteria for reimbursement. Our physician reviewer found that 
the procedure report documents 2 wounds were debrided. The first wound documents subcutaneous tissue 
debrided depth of 0.1 centimeters and the second wound documents muscle debrided depth of 0.1 
centimeters. Per Current Procedural Terminology (CPT) guidelines, wound debridement is reported by the 
depth of the wound. Wounds are summed together when documentation supports the same depth.  
 In this case, the documentation in conflicting, as the first wound states subcutaneous, and the second wound 
documents muscle; however, both document a depth of 0.1 centimeters and the modifier cannot be verified. 
 
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 debridement of subcutaneous tissue have not been met. Therefore, we decided 
that the Plan does not have to pay for a debridement of subcutaneous tissue (11042) provided on November 5, 
2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided May 11, 2021 to May 13, 2021.
You asked the Plan to pay for acute inpatient hospital care. You say that attached is supporting documentation for review. You are confident that the Plan will concur this enrollee's care was medically necessary. The Plan denied your request. The Plan says the enrollee did not meet criteria for inpatient services.
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 does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found based on the provided documentation, CVA was ruled out and no acute treatment was recommended. Following troponin trending and monitoring confusion could have been completed at a lower level of care and there was no suggestion from the notes that the patient would likely require hospital services that would cross 2 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 pay for the acute inpatient hospital care provided May 11, 2021 to May 13, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that this admission is medically necessary. The Plan 
denied your request. The Plan says the member cannot handle three days a week of rehab. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.  
 Our physician reviewer found there is not a reasonable expectation that this member will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hearing aids provided on April 29, 2021. 
 
You asked the Plan to pay for hearing aids. The Plan denied your request. The Plan says the hearing benefit is 
not covered if the services are not registered in advance and purchased via the Plan Hearing. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case.  
 
We looked at the file and the Plan's rules. The file shows that the hearing aids were not provider by the Plans 
hearing provider. Based on this information, we decided that the Plan's rules for coverage of hearing aids have 
not been met. Therefore, we decided that the Plan does not have to pay for hearing aids provided on  
April 29, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on August 16, 2021. 
 
You asked the Plan to pay for physician's services. The Plan denied your request. The Plan says Original 
Medicare would be responsible for payment of all Medicare covered services related or unrelated to the 
members terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all 
hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-
for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until 
the first day of the month following the month in which hospice was revoked or discharged. 
 
  
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for physician's services provided on August 16, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided from 
September 19, 2021, through October 18, 2021. 
 
You asked the Plan to pay for SNF services. The Plan denied your request. The Plan says while on Hospice, 
SNF level services are not a covered benefit. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for SNF services provided from September 19, 2021, through 
October 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on October 6, 2020. 
 
You asked the Plan to pay for periodontal maintenance. You say that this service should be covered. The Plan 
denied your request. The Plan says this service is not covered by 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 Plan's 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 
periodontal maintenance (D4910) provided on October 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a retrograde filling (D3430), and apicoectomy (D3425) 
for tooth # 3. 
 
You asked the Plan to pre-approve the dental services. You say that the requested services are necessary. The 
Plan denied your request. The Plan says the requested services are not listed as covered dental services. 
 
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 retrograde filling and 
apicoectomy are not among those covered under this benefit. Therefore, we decided that the Plan does not have 
to pre-approve a retrograde filling (D3430), and apicoectomy (D3425) for tooth # 3.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) 
provided on September 6, 2021. 
 
You asked the Plan to pay for ambulance response and treatment, no transport. You say that you were in a 
praying position and just needed to be helped from the floor to the bed. You say that the police helped to 
accomplish that task and then the EMS asked some questions and pricked your finger and showed you the 
numbers. You say 911 was called unnecessarily and without your consent. The Plan denied your request. The 
Plan says the ambulance benefit is a transport benefit, if no transport of a Medicare beneficiary occurs, then 
there is no Medicare covered service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on September 6, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport 
(A0998) provided on September 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dermatology services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve OON services. You say that a continuance of care exemption should be 
implemented. The Plan denied your request. The Plan says medically necessary care is available in network. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve 
additional dermatology services to be provided by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) 
provided on July 30, 2021. 
 
You asked the Plan to pay for ambulance response and treatment, no transport. The Plan denied your request. 
The Plan says the ambulance service is a transport benefit, and it is only payable when you are transported to a 
hospital. If an ambulance is called and you receive care, but decide not to be transported to a hospital, we do 
not cover those services. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on July 30, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport 
(A0998) provided on July 30, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on October 13, 2021. 
 
You asked the Plan to pay for physician's services. The Plan denied your request. The Plan says Original 
Medicare would be responsible for payment of all Medicare covered services related or unrelated to the 
members terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all 
hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-
for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until 
the first day of the month following the month in which hospice was revoked or discharged. Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for physician's services provided on October 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for eyeglasses provided on October 19, 2021. 
 
You asked the Plan to reimburse you for the eyeglasses. The Plan denied your request. The Plan says per the 
members Evidence of Coverage, Progressive lenses, no-line bifocal or trifocal lenses, tinting (except for 
certain ultraviolet screening coatings), scratch-resistant coatings, or oversized lenses are not covered unless 
required by Medicare coverage guidelines. 
 The Plan contract says covered eyeglasses after cataract surgery includes standard frames and lenses as defined 
by Medicare. 
 
We looked at the file, the Medicare rules and the Plan's rules. The file shows that Medicare and the Plan cover 
standard eyeglasses after cataract surgery. Progressive lenses, no-line bifocal or trifocal lenses, tinting (except 
for certain ultraviolet-screening coatings), scratch-resistant coatings, or oversized lenses are not covered unless 
required by Medicare coverage guidelines. Therefore, we decided that the Plan does not have to reimburse you 
for eyeglasses provided on October 19, 2021.