Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital care billed with a primary diagnosis of 
sepsis for March 4, 2021, through March 6, 2021. 
 
You asked the Plan to pay for the inpatient hospital care as billed. You say that the documentation supports the 
care as billed. The Plan denied your request. The Plan says the medical records do not support the diagnosis of 
sepsis. 
 
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 provided with the principal diagnosis of sepsis. 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 care as billed. Our reviewer says that 
the medical documentation does not support the inpatient care as billed. Our physician reviewer found the 
review indicates that 67-year-old male who was admitted for early pneumonia. Based on the medical records, 
there was no evidence of sepsis as a complication. The review has determined that the medical records did not 
support the diagnosis of sepsis associated with the inpatient hospital care as billed.  
 
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 the inpatient hospital care billed with a primary diagnosis of sepsis for March 4, 2021, through March 6, 
2021.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pay for the skilled nursing facility (SNF) services provided May 1, 2019, 
through May 15, 2019. 
 
You asked the Plan to pay for the SNF services. You say that this claim was billed correctly. The Plan denied 
your request. The Plan says that the claim was billed incorrectly and requires a corrected claim. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. We find that the Plan did not submit a compelling denial rationale in this case. 
The claim was denied due to lack of authorization for the SNF services. However, the Plan has attested that the 
SNF services were authorized with a HIPPS code that was calculated at the time that the approval was 
requested. Based on how the HIPPS code is calculated, however, it is not reasonable to expect or require that 
the code requested for authorization be the code that is billed. The HIPPS code billed must correspond to the 
enrollees actual condition and the services actually rendered during the statement period of the claim. It would 
therefore be expected that the billed code would differ from a code that was estimated prior to the services 
being rendered. The Plan has not made any argument that any of the digits of the billed HIPPS code are 
incorrect or not supported, only that the code, as a whole, was not approved. We find that this denial of 
payment has not been substantiated. Therefore, we decided that the Plan has to pay for the skilled nursing 
facility (SNF) services provided May 1, 2019, through May 15, 2019.  
 
 If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the hearing aids provided on January 11, 2021. 
 
You asked the Plan to pay more for the hearing aids. You say that the website states that the maximum benefit 
was already used, and one page says that no benefit has been used yet. You say that the purchase of the hearing 
aids came on the first day of your benefit period and the decision should be changed. The Plan denied your 
request. The Plan says your $2800 hearing aid allowance was exhausted. 
 
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. The Plan pays up to 
$1,400 per hearing aid every 60 months.  
 
We looked at the case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aids have not been met. Specifically, the Plan paid $1,400 for each hearing aid, which 
exhausted your benefit. Therefore, we decided that the Plan does not have to pay more for the hearing aids 
provided on January 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care services (99291) provided on January 18, 
2021. 
 
You asked the Plan to pay for the critical care services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
Medicare guidelines say that ICD-10-CM has a coding convention that requires the underlying condition to be 
sequenced first, followed by the manifestation. In this case, I46.2 is a manifestation code and cannot be used as 
the primary or first-listed diagnosis code on the claim. Therefore, we decided that the Plan does not have to pay 
for the critical care services (99291) provided on January 18, 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 an IRF admission is medically necessary. The Plan 
denied your request. The Plan says under Medicare, the request is not medically necessary. 
 
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 that the complexity of the enrollee's nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems 
are stable. There are no complex nursing or rehabilitation needs. While the documentation 
does support a need for physical and/or occupational therapy, there is no documented need for an intensive, 
multi-disciplinary rehabilitation program. There is not a reasonable expectation that the enrollee 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically 
necessary. 
 
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 there is no documentation provided necessitating admission to a LTACH. The 
enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at 
the LTACH that are not available at the present setting where he is currently receiving care. There are no 
services available at the LTACH that the enrollee requires that are not available at the health care setting being 
offered by the health plan. 
 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 long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the sales tax (D9985), and resin-based composite (D2394, 
D3332, D2335), provided on March 9, 2021, and April 26, 2021. 
 
You asked the Plan to pay for the resin-based composites and sales tax. You say that the service should be 
covered. The Plan denied your request. The Plan says these are not covered services. 
 
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 the sales tax (D9985), and resin-
based composite (D2394, D3332, D2335), provided on March 9, 2021, and April 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay in full for the complete maxillary denture (D5110) and 
mandibular partial denture (D5214) provided on August 9, 2021. 
 
You asked the Plan to pay in full for the complete maxillary denture and mandibular partial denture. You say 
that you were told that everything would be covered. You also say that the pre-treatment estimate showed that 
you would have no out of pocket expense for these services. The Plan denied your request. The Plan says your 
benefit period maximum has been reached. 
 
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 Plan offers a maximum payment of 
$1,500 per person total per Benefit Year. The record shows that you met the annual maximum benefit while processing this claim for the August 9, 2021 date of service and your annual maximum benefit has been 
exhausted. Therefore, we decided that the Plan does not have to pay in full for the complete maxillary denture 
(D5110) and mandibular partial denture (D5214) provided on August 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Home Prothrombin Time/International Normalized 
Ratio (PT/INR) Monitoring. 
 
You asked the Plan to pre-approve the Home Prothrombin Time/International Normalized Ratio (PT/INR) 
Monitoring. You say that you would like reconsideration because the requested service is medically necessary. 
The Plan denied your request. The Plan says there is no evidence that you had the face-to-face educational 
program or demonstrated the correct use of the device.  
The Plan follows Medicare rules. Medicare rules say that Medicare will cover for the use of home PT/INR 
monitoring forchronic, oral anticoagulation management for patients with mechanical heart valves, chronic 
atrial fibrillation, or venous thromboembolism on warfarin. The patient must undergo a face-to-face 
educational program on anticoagulation management and must have demonstrated the correct use of the device 
prior to its use in the home. 
 
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 Prothrombin 
Time/International Normalized Ratio (PT/INR) Monitoring. Our reviewer says that you do not meet Medicare 
criteria for coverage. Our physician reviewer found there is no evidence that you had the face-to-face 
educational program or demonstrated the correct use of the 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 the Home Prothrombin Time/International Normalized Ratio (PT/INR) 
Monitoring have not been met. Therefore, we decided that the Plan does not have to pre-approve the Home 
Prothrombin Time/International Normalized Ratio (PT/INR) Monitoring.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the gingivectomy or gingivoplasty to allow access for 
restorative procedure (D4212), pontic (D6245) and retainer crown (D6740) provided on April 1, 2021. 
 
You asked the Plan to pay for the gingivectomy or gingivoplasty to allow access for restorative procedure 
(D4212), pontic (D6245) and retainer crown (D6740). You say that the dentist stated the procedure was 
necessary for the tooth that was shifting and to prevent further damage to the tooth that has to be replaced. You 
say that you cannot afford the bill and the decision should be reconsidered, The Plan denied your request. The 
Plan says the services are not covered benefits. 
 
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 
gingivectomy or gingivoplasty to allow access for restorative procedure (D4212), pontic (D6245) and retainer 
crown (D6740) provided on April 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the acupuncture services provided from November 
13, 2020, to December 23, 2020. 
 
You asked the Plan to reimburse you for the acupuncture services. You say that you should be reimbursed for 
these claims. You say that all of your claims from 2021 have been paid.  
 You also say that these services are medically necessary. The Plan denied your request. The Plan says the 
provider in this case is not a physician or medical doctor. The Plan also says that the provider is not being 
supervised by a physician. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plan?s rules apply in this case.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the file does not show that the provider in this case is 
a physician or medical doctor, nor that the provider is being supervised by a physician. Therefore, we decided 
that the Plan does not have to reimburse you for the acupuncture services provided from November 13, 2020, 
to December 23, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided from September 18, 
2019, to September 22, 2019. 
 
You asked the Plan to pay for the inpatient services. You say that the diagnosis is supported by the 
documentation. The Plan denied your request. The Plan says the diagnosis cannot be validated. 
 
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 provided with J18.9, pneumonia, unspecified organism. 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 services. Our physician reviewer found that 
in this case, the enrollee presented as a transfer from an outside facility due to a urinary tract infection. While 
the physician noted a diagnosis of pneumonia and the enrollee was treated with antibiotics, the medical records 
provided for review did not include chest imaging from the transferring facility. In addition, there was no 
imaging of the chest imaging obtained during the current admission. The diagnosis of pneumonia was not 
established. The review has determined that the records did not show that the billed diagnosis was 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 the inpatient hospital services provided from September 18, 2019, to September 22, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Integra dermal regeneration services. 
 
You asked the Plan to pre-approve Integra dermal regeneration services. You say that this is ultimately the best 
procedure and can be done in an outpatient setting instead of needing a major surgery. The Plan denied your 
request. The Plan says the enrollee's wound measurement shows an area of 0.15 centimeters. The Plan says that 
this is less than the required minimum of at least 1 square centimeter in size needed for skin substitute 
application. 
 
The Plan follows Medicare rules. Medicare rules say that the application of skin substitutes to Ulcers or 
Wounds with failed response are covered for skin deficits that are at least 1.0 square centimeters in size.  
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 Integra dermal regeneration services. 
Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee 
has a diabetic ulcer to the right foot and ankle. She has received standard wound therapy. The wound 
measurement shows an area of 0.15 square centimeters, which is less than the required minimum of at least 1.0 
square centimeters in size needed for skin substitute application. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Integra dermal regeneration services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve Integra dermal regeneration services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the removal of residual tooth roots (D7250) provided on June 
2, 2021. 
 
You asked the Plan to pay for the removal of residual tooth roots. You say that this service was denied because 
the right code was not used. You also say that you contacted the Plan and were given the right codes which you 
advised them of. The Plan denied your request. The Plan says this service is not covered. The Plan also says 
that when your provider contacted the Plan on May 24, 2021, removal of residual tooth roots was not 
discussed. 
 
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 
removal of residual tooth roots (D7250) provided on June 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the amalgam (D2150), and to pay more for the bitewing x-
rays (D0274), and prophylaxis (D1110) provided on June 3, 2021, and June 21, 2021 by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for the amalgam, or pay more for the bitewing x-rays, and prophylaxis. You say that 
your Evidence of Coverage (EOC) shows that the Plan covers 50% of the cost for fillings, not zero. You also 
say that the EOC says x-rays and cleanings are covered at 50% OON. The Plan denied your request. The Plan 
says the amalgam is not a covered service. The Plan also says that if you see an OON dentist, the coinsurance 
level will apply to the average negotiated in-network fee schedule (INFS) in your area. You are responsible for 
the difference between the INFS and dentists' charged fees when visiting an OON dentist.  
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, amalgam (D2150) is not among those 
covered under this benefit. The only type of fillings that are covered under your plan are resin-based 
composites. The contract says that you are responsible for a 50% coinsurance for both bitewing x-rays (D0274) 
and prophylaxis (D1110), plus the difference between the billed amount and allowed amount because these 
services were received out-of-network. Therefore, we decided that the Plan does not have to pay for the 
amalgam (D2150), and to pay more for the bitewing x-rays (D0274), and prophylaxis (D1110) provided on 
June 3, 2021, and June 21, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the blood bank physician services (86077) provided on 
March 17, 2021. You asked the Plan to pay for code 86077. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says only one unit of 86077 is payable per Medicare 
guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 86077 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of code 
86077 have not been met. Therefore, we decided that the Plan does not have to pay for the blood bank 
physician services (86077) provided on March 17, 2021.