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

 
We decided that the Plan does not have to pay for procedure code 99233 billed for date of service September 
25, 2021. 
 
You asked the Plan to pay for the billed code. You say that the code was appropriately assigned. The Plan 
denied your request. The Plan says there is insufficient documentation to corroborate the services. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99233 is subsequent hospital care, per day, for the 
evaluation and management of a patient. Usually, the patient is unstable or has developed a significant new 
problem. We find that CPT code 99233 is not supported in the medical record. Specifically, the records do not 
show that the enrollee was unstable or that the enrollee had significant new complications or problems. Based 
on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 99233 billed for date of service September 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vision item or service (shipping fees) (V2799) provided 
on October 4, 2022. 
 
You asked the Plan to pay for the shipping fees. You say that you would like the shipping fees of $12.05 to be 
covered by the Plan because you saved them $23.16 from a promotion. The Plan denied your request. The Plan 
says this claim processed correctly. 
 
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 up to $300 for routine contact lenses or eyewear every year. 
 
We looked at the file and the Plan's rules. The record shows that you were denied coverage for shipping fees, 
but the Plan covered the contacts. Specifically, your vision allowance is for contact lens materials or 
eyeglasses, not shipping fees. Based on this information, we decided that the Plan's rules for coverage of the 
shipping fees have not been met. Therefore, we decided that the Plan does not have to pay for the vision item or 
service (shipping fees) (V2799) provided on October 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance (D4910), bitewing x-rays-four 
radiographic images (D0274), and the resin-based composite-two surfaces, posterior (D2392) provided on  
June 15, 2022 and June 23, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. 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 Plan's coverage rules apply in this case. 
 
The record shows you received the dental services from an out-of-network provider. Though the Plan offers a 
dental benefit in excess of Medicare coverage, the services provided are not covered under this benefit when 
received from an out-of-network provider. Therefore, we decided that the Plan does not have to pay for the 
periodontal maintenance (D4910), bitewing x-rays-four radiographic images (D0274), and the resin-based 
composite-two surfaces, posterior (D2392) provided on June 15, 2022 and June 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Medicare Part B prescription drugs 
provided on October 5, 2022. 
 
You asked the Plan to waive the coinsurance for Medicare Part B prescription drugs. You say that you disagree 
with coinsurance. 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 20% 
coinsurance for Medicare Part B prescription drugs.  
 
You have been asked to pay a 20% coinsurance for Medicare Part B prescription drugs. The total allowed 
amount for the prescription drugs is $499.41. You are being asked to pay $99.88 ($499.41 x 20% =$99.88). 
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 prescription drugs provided on October 5, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the low dose computed tomography (LDCT) scan for lung 
cancer screening provided on October 5, 2022. 
 
  You asked the Plan to pay for the requested LDCT scan. You say that the current procedural terminology 
(CPT) code billed is not restricted by gender or age specifics. You also say that you would like this claim to be 
reprocessed for payment. The Plan denied your request. The Plan says the enrollee was 79 years old on the date 
that this service was rendered 
 
The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung 
cancer screening for enrollees who meet all the criteria described in the Medicare rules section of this letter.  
 
We reviewed the file and the Medicare rules. We find that the enrollee was not between the ages of 50 and 77 
years old at the time this scan was provided. Therefore, we decided that the Plan does not have to pay for the 
low dose computed tomography (LDCT) scan for lung cancer screening provided on October 5, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve benzonanate tablets. 
 
You asked the Plan to pre-approve self-administered drug. You say that you are appealing this denial. The Plan 
denied your request. The Plan says this drug is not covered by Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve benzonanate tablets.  
 
Benefits for self-administered drug may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) 
 
You asked the Plan to pre-approve the CGM. You say that the CGM is medically necessary for you to control 
your blood sugar levels. The Plan denied your request. The Plan says the Medicare criteria was not met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
  We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of the CGM have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor 
(CGM)
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive periodontal evaluation (D0180) provided 
on August 10, 2022. You also asked the Plan to pay for guided tissue regeneration (D4266), bone replacement 
graft for ridge preservation (D7953), and  surgical removal of implant body (D6100) provided on October 24, 
2022. 
 
You asked the Plan to pay for codes D0180, D4266, D7953 and D6100. You say that the services were 
medically necessary. The Plan denied your request. The Plan says these services are 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 a 
comprehensive periodontal evaluation (D0180) provided on August 10, 2022. You also asked the Plan to pay 
for guided tissue regeneration (D4266), bone replacement graft for ridge preservation (D7953), and  surgical 
removal of implant body (D6100) provided on October 24, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care after 
February 22, 2023. 
 
You asked the Plan to pre-approve SNF care after February 22, 2023. You say that the continued admission to 
a SNF is medically necessary. The Plan denied your request. The Plan says the continued admission to a SNF is 
not medically necessary.  
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care after February 22, 2023. Our 
reviewer says that the requested SNF care is not considered medically reasonable and necessary based on 
Medicare guidelines. Our physician reviewer found you do not have daily skilled nursing needs that require the 
specialized skill, knowledge, and judgment of a skilled professional nurse. You do   not have daily skilled 
therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. 
You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility 
(SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care after February 22, 2023, have not been met. Therefore, we decided 
that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care after February 22, 
2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve epidural steroid injection. You say that the enrollee has completed 
conservative treatments and needs this procedure. The Plan denied your request. The Plan says that the enrollee 
does not meet criteria for this procedure. 
 
The Plan follows Medicare rules. Medicare rules state that epidural steroid injections are only covered if certain 
criteria 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 epidural steroid injection. Our reviewer 
says that the enrollee meets criteria for this procedure. Our physician reviewer found the enrollee has chronic 
neck pain and cervical radiculopathy. The enrollee takes Lyrica, Soma, Tizanidine, and Percocet for pain. The 
enrollee has had 2 anterior cervical discectomy and fusion (ACDF) procedures as well as placement of 
hardware. The enrollee has had physical therapy and a home exercise program. Imaging shows cervical 
degenerative changes. Diagnostic facet blocks were not helpful. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of epidural steroid injection have been met. Therefore, we decided that the Plan 
has to pre-approve an epidural steroid injection.  
 
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 for to pay for a periodic oral evaluation - established patient 
(D0120), prophylaxis - adult (D1110) provided on September 14, 2022. We also decided the plan does not have 
to waive the copayment for the resin-based composite - two surfaces, anterior (D2331) provided on November 
8, 2022. 
 
You asked the Plan to pay for pay for a periodic oral evaluation - established patient (D0120), prophylaxis - 
adult ( D1110) provided on September 14, 2022. You also asked the Plan to waive the copayment for the resin-
based composite - two surfaces, anterior (D2331) provided on November 8, 2022. You say that you are 
requesting reconsideration for the amount billed that you were advised you do not owe. 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 $25 
copayment for the resin-based composite - two surfaces, anterior (D2331). 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. 
 
You have been asked to pay a $25 copayment for pay for the resin-based composite - two surfaces. This 
item/service falls within the dental 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 coinsurance 
applied to the resin-based composite  two surfaces (D2331) provided on November 8, 2022. 
 
You have been asked to pay the difference between the out-of-network providers charge and the Plans 
payment for the periodic oral evaluation - established patient (D0120), prophylaxis - adult (D1110. 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 pay for to pay for a periodic oral evaluation - established 
patient (D0120), prophylaxis - adult (D1110) provided on September 14, 2022,
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for durable medical equipment (DME) 
provided on August 30, 2022, to October 30, 2022. 
 
You asked the Plan to waive the coinsurance for DME. You say that you disagree with the coinsurance. 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 20% 
coinsurance for durable medical equipment (DME).  
 
You have been asked to pay a 20% coinsurance for DME. The total allowed amount for the DME is $614.10. 
You are being asked to pay $122.82 ($614.10 x 20% =$122.82). 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 durable medical equipment (DME) provided on August 30, 2022, to October 30, 2022.
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 you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of authorization for IRF care is correct. 
 
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 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. While the 
record supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 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 acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that a slow turnaround time for the appeal can harm the 
enrollee. The Plan denied your request. The Plan says an IRF admission is not medically necessary, and the 
enrollee can receive the care they need in another setting. 
 
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 enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. 
 
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 IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye exam (92014), eye refraction (92015), and fundus 
photography (92250) provided on August 31, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the eye exam, eye refraction, and fundus photography. You say that you were not 
aware that the treating provider was OON. The Plan denied your request. The Plan says you received these 
services from an OON provider. The Plan also says that the medical records do not show that the services 
provided were urgent or emergent. 
 
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 eye exam (92014), eye refraction (92015), and 
fundus photography (92250) provided on August 31, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for Medicare Part B prescription drugs an 
outpatient diagnostic test and a specialist office visit provided on November 22, 2021, to May 31, 2022. 
 
You asked the Plan to waive the cost share for Medicare Part B prescription drugs an outpatient diagnostic test 
and a specialist office visit. You say that you disagree with the cost share. 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 20% coinsurance for Medicare Part B prescription drugs a $150 copayment for outpatient diagnostic tests/other 
diagnostic procedures and tests and a $20 copayment for physician/practitioner services/specialist.  
 
You have been asked to pay a 20% coinsurance for Medicare Part B prescription drugs a $150 copayment for 
outpatient diagnostic tests/other diagnostic procedures and tests and a $20 copayment for physician/practitioner 
services/specialist. The total allowed amount for the prescription drugs is $238.79. You are being asked to pay 
$47.76 ($238.79 x 20% = $47.76). The total amount for all the services is $217.76 ($150 + $47.76 + $20 = 
$217.76). 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 share for Medicare Part B prescription drugs an outpatient 
diagnostic test and a specialist office visit provided on November 22, 2021, to May 31, 2022.