Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit rendered on September 2, 2022. 
 
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 payment is included in the global surgical package. 
 
The Plan must follow Medicare rules. The rules say that post-operative care is included in the global surgical 
package. 
 
We looked at the file and Medicare rules. Procedure code 99214 was related to and billed within 90 days of 
major surgical procedure 28122 billed for June 17, 2022. Payment for code 99214 is included in the global 
surgical package. Therefore, we decided that the Plan does not have to pay for the office visit rendered on 
September 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an eye examination provided on April 5, 
2021. 
 
You asked the Plan to waive the copayment for eye exam. You say that this doctor was listed as in-network but 
would not honor your insurance. 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 $35 
copayment for each in-network covered eye exam.  
 
You have been asked to pay $35 copayment for eye exam. This item/service falls within the Vision Care - 
Medicare-Covered 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 eye examination 
provided on April 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve three endosteal implants (D6010 x3) and panoramic x-
ray (D0330). 
 
You asked the Plan to pre-approve the endosteal implants and panoramic x-ray. You say that you thought you 
read that after a certain amount paid out of pocket by the patient in a calendar year that extra help may be 
available. You also say that if any extra help is available, you could certainly use it. The Plan denied your 
request. The Plan says endosteal implants are not a covered benefit under your dental plan. The Plan also says 
your request for a panoramic x-ray exceeds the frequency limitation in your benefit plan. 
 
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, endosteal implant (D6010) is not 
among those covered under this benefit. The contract also says panoramic x-ray (D0330) is limited to one 
procedure every three plan years. The record shows that you received a panoramic x-ray (D0330) on July 18, 
2022, and your panoramic x-ray (D0330) benefit has been exhausted. Therefore, we decided that the Plan does 
not have to pre-approve three endosteal implants (D6010 x3) and panoramic x-ray (D0330).
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services provided on December 16, 2021. 
 
You asked the Plan to pay for the anesthesia services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the enrollee was enrolled in hospice for this date of service. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
 The enrollee ended Medicare Hospice benefits on December 10, 2021. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the anesthesia 
services provided on December 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two surgical placements of implant bodies: endosteal 
implants (D6010 x2), two prefabricated abutments (D6056 x2), and two abutment supported porcelain/ceramic 
crowns (D6058 x2). 
 
You asked the Plan to pre-approve the endosteal implants, prefabricated abutments, and abutment supported 
porcelain/ceramic crowns. You say that these implants are medically necessary. The Plan denied your request. 
The Plan says these services are not covered under your 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 pre-approve two 
surgical placements of implant bodies: endosteal implants (D6010 x2), two prefabricated abutments (D6056 
x2), and two abutment supported porcelain/ceramic crowns (D6058 x2).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 85060 billed for services provided on 
September 11, 2022. 
 
You asked the Plan to pay for the billed services. You say that the medical records document medical 
necessity. The Plan denied your request. The Plan says the code was billed with an inappropriate place of 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. We find that CPT code 85060 was billed with an outpatient hospital place of service code. No payment is 
recognized for code 85060 furnished to hospital outpatients. Based on this information, we decided that 
Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure code 85060 billed for services provided on September 11, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on May 13, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the enrollee was discharged home with their 
spouse. The Plan denied your request. The Plan says the enrollees claim would be covered under Original 
Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of 
the month in which hospice is revoked. The Plan also says it is the providers responsibility to verify the 
enrollees coverage before rendering services and to know proper billing procedures for a Medicare Advantage 
member on hospice. 
 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 the laboratory services provided on May 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oncology prostate probability score (81539) provided on 
June 10, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the lab testing. You say that this FDA approved testing was medically necessary. 
The Plan denied your request. The Plan says this service is not covered because it was provided OON without 
prior authorization. 
 
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 oncology prostate probability score (81539) 
provided on June 10, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture (D5213). 
 
You asked the Plan to pre-approve a maxillary partial denture. You say that it is imperative for you to get a 
new set of dentures. 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 item or service was exhausted on date of service September 19, 2018. 
Therefore, we decided that the Plan does not have to pre-approve a maxillary partial denture (D5213).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an apicoectomy (D3410), retrograde filling (D3430), 
and drugs or medicaments dispensed in the office for home use (D9630). 
 
You asked the Plan to pre-approve the apicoectomy, retrograde filling, and drugs or medicaments. You say that 
you have to take multiple antibiotics before going to the dentist. You also say someone needs to check what 
could happen. The Plan denied your request. The Plan says these services are not covered under your 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 pre-approve an 
apicoectomy (D3410), retrograde filling (D3430), and drugs or medicaments dispensed in the office for home 
use (D9630).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99232 billed for date of service January 7, 
2022. 
 
You asked the Plan to pay for procedure code 99232. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 99232 is bundled into payment for code 99233.  
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 99232 
is a column II code to column I code 99233. 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 99232 billed for date of service January 7, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 47000 billed for date of service July 14, 
2022. 
 You asked the Plan to pay for procedure code 47000. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 47000 is bundled into payment for code 49405. 
 
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 47000 
is a column II code to column I code 49405. 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 47000 billed for date of service July 14, 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. The Plan denied your request. The Plan says there is no 
documentation provided of intense and complex care needs, unstable medical issues, or care needs that are only 
available at Inpatient Rehabilitation Facility level of care requiring medical supervision with a rehabilitation 
physician conducting face to face visit with the enrollee at least 3 days per week. 
 
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 enrollee has no acute medical complexity and no acute rehab nursing needs for an 
IRF admission.  
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 pay for the hospital discharge day management services coded 
99239 provided on July 23, 2022. 
 
You asked the Plan to pay for the hospital discharge day management services. You say that you disagree with 
the Plan's denial. The Plan denied your request. The Plan says the services billed are not supported. 
 
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 99239 is hospital discharge day management; more than 
30 minutes. 
 
 
 We find that CPT code 99239 is not supported in the medical record. Specifically, the submitted discharge 
summary does not support a hospital discharge day management of more than 30 minutes was performed. A 
documented duration of time of 31 minutes or more is required to support this code. Based on this information, 
we decided that Medicare rules for coverage of the hospital discharge day management services have not been 
met. Therefore, we decided that the Plan does not have to pay for the hospital discharge day management 
services coded 99239 provided on July 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110). 
 
You asked the Plan to pre-approve a complete maxillary denture. You say that not having teeth is affecting 
your health. 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 item or service was exhausted on date of service June 30, 2020. Therefore, 
we decided that the Plan does not have to pre-approve a complete maxillary denture (D5110).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an adjust maxillofacial prosthetic appliance, by report 
tooth #'s 3 and 14 (D6010). 
 
You asked the Plan to pre-approve the adjust maxillofacial prosthetic appliance, by report tooth #'s 3 and 14 
(D6010). You say that you are having a lot of pain and this is causing your trouble when eating. The Plan 
denied your request. The Plan says coverage for specific dental procedures listed. Non-listed procedures are not 
covered. 
 
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 an 
adjust maxillofacial prosthetic appliance, by report tooth #'s 3 and 14 (D6010).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code (A6531). 
 
You asked the Plan to pre-approve the compression stockings. You say that the enrollee has a history of lower 
extremity of deep vein thrombosis (DVT). The Plan denied your request. The Plan says the services denied 
correctly as they do not meet the clinical requirements to be approved. 
 
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code 
(A6531) are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that 
compression bandages and gradient compression wraps are covered only when they are used as dressings over 
a qualifying wound. 
 
The record does not show that the enrollee has open venous stasis ulcers or a qualifying wound. This means 
that the enrollee does not have a medical condition for which compression stockings can be covered or paid for 
by Medicare. Therefore, we decided that the Plan does not have to pre-approve compression stockings 
identified with code (A6531).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two gingival irrigations (D4921 x2). 
 
You asked the Plan to pre-approve the gingival irrigations. The Plan denied your request. The Plan says this 
service is not covered under the enrollee's benefit plan. 
 
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 two 
gingival irrigations (D4921 x2).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve outpatient cardiac rehabilitation (93797, 93798) to be 
provided at a tertiary facility. 
 
You asked the Plan to pre-approve outpatient cardiac rehabilitation to be provided at a tertiary facility.. You 
say that the service is medically necessary. The Plan denied your request. The Plan says this service can be 
performed at a community level. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 outpatient cardiac rehabilitation to be 
provided at a tertiary facility. Our reviewer says that the requested services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found you appeared to be clinically stable 
without chest pain, dyspnea, orthopnea, palpitations, syncope or any other symptoms. There are no test results 
showing instability to require tertiary care for your cardiac rehabilitation, which can safely be completed at a 
community level 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 outpatient cardiac rehabilitation to be provided at a tertiary facility. have not 
been met. Specifically, the provider is a tertiary provider and the services are available in-network at the 
community level. Therefore, we decided that the Plan does not have to pre-approve outpatient cardiac 
rehabilitation (93797, 93798) to be provided at a tertiary facility.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6536. 
 
You asked the Plan to pre-approve the compression stockings. You say that you are appealing the denied code. 
The Plan denied your request. The Plan says the requested item is non-covered item. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6536 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
  Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6536.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye exam (92004) provided on October 7, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the eye exam. You say that you should not be responsible for this because you 
were unaware a referral was required. The Plan denied your request. The Plan says this service was rendered by 
an out-of-network provider, and prior authorization was not obtained. 
 
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 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 (92004) provided on October 7, 
2022, by an out-of-network (OON) provider.