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

 
We decided that the Plan does not have to pay for inpatient services (99223, G8427, 1123F) billed for date of 
service July 26, 2022. 
 
You asked the Plan to pay for inpatient services. You say that the enrollee was admitted to the hospital and 
these services were reported correctly. The Plan denied your request. The Plan says this claim conflicts with 
another claim which indicates that the enrollee was outpatient observation status at the time of services. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that billing inpatient services is not supported in the documentation provided. Specifically, the record 
shows that the enrollee was admitted for outpatient observation from July 26, 2022, to July 28, 2022. Based on 
this information, we decided that Medicare rules for coverage of inpatient services have not been met. 
Therefore, we decided that the Plan does not have to pay for inpatient services (99223, G8427, 1123F) billed 
for date of service July 26, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve shoulder joint replacement surgery to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve shoulder joint replacement surgery to be provided by an OON provider. 
You say that the services are necessary. The Plan denied your request. The Plan says there are in-network 
providers that are able to provide these services. Therefore, coverage criteria have not been met. 
 
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 items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
shoulder joint replacement surgery to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to hold you harmless for diagnostic services (A9531, 79005, A9512, 78014) 
provided on September 8, 2022. 
 
You asked the Plan to hold you harmless for diagnostic services. You say that these services were urgently 
needed, and you could not wait to have them done. You paid up front for these services and disagree with the 
amount you have been reimbursed. The Plan denied your request. The Plan says that the reimbursement for 
these services is correct. Code 78014 is denied because this service is included in code 79005. The 
reimbursement provided for the other services is the correct allowed amount. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for diagnostic services by a contract provider. The file does not show that the Plan provided 
notice that diagnostic services would not be covered. Under Medicare rules, this means diagnostic services is 
considered approved by the Plan. These services were rendered by an in-network provider and were paid at the 
time of services by the enrollee. The enrollee should be held harmless for the cost of services over the allowed 
amount, and the enrollee is not responsible for billing errors on the part of the provider. The Plan should either 
have the in-network provider refund the difference between what the Plan has paid and what the enrollee has 
paid, or the Plan should reimburse the enrollee for the full amount paid and seek the overages from the provider 
directly. Therefore, we decided that the Plan has to hold you harmless for diagnostic services (A9531, 79005, 
A9512, 78014) provided on September 8, 2022.  
 
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 pre-approve transosteal implants (D6050) for tooth #'s 4, 6, 9, 11, 
and 13, custom fabricated abutments (D6057) for tooth #'s 4, 6, 9, 11, and 13, and abutment supported 
porcelain/ceramic crowns (D6058) for tooth #'s 4, 6, 9, 11, and 13. 
 
You asked the Plan to pre-approve the transosteal implants, custom fabricated abutments, and abutment 
supported porcelain/ceramic crowns. The Plan denied your request. The Plan says the provided documentation 
did not meet the Plan's clinical criteria for the requested 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. The Plan covers the 
transosteal implants, custom fabricated abutments, and abutment supported porcelain/ceramic crowns when the 
services are medically necessary and reasonable.  
 
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 transosteal implants, custom 
fabricated abutments, and abutment supported porcelain/ceramic crowns. Our reviewer says that the implant 
restorations would not be considered necessary, and medical necessity has not been established for the 
requested procedures.  Our physician reviewer found the enrollee presented with a fully edentulous upper arch. 
The treatment plan was to place multiple implants on the upper arch and restore them with a fixed prosthesis. 
Our reviewer found that the ridge is not clearly sufficient to accept an implant due to pneumatization of the 
maxilla following tooth loss. Further evaluation of the bone would be necessary to verify the ability to place the 
requested implants as indicated, particularly in the premolar region. Our physician reviewer also found that 
there is no indication that the enrollee is not able to wear an upper denture. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the transosteal implants, custom fabricated abutments, and abutment supported 
porcelain/ceramic crowns have not been met. Therefore, we decided that the Plan does not have to pre-approve 
transosteal implants (D6050) for tooth #'s 4, 6, 9, 11, and 13, custom fabricated abutments (D6057) for tooth 
#'s 4, 6, 9, 11, and 13, and abutment supported porcelain/ceramic crowns (D6058) for tooth #'s 4, 6, 9, 11, and 
13.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 a ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found in this case, the record indicates that the 
enrollee has chronic hypoxic and hypercapnic respiratory failure from chronic obstructive pulmonary disease. 
The record indicates that the enrollee was successfully treated with bilevel positive airway pressure (BiPAP). 
The provided primary source documentation does not contain sufficient detailed information in the medical 
record to justify the treatment selected. The enrollee could be treated with a BiPAP machine with average volume-assured pressure support (AVAPS) capability. The plan has indicated coverage for such a device is 
available upon request. The elements of the coverage criteria are not satisfied. The requested service cannot be 
recommended. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the cost for the arthrocentesis and injections provided from February 10, 
2022, through March 10, 2022. 
 
You asked the Plan to waive the cost for the arthrocentesis and injections. You say that you are on a fixed 
income and are not able to pay because your Medicaid was canceled. The Plan denied your request. The Plan 
says that 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 does not say in clear and accurate terms 
how much you should expect to pay for Part B drugs and specialist services.  
 
We looked at your contract with the Plan. We did not see where the contract says enrollees must pay 20% 
coinsurance for Part B drugs and specialist services. The Plan contract only lists a range of costs and does not 
clearly say that enrollees must always pay 20% coinsurance. This means that the Plan did not follow Medicare 
rules for disclosure of cost sharing information. Therefore, we decided that the Plan has to waive the cost for 
the arthrocentesis and injections provided from February 10, 2022, through March 10, 2022.  
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service August 3, 
2022. 
 
You asked the Plan to pay for procedure code 76705. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 76705 is bundled into payment for code 93976. 
 
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 76705 
is a column II code to column I code 93976. 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 76705 billed for date of service August 3, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for crutches provided on March 10, 2022, by an out-of-network (OON) 
provider. 
 
You asked the Plan to pay for crutches. You say that the crutches should be covered regardless of authorization 
due to the extent of your injury and you could not walk. The Plan denied your request. The Plan says that the 
services were provided out-of-network and were not approved in advanced. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider at issue in this case is not a network provider with the Plan. 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 crutches. Our physician reviewer found due to the urgent situation of needing the 
crutches in order to leave the Urgent Care center and requiring an authorization from an in-network provider 
would have been unreasonable at the time the crutches will be considered medically necessary. The enrollee 
could not have reasonably foreseen the need or delay the use of crutches. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of crutches have not been met.  
 
The Plan has network providers available who can provide the items/services at issue in this appeal. We found 
no exception that would require the Plan to pay for crutches. Therefore, we decided that the Plan has to pay for 
crutches provided on March 10, 2022, by an out-of-network (OON) provider.  
 
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 the Nutribullet and oxygen saturation monitor provided on 
June 21, 2022, to July 21, 2022. 
 
You asked the Plan to pay for the Nutribullet and oxygen saturation monitor. You say that you would like to be 
reimbursed for the items. You say the items were required for your post-hernia surgery recovery. The Plan 
denied your request. The Plan says the services are not covered benefits. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
 The Nutribullet and oxygen saturation monitor do not serve a purpose that is primarily medical in nature. This 
item is available to the general public and would be helpful even to those who are not sick or injured. Although 
the Plan has supplemental benefits for some items and services not covered by Medicare, these items with no 
medical purpose are not covered by Medicare or the Wellness Wallet benefit. Therefore, we decided that the 
Plan does not have to pay for the Nutribullet and oxygen saturation monitor provided on June 21, 2022, to July 
21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections (64493, 64494). 
 
You asked the Plan to pre-approve the injections. You say that the injections help the enrollee manager her 
pain. You say that say that the injections help with their mobility. You also say that the enrollee is doing 
physical therapy. The Plan denied your request. The Plan says the requested services are not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that therapeutic facet joint procedures are considered 
medically reasonable and necessary for patients who meet all of the criteria. 
 
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 injections. Our reviewer says that 
the requested injections are not medically necessary. Our physician reviewer found the provided documentation 
does not indicate at least three months of pain relief from the previous injections to the same area of the spine. 
The reviewer found that there were no records provided that stated why the enrollee could not receive a 
radiofrequency ablation procedure instead. Therefore, the reviewer found that the requested injections are not 
medically necessary. 
 
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 injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve facet joint injections (64493, 64494).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Restrata skin substitute. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says there is a similar treatment covered by the plan called Actigraft. 
 
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 the procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that it is well established that this patient has been suffering with an ulceration to the lateral 
aspect of the left foot. The most recent progress note enclosed dated 11/1/22 advises that the patients 
ulceration is responding to conservative care. First and foremost, it is noted that the patients ulceration is 
healing with current standard conservative wound care. Furthermore, the health plan has offered a similar 
product, Actigraft, to facilitate healing of this patients ulceration. Because the ulceration is noted to be healing 
with current conservative treatments and the health plan is offering a similar product, Actigraft, the request is 
not medically reasonable or necessary at this time. 
 
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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Restrata skin substitute.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from August 1, 2021, to 
April 14, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the home health services. You say that the enrollee has progressively worsened, 
and you feel you have acted in good faith submitting this request in a timely manner. The Plan denied your 
request. The Plan says these services were rendered by an OON 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 home health services provided from August 1, 
2021, to April 14, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture services (97813, 97814) provided on  
July 24, 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 these services are not payable as you have 
exhausted the allowable wellness benefit. 
 
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 
Plans rules apply in this case.  
 
We looked at the file and the Plans rules. Based on this information, we decided that you have exhausted the 
allowable Wellness benefit for these services. Specifically, the wellness benefit allows for reimbursement up to 
$150 for acupuncture services. You previously received acupuncture services that applied to the wellness 
benefit on July 10, 2022 and July 17, 2022 in the amount of $150, that were paid for by the Plan. Therefore, 
you have exhausted the allowable wellness benefit for these services. Please note that if the non-contracted 
provider submits a claim with a valid chronic low back pain diagnosis code, the Plan may cover those visits 
under the supplemental acupuncture benefit. Therefore, we decided that the Plan does not have to pay for the 
acupuncture services (97813, 97814) provided on July 24, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a duplex scan (93880) provided on July 23, 2022. 
 
You asked the Plan to pay for the duplex scan. You say that this service was reported correctly and was 
provided in an appropriate place of service. The Plan denied your request. The Plan says this claim was 
submitted with an inappropriate place of service code. 
 
The Plan must follow Medicare rules. Medicare rules say that, for services rendered to a patient who is 
registered inpatient or outpatient of a hospital, the correct POS code, regardless of where the face-to-face 
service occurs, is that of the appropriate inpatient POS code or that of the appropriate outpatient hospital POS 
code.  We looked at the file and Medicare rules. The service at issue was billed with POS code 22 (on campus - 
outpatient hospital). However, the record shows that the enrollee was registered inpatient on the date this 
service was performed. This means that this claim must be submitted with an inpatient POS code. Based on this 
information, we decided that Medicare rules for coverage of the duplex scan have not been met. Therefore, we 
decided that the Plan does not have to pay for a duplex scan (93880) provided on July 23, 2022.