Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bitewing x-ray (D0270), caries risk assessment and 
documentation (D0602), and oral hygiene instruction (D1330) provided on October 18, 2021. 
 
You asked the Plan to pay for the dental services. You say that you had a painful tooth. You say that you made 
this emergency appointment. You also say that you did not ask for the x-ray or any other procedure. The Plan 
denied your request. The Plan says 1 set of bitewing x-rays are covered per plan year. The Plan says that the 
frequency limit has been exceeded. The Plan also says caries risk assessment and documentation and oral 
hygiene instruction are not listed as covered services. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage and bitewing x-rays are listed as 
covered, the frequency limit has been exceeded. The record shows that the Plan paid for bitewing x-rays that 
you received on January 14, 2021. Additionally, caries risk assessment and documentation and oral hygiene 
instruction are not among those covered under this benefit. Therefore, we decided that the Plan does not have 
to pay for the bitewing x-ray (D0270), caries risk assessment and documentation (D0602), and oral hygiene 
instruction (D1330) provided on October 18, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on September 8, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of 
service (POS) code. 
 
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a 
laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have 
been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory 
services rendered on September 8, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the emergency room visit (99285) and the 
inpatient hospital care provided from July 20, 2021, through August 2, 2021. 
 
You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayments have been applied correctly to 
the services provided. 
 
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 $90 
copayment per visit for emergency care and a $250 copayment per day, for days 1-7 per admission for inpatient 
hospital care. The copayment for emergency care is not waived if admitted to an inpatient hospital.   
You have been asked to pay $1840 ($250 copayment x 7 days + $90) for the inpatient hospital care and the 
emergency room visit provided. 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 copayments for the emergency room visit 
(99285) and the inpatient hospital care provided from July 20, 2021, through August 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a topical hyperbaric oxygen chamber (A4575). 
 
You asked the Plan to pre-approve a topical hyperbaric oxygen chamber. You say that this is medically 
necessary. The Plan denied your request. The Plan says this service is not a Medicare-covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that topical hyperbaric oxygen chambers (A4575) 
will be denied as not reasonable and necessary 
 
We looked at the file and Medicare rules. This service is statutorily non-covered by Medicare rules. Based on 
this information, we decided that Medicare rules for coverage of a topical hyperbaric oxygen chamber have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a topical hyperbaric oxygen 
chamber (A4575).
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extracapsular cataract removal with insertion of 
intraocular lens prosthesis (66984) provided on August 26, 2021. 
 
You asked the Plan to pay for the surgical service. You say that the claim should be paid. 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 extracapsular cataract removal with insertion of 
intraocular lens prosthesis (66984) provided on August 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on November 
6, 2021. 
 
You asked the Plan to pay for the dental service. You say that you told the dentist you did not have dental 
insurance or supplemental dental benefit. You say that you paid $1,800 for partials that do not fit properly. You 
also say that you keep using your old ones. The Plan denied your request. The Plan says limited oral evaluation 
is not listed as a covered service. 
 
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 limited oral evaluation is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
limited oral evaluation (D0140) provided on November 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the special anesthesia service (99100) provided on 
September 10, 2021. 
 
You asked the Plan to pay for the special anesthesia service. You say that you would like reconsideration based 
on the records submitted. The Plan denied your request. The Plan says CPT code 99100 has a status indicator 
of B. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
 
 
 
  
We find that CPT code 99100 is not supported in the record. Specifically, CPT code 99100 has a status 
indicator of B. This means that the payment for CPT code 99100 is always bundled into the payment for 
another service or procedure. Based on this information, we decided that Medicare rules for coverage of the 
special anesthesia service have not been met. Therefore, we decided that the Plan does not have to pay for the 
special anesthesia service (99100) provided on September 10, 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. The Plan denied your request. The Plan says medical needs for 
IRF services have not been met because the records do not show that you need an intensive program with a 
team of healthcare professionals and doctors that specialize in complex medical needs as well as rehabilitation. 
 
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 patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer 
found that the documentation does not support that the enrollee requires at least 3 hours a day, 5 days a week, 
or 15 hours over 7 consecutive days, of therapy services. Our physician reviewer also found that there is a 
reasonable expectation that this patient will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF, however, therapy services may be provided at a lower 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a skilled nursing facility stay provided from 
September 2, 2021, to September 24, 2021. 
 
You asked the Plan to waive the copayment for a skilled nursing facility stay. You say that the provider failed 
to let you know the stay was over 20 days and a copayment would be charged. The Plan denied your request. 
The Plan says the proper copayment amount was charged for the services. 
 
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 $184 
copayment for each skilled nursing facility stay for days 21 to 39. The total copayment amount was $368 ($184 
copayment amount x 2 days). 
 
  You have been asked to pay a $368 copayment for a skilled nursing facility stay. A skilled nursing facility stay 
falls within the Skilled Nursing Facility (SNF) Care 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 a skilled nursing facility stay provided from September 2, 2021, to September 24, 2021.  
 
Your complaint about your experience with this provider is not a valid appeal for medical coverage. This part 
of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a vitrectomy chair rented on October 19, 2021. 
 
You asked the Plan to pay for this equipment. You say that the Plan should pay for the rental of this equipment 
because it was needed after eye surgery. The Plan denied your request. The Plan says this equipment is not 
covered by Medicare, and you did not have prior authorization. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose. Precautionary equipment is not covered. The Plan contract says that durable medical 
equipment requires prior authorization. A vitrectomy chair is precautionary and is not covered by Medicare. 
You also did not have prior authorization for this equipment. Therefore, we decided that the Plan does not have 
to pay for a vitrectomy chair rented on October 19, 2021.
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 LTACH care is medically reasonable 
and necessary.. The Plan denied your request. The Plan says rules for LTACH care have not been met. 
 
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 the enrollee was found down and admitted to undergo decompressive craniotomy.  
The record indicates that the enrollee has had a complicated hospital course and is currently bed bound, 
nonverbal, and does not follow commands. The enrollee continues to receive acute care services, and these 
have not been denied. The medical record does not indicate that the enrollee requires services that he is not 
currently receiving but that would be available at the LTACH facility. The elements of the coverage rules 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 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve viscosupplementation with hyaluronan (GenVisc 850). 
 
You asked the Plan to pre-approve viscosupplementation. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the denial of authorization for this service is correct, 
because use of GenVisc 850 is not medically accepted when less than 6 months have elapsed since the prior 
series of injections. 
 
The Plan follows Medicare rules. Medicare rules state that repeat viscosupplementation may be covered under 
certain circumstances. 
 
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 viscosupplementation. Our reviewer 
says that the enrollee does not meet the Medicare criteria for the requested use of hyaluronan. Our physician 
reviewer found the records show that the enrollee had a prior injection of hyaluronic acid to the knees less than 
6 months ago in October 2021. There is insufficient documentation of the enrollee having measurable benefit 
from the prior injection. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of viscosupplementation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve viscosupplementation with hyaluronan (GenVisc 850).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), complete series 
x-ray (D0210), and 2D photographic images (D0350 x 4) provided on October 18, 2021, by an out of network 
provider. 
 
You asked the Plan to pay for the dental services. You say that you were led to believe that all of the services 
were covered, and the provider was in network. You say that you were not advised of the type of x-ray you 
were receiving. You also say that you cannot afford to pay this bill. The Plan denied your request. The Plan 
says out of network providers may bill you for any amount greater than what the plan pays the provider. The 
Plan also says 2D photographic images are not listed as covered services. 
 Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage and the oral evaluation and complete 
series x-ray are listed as covered, out of network providers may bill you for any amount greater than what the 
plan pays the provider. Additionally, the 2D photographic images are not among those covered under this 
benefit. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation 
(D0150), complete series x-ray (D0210), and 2D photographic images (D0350 x 4) provided on October 18, 
2021, by an out of network provider.
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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee can safely receive the services she needs in other settings. 
 
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. The 
complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care.  The documentation does not support that the enrollee requires at least 3 hours a day for 5 days a week, or 15 
hours over 7 consecutive days, of therapy services. It is not clear that the enrollee can fully participate in and 
benefit from the intensive rehabilitation therapy program provided in an IRF at this time. Our physician 
reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment and coinsurance for tumor imaging (SPECT) 
with iodine contrast provided on June 30, 2021. 
 You asked the Plan to waive the copayment and coinsurance for the SPECT with iodine contrast. You say that 
you have not been asked to pay additional amounts for radiology services in the past. The Plan denied your 
request. The Plan says the correct copayment and coinsurance was applied. 
 
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 $175 
copayment for radiological diagnostic services, not including X-rays, performed in a physician's office or at a 
free-standing facility. 
 
Your contract with the Plan clearly says that you must pay a 20% coinsurance for medical supplies, including 
chemical agents used in certain diagnostic procedures. 
 
You have been asked to pay a $175 copayment for the SPECT imaging. You have also been asked to pay 
$562.70 for the iodine contrast agent, which is 20% of the allowed amount ($2,813.52 allowed amount x 20% 
coinsurance = $562.70). Yhe SPECT with iodine contrast falls within the Outpatient Diagnostic Tests and 
Therapeutic Services and Supplies 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 and 
coinsurance for tumor imaging (SPECT) with iodine contrast provided on June 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140), initial periapical x-ray 
(D0220), and additional periapical x-ray (D0230) provided on October 21, 2021. 
 
You asked the Plan to pay for the dental service. You say that you were experiencing severe tooth pain. You 
also say that you feel this should be covered. The Plan denied your request. The Plan says limited oral 
evaluation is not listed as a covered service. The Plan also says periapical x-rays are not listed as covered 
services either. 
 
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 limited oral evaluation and 
periapical x-rays are not among those covered under this benefit. Therefore, we decided that the Plan does not 
have to pay for the limited oral evaluation (D0140), initial periapical x-ray (D0220), and additional periapical 
x-ray (D0230) provided on October 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two surgical placements of implant bodies: endosteal 
implants (D6010 x2), two surgical accesses to an implant body (D6011 x2), and bone graft at time of implant 
placement (D6104) provided on April 23, 2021, and September 22, 2021. 
 
You asked the Plan to pay for the endosteal implants, surgical accesses to an implant body, and bone graft. You 
say that you received information that these services were covered under your plan for the 2021 benefit year. 
The Plan denied your request. The Plan says these services 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. The provided documentation does not show that your mandibular arch 
is completely toothless, or that the implant services were provided to hold a complete denture. Therefore, we 
decided that the Plan does not have to pay for the two surgical placements of implant bodies: endosteal 
implants (D6010 x2), two surgical accesses to an implant body (D6011 x2), and bone graft at time of implant 
placement (D6104) provided on April 23, 2021, and September 22, 2021.