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

 
We decided that the Plan does not have to pay for an infusion pump and supplies provided from March 22, 
2023, to March 28, 2023. 
 You asked the Plan to pay for the infusion pump and supplies. You say that the enrollee was not on hospice 
during this period. The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
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 an infusion pump and supplies provided from March 22, 
2023, to March 28, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bone replacement graft (D4263 x 2) provided on 
December 17, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were not informed these procedures would 
not be covered and the bill is too much for you to pay. The Plan denied your request. The Plan says this service 
is not a covered benefit under your dental 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 pay for the bone 
replacement graft (D4263 x 2) provided on December 17, 2022.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from November 23, 2022, to December 14, 2022.

You asked the Plan to pay for SNF care. You say that the services should be covered under the Medicare Act. The Plan denied your request. The Plan says the enrollee's condition no longer required SNF services for the dates in question.

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 pay for SNF care. Our reviewer says that the requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee did not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did 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 have not been met. Therefore, we decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from November 23, 2022, to December 14, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on 
February 10, 2023, to February 13, 2023. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you disagree with the 
copayment. 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 $230 
copayment per day for days 1-7 for inpatient hospital care.  
 
You have been asked to pay a $230 copayment per day for days 1-7 for inpatient hospital care. The total 
amount you are being asked to pay is $690 ($230 x 3 days = $690). This item/service falls within the inpatient 
hospital 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 inpatient hospital care 
provided on February 10, 2023, to February 13, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve kyphoplasty at L3 (22514).  

You asked the Plan to pre-approve kyphoplasty. You say that the services are necessary. The Plan denied your 
request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been 
met. 
 
The Plan follows Medicare rules. Medicare rules say that percutaneous vertebroplasty and percutaneous 
vertebral augmentation (PVA or Kyphoplasty) procedures will be considered medically reasonable and 
necessary for certain indications. 
 
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 kyphoplasty. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found detailed documentation is not evident 
regarding worsening pain. There is no indication of a progression of the body height or a severe impact on 
daily activities. Moreover, there is magnetic resonance imaging (MRI) corroboration of retropulsion and other 
plausible causes for back pain. Therefore, the enrollee does not meet the coverage criteria detailed in the LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve kyphoplasty at L3 (22514).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided on May 26, 2023. 
 
You asked the Plan to pay for the medication. You say that the medication was given in the emergency room. 
The Plan denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
  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 pay for self-administered drugs provided 
on May 26, 2023.  
 
Benefits for the medication 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 pay for the compression stockings identified with code A6549 that 
were issued on March 1, 2023. 
 You asked the Plan to pay for the compression stockings. You say that you made a purchase and was told to 
request reimbursement since the physician deemed compression stockings medically necessary. You also say 
that the physician provided a prescription for them and insurance has paid for them in the past. The Plan denied 
your request. The Plan says there is no documentation of there being wounds that meet the requirements and 
criteria per this policy 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 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 pay for the compression 
stockings identified with code A6549 that were issued on March 1, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing billed for date of service December 22, 
2022. 
 
You asked the Plan to pay for the billed services. You say that the treatment sought was medically necessary. 
The Plan denied your request. The Plan says there is a more appropriate code that should be used. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
The file shows that panel testing was billed with multiple codes including 81225, 81226, 81240, 81241. We 
find that the panel testing was not billed with a single code as required. The records do not show that the codes 
billed with the -59 modifier were separate and distinct services. 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 the panel testing billed for date of service December 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the re-cement or re-bond crown (D2920) provided on March 
28, 2023. 
 
You asked the Plan to pay for the  re-cement or re-bond crown. You say that you were traveling when your 
bridge worked its way loose. You also say that you contacted the dentist who originally put the bridge in and he 
was able to re-cement the bridge. The Plan denied your request. The Plan says our records indicate that you are 
covered under a different insurance policy with your spouse as the subscriber. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers.  Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill 
directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the 
primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary 
insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has confirmed 
that the other insurance carrier paid the $133.00 for this date of service with a $41.00 write-off. The account 
ledger reflects a balance of $133.00 on March 27, 2023. You paid $66.00 on March 28, 2023 bringing the 
balance to $67.00. The account ledger also reflects the other insurance carrier paid $133.00 for date of service 
March 28, 2023, with a $41.00 insurance write-off. The account ledge reflects a balance of $25.00 which 
appears to be coming from the previous account balance of $133.00. As the secondary insurer, the Plan cannot 
be held responsible for the re-cement or re-bond crown until the primary insurer has denied the claim for these 
services. Therefore, we decided that the Plan does not have to pay for the re-cement or re-bond crown (D2920) 
provided on March 28, 2023.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pay for the procedure codes J9190, A4306, 96413, 96415 received on March 7, 
2023, to April 14, 2023. 
 
You asked the Plan to pay for the procedure codes J9190, A4306, 96413, 96415. You say that the Plan should 
be the primary payer. The Plan denied your request. The Plan says that the claim was processed correctly. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has not met its obligation with regards to coordination of benefits. Specifically, the record does not 
show that the Plan has sent the bill directly to the primary insurer for payment, directed the provider to send the 
bill to the primary insurer or paid for the services and submitted a bill for reimbursement to the primary insurer. 
Therefore, we decided that the Plan has to pay for the procedure codes J9190, A4306, 96413, 96415 received 
on March 7, 2023, to April 14, 2023.  
 
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 deluxe frame, the lens, and the anti-reflective coating 
provided on March 14, 2023. 
 
You asked the Plan to pay for the vision services. You say that you believed you could go out-of-network and 
you would like an additional reimbursement due to the costly eyewear. The Plan denied your request. The Plan 
says the benefit has been exhausted. 
 
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 one pair of eyeglasses and pair of lenses or contact lenses per calendar year. 
 
We looked at the file and the Plan's rules. Specifically, the Plan paid $200 towards one pair of eyewear on 
March 14, 2023, for claim number 112777892700, which exhausted the benefit. Based on this information, we 
decided that the Plan's rules for coverage of the vision services have not been met. Therefore, we decided that 
the Plan does not have to pay for the deluxe frame, the lens, and the anti-reflective coating provided on March 
14, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code H2001 billed for date of service April 25, 
2023. 
 
You asked the Plan to pay for procedure code H2001. The Plan denied your request. The Plan says the billed 
code is invalid for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. We find that procedure code H2001 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code H2001 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code H2001 billed for date of service April 25, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) device (E 
 You asked the Plan to pre-approve a CPAP device. You say that the item is medically necessary. The Plan 
denied your request. The Plan says the item is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that For PAP devices with initial dates of service on 
or after November 1, 2008, documentation of clinical benefit is demonstrated by: 
1. In-person clinical re-evaluation by the treating practitioner with documentation that symptoms of obstructive 
sleep apnea are improved; and, 
2. Objective evidence of adherence to use of the PAP device, reviewed by the treating practitioner. Adherence 
to therapy is defined as use of PAP greater than or equal to 4 hours per night on 70% of nights during a 
consecutive thirty (30) day period anytime during the first three (3) months of initial usage. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a CPAP device have not been met. Specifically, the documentation submitted does not show 
adherence to therapy. Therefore, we decided that the Plan does not have to pre-approve a continuous positive 
airway pressure (CPAP) device (E
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral - periapical first radiographic image (D0220), 
and each additional radiographic image (D0230) provided on April 18, 2023. 
 
You asked the Plan to pay for the comprehensive oral evaluation, intraoral - periapical first radiographic image 
and each additional radiographic image. You say that you needed to change your dental providers as your 
previous dentist no longer accepted your insurance plan. The Plan denied your request. The Plan says these 
services are not covered under your plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the intraoral - periapical first 
radiographic image and each additional radiographic image are not among those covered under this benefit. 
Therefore, we decided that the Plan does not have to pay for the intraoral - periapical first radiographic image 
(D0220) and each additional radiographic image (D0230) provided on April 18, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652). 
 
You asked the Plan to pre-approve a pneumatic compression device . You say that the item should be covered. 
The Plan denied your request. The Plan says the use of this device is experimental for the enrollee's diagnosis. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
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 Flexitouch device. Our reviewer 
says that the item is not medically necessary. Our physician reviewer found this device is not studies in face 
and neck lymphodema. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this device is experimental for the enrollees diagnosis. 
Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the application of a modality, vertebral axial 
decompression and manipulative treatment provided by a chiropractor on April 17, 2023, to April 27, 2023. 
 
You asked the Plan to pay more for chiropractic services. You say that insurance should cover more than just 
manipulation for subluxation. The Plan denied your request. The Plan says these services are not a covered 
chiropractic service. 
 The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation. 
 
The records show that application of a modality and vertebral axial decompression are not manual 
manipulation of the spine. Therefore, we decided that the Plan does not have to pay for application of a 
modality and vertebral axial decompression provided by a chiropractor on April 17, 2023, to April 27, 2023. 
 
The Plan must follow Medicare rules. Medicare rules say that when services or supplies are rendered by a non-
contracting, original Medicare, participating provider, there is no balance billing paid by either the Plan or the 
enrollee. The rules also 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 copayment for each Medicare-covered chiropractic visit. 
 
You have been asked to pay a total of $80 for manual manipulation ($20 copayment x 4/visits = $80). This 
service falls within the chiropractic 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. The record also indicates that the Plan, in combination with your 
copayment, has paid the Medicare allowed amount for this service. A Medicare provider should accept the 
Medicare allowed amount as payment in full. In this case, the Plan is not responsible for paying the balance 
that remains after the Medicare allowed payment. Therefore, we decided that the Plan does not have to pay 
more for manual manipulation provided by a chiropractor on April 17, 2023, to April 27, 2023.
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 you need acute inpatient rehab so that you can regain 
maximum function. The Plan denied your request. The Plan says an IRF admission is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that your 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.