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

 
We decided that the Plan does not have to pay for radiotherapy services (77427) provided on December 20, 
2022. 
 
You asked the Plan to pay for the radiotherapy services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the billed services. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 77427 is not supported in the medical record. Specifically, the claim does not indicate 
how many fractions were performed. Based on this information, we decided that Medicare rules for coverage 
of the radiotherapy services have not been met. Therefore, we decided that the Plan does not have to pay for 
radiotherapy services (77427) provided on December 20, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the cost share for an in-network knee x-ray and office visit provided 
from November 22, 2022, to February 9, 2023. 
 
You asked the Plan to waive the cost share for an in-network knee x-ray and office visit. You say that these 
charges are too high. You are on a limited income and cannot afford this. You thought everything would be 
covered because this was from a surgery. The Plan denied your request. The Plan says that this is a required 
copayment. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. the Plain failed to forward all the information we required. Therefore, we 
decided that the Plan has to waive the cost share for an in-network knee x-ray and office visit provided from 
November 22, 2022, to February 9, 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 an office visit (D9430) provided on December 21, 2022. 
 
You asked the Plan to pay for the dental service. You say that the provider submitted the wrong code and 
would like for the service to be paid. The Plan denied your request. The Plan says the denial of payment for this 
service is correct, because the office visit and the adjustment to complete denture is not covered by the 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, neither the office visit or the 
adjustment to complete denture are among those covered under this benefit. Therefore, we decided that the 
Plan does not have to pay for an office visit (D9430) provided on December 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services (74230) provided on November 15, 2022. 
 
You asked the Plan to pay for the radiology services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
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 74230 is not supported in the medical record. Specifically, this service was billed with 
an outpatient place of service (22), however records show the enrollee was an inpatient at the time the service 
was provided. Based on this information, we decided that Medicare rules for coverage of the radiology services 
have not been met. Therefore, we decided that the Plan does not have to pay for radiology services (74230) 
provided on November 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on November 30, 2022, by an out-
of-network (OON) provider.  
 
You asked the Plan to pay for the lab services. You say that the services billed are supported in the records. The 
Plan denied your request. The Plan says enrollees must receive their care from a network provider. 
 
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 
items/services 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 lab services provided on November 30, 2022, 
by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a limited oral evaluation and intraoral x-rays (D0220, 
D0140, D0230 ) provided on October 22, 2020. 
 
You asked the Plan to pay more for the dental services. You say that the services should be covered as you 
disagree with the charges. The Plan denied your request. The Plan says you are responsible for any charged 
amount above the Plans cost-sharing amount when your services are received from an out-of-network 
provider.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to pay more for a limited oral evaluation and intraoral x-rays 
(D0220, D0140, D0230 ) provided on October 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the 2D oral/facial photographic image, cone beam CT 
capture and interpretation and panoramic x-ray provided on January 20, 2023. 
 
You asked the Plan to pay for the dental services. You say that you assumed these were all covered benefits. 
The Plan denied your request. The Plan says these services are either not a covered benefit under your dental 
plan or the benefit has 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, the requested items or services are not 
among those covered under this benefit. Additionally, your benefit for the panoramic x-ray was exhausted on 
the same date of service with another diagnostic procedure. Therefore, we decided that the Plan does not have 
to pay for the 2D oral/facial photographic image, cone beam CT capture and interpretation and panoramic x-ray 
provided on January 20, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye refraction (92015) provided on February 21, 2023. 
 You asked the Plan to pay for an eye refraction. You say that this should be covered. The Plan denied your 
request. The Plan says the service at issue is not a covered benefit when performed during a medical eye 
examination. 
 
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 these services when The Plan covers this service when it is performed by a 
participating provider and as a routine screening. 
 
We looked at the file and the Plan's rules.  Based on this information, we decided that the Plan's rules for 
coverage of an eye refraction have not been met. Specifically, eye refraction is only covered by the Plan when 
it is performed as part of a routine screening by a participating provider. This service was performed for 
medical vision purposes, and therefore is not a covered benefit. Therefore, we decided that the Plan does not 
have to pay for an eye refraction (92015) provided on February 21, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided from December 30, 2022, 
through December 31, 2022. 
 
You asked the Plan to pay for self-administered drugs. You say that the claim should be reprocessed. The Plan 
denied your request. The Plan says self-administered drugs do not fall under Medicare Part B coverage. 
 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 
from December 30, 2022, through December 31, 2022.  
 
Benefits for self-administered drugs 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abutment supported crown provided on February 23, 
2023. 
 
You asked the Plan to pay for the dental services. You say that in August of 2022 the Plan approved this 
procedure and it is a covered benefit. 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 
abutment supported crown provided on February 23, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that  the enrollee currently meets acute inpatient 
rehabilitation admission criteria The Plan denied your request. The Plan says  the IRF care is not medically 
necessary, and the enrollee's needs can be met at a lower level of care, such as a skilled nursing facility, home 
with home health services, or home with outpatient therapy. 
 
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 was admitted for emphysema and pneumonia. The enrollee's medical 
problems are stable, and there are no complex nursing or rehabilitation needs. The enrollee does not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While the medical record supports a need for physical and/or occupational 
therapy, there is no documented need for intensive rehabilitation services. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custom foot orthotics.  
 
You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says these items are not a covered benefit for your condition. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve custom foot orthotics.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-emergent transportation through another mean 
besides ambulance. 
 
You asked the Plan to pre-approve non-emergent transportation through another mean besides ambulance. You 
say that you are bed bound and cannot walk. The Plan denied your request. The Plan says the requested 
services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport 
services.  
 
 The services you have asked the Plan to pre-approve are non-emergent transportation through means other than 
ambulance. While the transportation may be necessary through an ambulance, there is no benefit that covers 
non-emergent transportation through other means than an ambulance. Therefore, we decided that the Plan does 
not have to pre-approve non-emergent transportation through another mean besides ambulance.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the rest home visit provided on October 24, 2022. 
 
 You asked the Plan to pay for the rest home visit. 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. 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 October 4, 2022. 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 rest home visit 
provided on October 24, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion of interlaminar/interspinous process 
stabilization device. 
 
You asked the Plan to pre-approve the device. You say that the enrollee has failed conservative approaches to 
treatment. You say the device is considered safe and effective and will dramatically improve the enrollee's 
quality of life. The Plan denied your request. The Plan says  the insertion of interlaminar/interspinous process 
stabilization device is considered experimental. 
 
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 device. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found interlaminar spacers are experimental, and more research is needed.  
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the insertion of interlaminar/interspinous process stabilization device.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on January 17, 2023. 
 You asked the Plan to pay for lab services. 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 lab services provided on January 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on December 9, 2022. 
 
You asked the Plan to pay for lab services. You say that the claim should be reprocessed. 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 lab services provided on December 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture treatments (97813, 97814) and the office 
visit (99213) provided on September 2, 2021 and September 23 2021. 
 
 
  
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services are not payable as they were 
rendered by an ineligible provider.  
 
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.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the acupuncture services in this case were not 
rendered under the supervision of a physician, physicians assistant, nurse practitioner, or clinical nurse 
specialist. Therefore, we decided that the Plan does not have to pay for the acupuncture treatments (97813, 
97814) and the office visit (99213) provided on September 2, 2021 and September 23 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the problem focused limited oral evaluation, 
endodontic therapy, periapical first x-ray and cone beam CT capture and interpretation provided on February 
17, 2023. 
 
You asked the Plan to pay more for the dental services. You say that the Plan assured you that you would be 
covered at the in-network rate. The Plan denied your request. The Plan says these services are either not a 
covered benefit under your dental plan or the benefit has been exhausted. Additionally, you are responsible for 
any charged amount above the Plans cost-sharing amount when your services are received from an out-of-
network provider. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Additionally, the record shows your benefit for the periapical first x-ray was exhausted on date of service 
February 14, 2023, and cone beam CT capture and interpretation is not covered any circumstance. Therefore, 
we decided that the Plan does not have to pay more for the problem focused limited oral evaluation, endodontic 
therapy, periapical first x-ray and cone beam CT capture and interpretation provided on February 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital discharge day management provided on July 8, 
2022. 
 
You asked the Plan to pay for hospital discharge day management. You say that the enrollee was not in hospice 
at the time of service. 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 hospital discharge day management provided on July 8, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services provided on July 30, 2022. 
 You asked the Plan to pay for emergency room services. You say that the claim should be reprocessed. 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. 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 July 27, 2022. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for emergency room services 
provided on July 30, 2022.