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

 
We decided that the Plan does not have to pay for oral hygiene instructions (D1330) provided on January 25, 
2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental benefits. 
 
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 oral 
hygiene instructions (D1330) provided on January 25, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the orthodontic retention (D8680 x 2) provided on January 
10, 2023. 
 
You asked the Plan to pay for the dental services. You say that new retainers were required after a change in 
your bite from getting a crown. 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 
orthodontic retention (D8680 x 2) provided on January 10, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services billed with code 87631 for date of 
service July 27, 2022. 
 
You asked the Plan to pay for the laboratory services billed with code 87631. You say that you disagree with 
the Plan's denial. The Plan denied your request. The Plan says the claim for this molecular pathology testing 
did not include the required unique identifier. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the laboratory services 
billed with code 87631 have not been met. Therefore, we decided that the Plan does not have to pay for the 
laboratory services billed with code 87631 for date of service July 27, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.

You asked the Plan to pre-approve IRF care. You say that the enrollee's acute medical problems have left them
at a functional status below their baseline and you believe that those problems can best be managed by close
daily oversight of care by a physician in an inpatient setting. The Plan denied your request. The Plan says the
enrollee is not shown to be ready for discharge and does not meet the criteria for inpatient rehabilitation
admission.

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 does not require treatment by multiple therapies. 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department and related services provided on 
December 6, 2022. 
 
You asked the Plan to pay for the emergency department and related services. You say that you disagree with 
the Plan's denial. The Plan denied your request. The Plan says the services billed are not payable. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the emergency department and related 
services provided on December 6, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CT scan of the lumbar spine. 
 
You asked the Plan to pre-approve a CT scan of the lumbar spine. You say that the enrollee would like 
reconsideration because the services are medically necessary. The Plan denied your request. The Plan says a 
CT scan of the lumbar spine is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
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 CT scan of the lumbar spine. Our 
reviewer says that a CT scan of the lumbar spine is not medically necessary Our physician reviewer found that 
while the enrollee has low back pain there are no radicular symptoms or red flags noted. Also, there are no plan 
films of the lumbar spine and no history of trauma. Therefore, the medical necessity of the requested Ct of the 
lumbar spine has not been established in the submitted records. 
 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 CT scan of the lumbar spine have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a CT scan of the lumbar spine.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist office visit provided on 
January 25, 2023. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that you should not have to 
pay to see a nurse practitioner. 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 $40 
copayment for in-network specialist physician/practitioner services. 
 
You have been asked to pay a $40 copayment for the specialist office visit. This item/service falls within the 
in-network specialist physician/practitioner 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. Therefore, we decided that the Plan does not have to waive the 
copayment for the specialist office visit provided on January 25, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room services provided on November 15, 
2022. 
 
You asked the Plan to pay for the emergency room services. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. In this case, coding guidelines state that a type 1 Excludes note is a 
pure excludes note. It means "Not Coded Here!" An Excludes1 note indicates that the code excluded should 
never be used at the same time as the code above the Excludes1 note. An Excludes1 is used when two 
conditions cannot occur together, such as a congenital form versus an acquired form of the same condition. 
Diagnosis codes S09.90XA and S06.378A should not be reported together. Therefore, we decided that the Plan 
does not have to pay for the emergency room services provided on November 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental crowns (D2750). 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as you do 
not meet the clinical requirements to be approved. 
 
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 are covered, 
however, the record indicates that you do not meet the clinical requirements to be approved. Therefore, we 
decided that the Plan does not have to pre-approve dental crowns (D2750).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for end-stage renal disease services provided on December 31, 
2022. 
 
You asked the Plan to pay for end-stage renal disease services. You say that this is supported in the records. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for end-stage renal disease 
services provided on December 31, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan 
provided on December 20, 2022. 
 
You asked the Plan to waive the copayment for a computed tomography (CT) scan. You say that you had an 
order for a free annual lung CT scan for smokers but after you were diagnosed with cancer, a new order was 
required and no one mentioned a 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 $125 
copayment for outpatient diagnostic test. 
 
You have been asked to pay a $125 copayment for a computed tomography (CT) scan. This item/service falls within the outpatient diagnostic test 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 total you owe is $107.76, which is less than the standard $125 copayment 
for a CT scan. Therefore, we decided that the Plan does not have to waive the copayment for a computed 
tomography (CT) scan provided on December 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the inpatient hospital stay provided from 
October 1, 2022, to October 4, 2022.  
 
You asked the Plan to waive the coinsurance for the inpatient hospital stay. You say that you cannot afford the 
coinsurance. 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 30% 
coinsurance per stay, for out-of-network inpatient hospital services.  
 
 
 
 You have been asked to pay $2,549.79, which is 30% coinsurance of the allowed amount for the inpatient 
hospital stay ($8,499.30 allowed amount x 30% = $2,549.79). 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 coinsurance for the inpatient hospital stay 
provided from October 1, 2022, to October 4, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for inpatient hospital stay on November 19, 
2022, to November 21, 2022. 
 
You asked the Plan to waive the deductible for inpatient hospital stay. You say that you have a statement that 
says you already paid. 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. Your 
contract with the Plan says that there is a $300 deductible which applies to inpatient hospital care.  
 
The item or service you asked the Plan to waive the deductible for falls within the inpatient hospital care 
benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $300 
deductible which applies to inpatient hospital care. This cost sharing is a contractual obligation that had not 
been met at the time inpatient hospital stay was received on November 19, 2022, to November 21, 2022. 
Therefore, we decided that the Plan does not have to waive the deductible for inpatient hospital stay on 
November 19, 2022, to November 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each arthrocentesis and drug injection 
provided from November 29, 2022, to December 13, 2022. 
 
You asked the Plan to waive the copayment for each arthrocentesis and drug injection. You say that this was 
split into three visits which caused the copayments to triple. 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 $300 copayment for in-network outpatient surgery provided at an outpatient hospital. Your contract with the Plan 
also says that you must pay 20% coinsurance for in-network Medicare Part B drugs. 
 
Date of Service CPT Allowed Amount Coinsurance Copayment 
November 29, 2022 20610 $281.22 - $150 
November 29, 2022 J7324 $305.83 $61.17 - 
December 6, 2022 20610 $421.83 - $150 
December 6, 2022 J7324 $305.83 $61.17 - 
December 13, 2022 20610 $421.83 - $150 
Total $572.34 
 
You have been asked to pay $150, which is less than the standard $300 copayment for each arthrocentesis. This 
item/service falls within the outpatient surgery benefit category. You have also been asked to pay 20% 
coinsurance for each drug injection. 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 each arthrocentesis 
and drug injection provided from November 29, 2022, to December 13, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for each physical therapy (PT) visit provided 
on December 08, 2022. 
 
You asked the Plan to waive the coinsurance for each physical therapy (PT) visit. You say that the 
authorization does not mention the requirement for a 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 20% 
coinsurance for outpatient rehabilitation service.  
You have been asked to pay 20% coinsurance for each physical therapy (PT) visit. This item/service falls 
within the outpatient rehabilitation service 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 coinsurance 
for each physical therapy (PT) visit provided on December 08, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hip and elbow x-rays provided on February 12, 2023. 
 
You asked the Plan to pay for the x-rays. You say that hospice ended after the patient was seen. 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 hip and elbow x-rays provided on February 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a skilled nursing facility visit provided on December 19, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a skilled nursing facility visit. You say that it is not up to you who the patient 
sees. You and the patient depend upon the facility staff to verify eligibility and to obtain authorization. The 
Plan denied your request. The Plan says there was no preauthorization by a primary care provider (this is 
different than a referral) for an out-of-network (OON) 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 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 a skilled nursing facility visit provided on 
December 19, 2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a PET with CT scan  
 
You asked the Plan to pre-approve a PET with CT scan of the whole body You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says that a PET scan 
with CT scan of the whole body is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
medically necessary.  
 
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 PET with CT of the whole body. Our 
reviewer says that a PET scan with CT of the whole body is medically necessary. Our physician reviewer found 
that your local recurrence in the submental area of the face and neck included multiple nodules which proved to 
all be malignant. Since the last PET scan that was done on December 1, 2022, the requested PET/CT would be 
a 6-month surveillance for you. Since the recurrence included malignant nodules and you are a high risk for 
further recurrence, the requested PET scan with CT is reasonable and should be approved. 
 
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 PET with CT of the whole body have been met. Therefore, we decided that 
the Plan has to pre-approve a PET with CT of the whole body.  
 
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genetic testing (81240, 81241).

You asked the Plan to pre-approve genetic testing. You say that the enrollee has a history of unprovoked extensive lower leg extremity deep vein thrombus (DVT), status-post thrombectomy. It is medically necessary. The Plan denied your request. The Plan says the request is not medically necessary because testing for F2 and F5 is only indicated in pregnant patients.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.

We looked at the file and Medicare rules. The requested testing is only indicated for pregnant enrollees. Based on this information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pre-approve genetic testing (81240, 81241).