Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on August 3, 
2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on August 3, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pulp vitality tests (D0460) provided on September 21, 
2023. 
 
You asked the Plan to pay for the pulp vitality tests. You say that you needed this procedure to be done to find 
out if you needed to get a root canal. The Plan denied your request. The Plan says this is not a covered service 
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 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 pulp 
vitality tests (D0460) provided on September 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for naturopath services provided on June 14, 2023, to July 31, 
2023. 
 
You asked the Plan to pay for naturopath services. You say that you are requesting reconsideration for the 
denied claim. The Plan denied your request. The Plan says the requested services are not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that certain individuals and entities frequently 
attempt to enroll in Medicare but are not eligible to do so. If the Medicare contractor receives an enrollment 
application from the individual or entity, the contractor shall deny the application. Naturopathic doctor is 
among the provider types that are not eligible to enroll in Medicare.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of naturopath services have not been met. Therefore, we decided that the Plan does not have to pay 
for naturopath services provided on June 14, 2023, to July 31, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for dental services provided on September 6, 2023. 
 
You asked the Plan to pay more for the dental services. You say that this should be covered. 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 dental services provided on September 6, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for supplies and materials provided by the physician or other 
qualified healthcare professional (99070) provided on June 6, 2023. 
 
You asked the Plan to pay for supplies and materials provided by the physician or other qualified healthcare 
professional (99070). You say that you are appealing with supporting records. The Plan denied your request. 
The Plan says the services are not a covered benefit. 
 
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 supplies 
and materials provided by the physician or other qualified healthcare professional (99070) provided on June 6, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for anti-reflective coating (V2750), polycarbonate lenses 
(V2784) and photochromatic lenses (V2744) provided on July 7, 2023. 
 
You asked the Plan to reimburse for anti-reflective coating (V2750), polycarbonate lenses (V2784) and 
photochromatic lenses (V2744). You say that the costs associated with the glasses you purchased from this 
provider were significantly lower than had you purchased them from your eye care provider. You also say you 
have photochromatic lenses made for you since you are in and out of doors throughout the daylight hours. The 
Plan denied your request. The Plan says these service codes are not covered services. 
 
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 lenses are standard lenses. 
 
We looked at the file and the Plan's rules. The Plan rules say that the Plan covers one set of frames and standard 
lenses every calendar year. The Plan rules also say that lenses include basic single vision, lined bifocal, lined 
trifocal and lenticular lenses only. Based on this information, we decided that the Plan's rules for coverage of 
anti-reflective coating (V2750), polycarbonate lenses (V2784) and photochromatic lenses (V2744) have not 
been met. Therefore, we decided that the Plan does not have to reimburse for anti-reflective coating (V2750), 
polycarbonate lenses (V2784) and photochromatic lenses (V2744) provided on July 7, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140), and 
re-cement or re-bond crown (D2920) provided on July 18, 2023. 
 
You asked the Plan to pay for the dental services. You say that the claim should be reprocessed as the provider 
is in-network. The Plan denied your request. The Plan says the dental services were received from an out-of-
network provider and are not covered by the enrollees supplemental 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. 
 
The record shows the enrollee received the requested dental services from an out-of-network provider. Though 
the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered 
under this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not 
have to pay for the limited oral evaluation - problem focused (D0140), and re-cement or re-bond crown 
(D2920) provided on July 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for resin-based composite for one surface posterior (D2391), 
resin-based composite for three surfaces posterior (D2393) and occlusal guard (D9944) provided on September 
7, 2023. 
 
You asked the Plan to pay for the dental services. You say that you are not sure why a cavity filling is not 
covered. The Plan denied your request. The Plan says your benefit for resin-based composite for one surface 
posterior (D2391), resin-based composite for three surfaces posterior (D2393) has already been exhausted. The 
Plan also says that occlusal guards (D9944) is excluded from this benefit. 
 
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, certain limitations apply. The record 
shows your benefit for resin-based composite for one surface posterior (D2391), resin-based composite for 
three surfaces posterior (D2393) was exhausted on date of service September 7, 2023. The record shows that 
occlusal guards (D9944) are excluded from this benefit. Therefore, we decided that the Plan does not have to 
pay for resin-based composite for one surface posterior (D2391), resin-based composite for three surfaces 
posterior (D2393) and occlusal guard (D9944) provided on September 7, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for frames (V2020) and progressive lenses (V2781) 
provided on June 5, 2023. 
 
You asked the Plan to reimburse for frames (V2020) and progressive lenses (V2781). You say that at the time 
of claiming the refund the payment receipts were exchanged with that of your spouse. The Plan denied your 
request. The Plan says this service was not authorized. 
 
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 out-of-network vision services are pre-authorized. 
 
We looked at the file and the Plan's rules. The Plan rules say that authorization rules apply for out-of-network 
covered services. Based on this information, we decided that the Plan's rules for coverage of frames (V2020) 
and progressive lenses (V2781) have not been met. Therefore, we decided that the Plan does not have to 
reimburse for frames (V2020) and progressive lenses (V2781) provided on June 5, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve stenosis in the iliac or tibial arteries (37221, 37231, 
37229). 
 
You asked the Plan to pre-approve stenosis in the iliac or tibial arteries. You say that the services are necessary. 
The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not 
been met. 
 
The Plan follows Medicare rules. Medicare rules say that PTA is covered when used under certain conditions. 
 
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 stenosis in the iliac or tibial arteries. Our reviewer says that the services are not medically necessary. Our physician reviewer found the 
documentation does not provide sufficient support that the intervention in question will provide the enrollee 
with meaningful improvement is quality of life or evidence of limb threat. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of stenosis in the iliac or tibial arteries have not been met. Therefore, we decided 
that the Plan does not have to pre-approve stenosis in the iliac or tibial arteries (37221, 37231, 37229).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for two additional units of code 97750, defined as physical 
performance test or measurement (for example, musculoskeletal, functional capacity), with written report, each 
fifteen minutes, performed on August 11, 2023. 
 
You asked the Plan to pay for two additional units of code 97750. You say that two additional units of 97750 
should be paid as billed because they are supported in the documentation. The Plan denied your request. The 
Plan says two additional units of 97750 are denied because they are not supported in the record. The record 
does not support the total time required for these services.  

The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
We find that 6 units of CPT code 97750 are not supported in the medical record. The medical record only 
supports 4 units of CPT code 97750. Based on this information, we decided that Medicare rules for coverage of 
two additional units of code 97750 have not been met. Therefore, we decided that the Plan does not have to pay 
for two additional units of code 97750, defined as physical performance test or measurement (for example, 
musculoskeletal, functional capacity), with written report, each fifteen minutes, performed on August 11, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on September 5, 
2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on September 5, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services billed with codes 81321 and 81351 provided on 
May 22, 2023. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services billed with codes 81321 and 81351 provided on May 22, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services rendered from August 20, 2022, to 
October 3, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says a review resulted in a revised reimbursement. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
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 the services Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found that in 
terms of August 20, the provider reported two units for the same date of service for subsequent continuous 
positive airway pressure/bilevel positive airway pressure (CPAP/BIPAP). Only one unit for each date of 
service is performed until discontinued.  
 
In terms of September 5, the provider reported initial vent management and subsequent management on the 
same date of services. This resulted in overbilling. Initial vent management would be reported on the ventilator 
start date, and subsequent care each day after until service is discontinued. 
 
In terms of September 20 and October 3, the itemized bill supports that this procedure was approved on 
reimbursed already for these days. Additional units of service would not be supported. Vent management is 
billed as one unit per date of service. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for inpatient hospital services rendered from August 20, 2022, to October 3, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services (ventilator management) 
performed from July 7, 2022, to August 8, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says once the itemized bill was received, a review was completed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
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 the services Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found that 
itemized charges document that vent management was billed twice for same date of service on July 7, 2022 and 
August 8, 2022.  These charges were denied correctly, as one unit would be billed per date of service.  The 
documentation does not support the additional units. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for inpatient hospital services (ventilator management) performed from July 7, 2022, to August 8, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental service (D4265) on June 21, 2023. 
 
You asked the Plan to pay for the dental service (D4265). You say that you would like to request 
reconsideration for payment. The Plan denied your request. The Plan says your benefit for the requested item or 
service has already 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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service June 21, 2023. Therefore, 
we decided that the Plan does not have to pay for the dental service (D4265) on June 21, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is stable for transfer and 
their ongoing medical needs would be best met at an LTACH. The Plan denied your request. The Plan says the 
enrollee is receiving adequate services at their current facility. 
 
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 documentation does not support that the enrollee requires services at the LTACH 
that are not available at the acute care hospital provided by the health Plan. The requested LTACH services are 
not medically necessary for the diagnosis and condition of the enrollee at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the 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: Home Health
Decision: Favorable

 
We decided that the Plan has to pre-approve 5 home health skilled nursing and 2 physical therapy visits. 
 
You asked the Plan to pre-approve 5 home health skilled nursing and 2 physical therapy visits. You say that 
you would like to request reconsideration of the denied home health skilled nursing and physical therapy visits 
and that the services requested are medically necessary. The Plan denied your request. The Plan says that the 
services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health skilled nursing and 
physical therapy visits. Our reviewer says that the services are medically reasonable and necessary. Our 
physician reviewer found the clinical documentation shows that the enrollee has required multiple medication 
changes/intervention for uncontrolled blood glucose (with recent episodes of hypoglycemia and 
hyperglycemia) and not all appropriate home health skilled nursing goals have been completed thus the records 
do show that 5 additional home health skilled nursing visits are required to effectively provide care in order to 
improve the enrollee's condition. The documentation shows that the enrollee has functional impairments the 
records do show that 6 additional home health physical therapy visits are required to effectively provide care to 
improve the enrollee's level of function.  

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health skilled nursing and physical therapy visits have been met. 
Therefore, we decided that the Plan has to pre-approve 5 home health skilled nursing and 2 physical therapy 
visits.  
 
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.