Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on 
December 27, 2022, to December 29, 2022. 
 
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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $350 copayment per day for days 1-5 for inpatient hospital care.  
 
The enrollee has been asked to pay a $350 copayment per day for days 1-5 for inpatient hospital care. The total 
amount you are being asked to pay is $700 ($350 x 2 days = $700). This item/service falls within the inpatient 
hospital care benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon 
enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for inpatient 
hospital care provided on December 27, 2022, to December 29, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided on April 27, 2023. 
 
You asked the Plan to pay for the medication. You say that you were advised to go to emergency to have your 
prescriptions taken care of. 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 April 27, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the biologic materials to aid in soft and osseous tissue 
regeneration, per site (D4265), bone replacement graft-of a retained natural tooth-first site in quadrant (D4263), 
and the autogenous connective tissue graft procedure (D4273) provided on March 21, 2023.   
 
You asked the Plan to pay for these dental items/services. You say that you are requesting a reconsideration of 
the Plan's denial for payment. The Plan denied your request. The Plan says these dental items/services are not a 
covered benefit under the supplemental dental policy.  
 
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 items/services provided are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the bone 
replacement graft-of a retained natural tooth-first site in quadrant (D4263) and the autogenous connective 
tissue graft procedure (D4273) provided on March 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on November 4, 2022, billed 
with evaluation and management (EM) code 99214-25. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support level of care. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99214 is office or other outpatient visit for the evaluation 
and management of an established patient, which requires a medically appropriate history and/or examination 
and moderate level of medical decision making. When using time for code selection, 30-39 minutes of total 
time is spent on the date of the encounter. 
 
We asked our physician 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 practitioner services provided. Our reviewer says that 
documentation does not support the billed code. Our reviewer found that the documentation reflects an 
appropriate exam, but not a history or medical decision making of at least moderate complexity. 
 
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 practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on November 4, 2022, billed with evaluation 
and management (EM) code 99214-25.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on December 30, 2022 to 
January 28, 2023. 
 You asked the Plan to pay for the home health services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim was 
correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is December 30, 2022. The NOA was not received by the Plan until March 7, 
2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
on December 30, 2022 to January 28, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an abdominoplasty/panniculectomy, a breast lift, a thigh 
lift, and an arm lift. 
 
You asked the Plan to pre-approve an abdominoplasty/panniculectomy, a breast lift, a thigh lift, and an arm lift. 
You say that the removal of the excess skin would greatly improve their daily life. The Plan denied your 
request. The Plan says these procedures are not medically necessary. 
 
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 an abdominoplasty/panniculectomy, a 
breast lift, a thigh lift, and an arm lift. Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found the record provided does not 
document the presence of chronic intertrigo that remains refractory to appropriate medical therapy over a 
period of three months or the presence of functional impairment that would require the requested 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 an abdominoplasty/panniculectomy, a breast lift, a thigh lift, and an arm lift 
have not been met. Therefore, we decided that the Plan does not have to pre-approve an 
abdominoplasty/panniculectomy, a breast lift, a thigh lift, and an arm lift.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on April 16, 2023. 
 
You asked the Plan to pay for medical services. You say that this was medically necessary. 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 medical services provided on April 16, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from January 26, 2022, to 
February 23, 2022. 
 You asked the Plan to pay for the home health services. You did not provide a specific argument with your 
appeal request. The Plan denied your request. The Plan says the NOA was not received. As such, this final 
claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is December 27, 2021. The NOA was not received by the Plan, so no payment 
can be made on this claim. Therefore, we decided that the Plan does not have to pay for home health services 
provided from January 26, 2022, to February 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bitewings (D0274) provided on May 2, 2023. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to reconsider payment 
for these services. 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 D0274 was exhausted on date of service May 2, 2023, after intraoral imaging was provided. Therefore, we decided that the Plan does not have to pay for bitewings (D0274) provided on May 2, 
2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for laboratory services and a CT scan performed 
by an OON provider on April 21, 2023. 
 
You asked the Plan to waive the cost share for laboratory services and a CT scan. You say that the agent 
advised the provider would be in-network. 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 $15 
copayment for laboratory services and 40% coinsurance for OON Medicare-covered radiology.  
 
 You have been asked to pay a $478.49 for laboratory services and a CT scan. This total includes a $15 
copayment for laboratory services and $463.49, which is 40% of the allowed amount for a CT scan. These 
items/services fall within the outpatient diagnostic tests 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 cost share for laboratory services and a CT scan performed by an OON provider on April 21, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.  
 
You asked the Plan to pre-approve the PET scan. You say that the records provided support medical necessity. 
The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered 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 the PET scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found the enrollee is not noted to have or be 
suspected of having FTD. The NCD does not provide coverage of a PET/CT scan of the brain for Lewy Body 
Dementia (LBD) or Charles Bonnet syndrome. The requirements of the NCD have not been met. 
 
 
  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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided form April 3, 2022, to May 2, 
2023. 
 You asked the Plan to pay for the home health services. You say that you believe the NOA was submitted 
timely but there was a system issue that rejected the claim.  The Plan denied your request. The Plan says the 
NOA was not received timely. As such, this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is January 3, 2023. The NOA was not received by the Plan until May 31, 
2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
form April 3, 2022, to May 2, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intravenous moderate (conscious) sedation for the first 15 
minutes (D9239), intravenous moderate (conscious) sedation for each subsequent 15 minute increments 
(D9243), a tooth extraction (D7210) of teeth numbers 22, 23, 24, 25, 26 and an alveoloplasty in conjunction 
with extractions (D7311) provided on February 18, 2022. 
 
  You asked the Plan to pay for intravenous moderate (conscious) sedation for the first 15 minutes (D9239), 
intravenous moderate (conscious) sedation for each subsequent 15 minute increments (D9243), a tooth 
extraction (D7210) of teeth numbers 22, 23, 24, 25, 26 and an alveoloplasty in conjunction with extractions 
(D7311). You say that all you want is to get your money from the Plan. The Plan denied your request. The Plan 
says the claim was not filed until March 1, 2023, without good cause. The Plan also says that there is no 
coverage for the appealed services. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, 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 
intravenous moderate (conscious) sedation for the first 15 minutes (D9239), intravenous moderate (conscious) 
sedation for each subsequent 15 minute increments (D9243), a tooth extraction (D7210) of teeth numbers 22, 
23, 24, 25, 26 and an alveoloplasty in conjunction with extractions (D7311) provided on February 18, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve the injection. The Plan denied your request. The Plan says that an epidural 
steroid injection is not medically necessary.  
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 the injection. Our reviewer says that the 
enrollee does meet the coverage criteria. Our physician reviewer found that the enrollee has chronic low back 
pain with radiation down their leg. The enrollee's magnetic imaging (MRI) shows disc bulges and annular tear 
at L3-L4 and L4-L5. Therefore, the request is medically reasonable and necessary. 
 
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 injection have been met. Therefore, we decided that the Plan has to pre-
approve an epidural steroid injection.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 96365 and 96366 billed for date of service 
February 21, 2023. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the services are 
not covered. 
 
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 96365 and 96366 is not supported in the medical record. Specifically, there is a more 
accurate code to describe the services provided. 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 
procedure codes 96365 and 96366 billed for date of service February 21, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periapical first film (D0220), pulp vitality test (D0460), 
bitewing single film (D0270) and incomplete endo therapy (D3332) provided on May 12, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. 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. Therefore, we decided that the Plan does 
not have to pay for periapical first film (D0220), pulp vitality test (D0460), bitewing single film (D0270) and incomplete endo therapy (D3332) provided on May 12, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Minuteman procedure at L3-L4. 
 
You asked the Plan to pre-approve a Minuteman procedure. You say that the enrollee has lower back pain that 
is radiating to the right hip and leg. The Plan denied your request. The Plan says this procedure is 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 a Minuteman procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the minuteman device is experimental, and more research is needed to show the 
safety and efficiency of this procedure. 
 
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 Minuteman procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Minuteman procedure at L3-L4.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous positive airway pressure (CPAP) device 
(E0601) provided on September 16, 2022. 
 
You asked the Plan to pay for the continuous positive airway pressure (CPAP) device (E0601). You say that 
the item should be covered. 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 the continuous positive 
airway pressure (CPAP) device (E0601) provided on September 16, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from September 25, 2022, 
to October 24, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the required NOA was 
submitted. You also say that a system issue prevented the correct admission date from being on the claim, but 
this has since been corrected. The Plan denied your request. The Plan says the claim has not been billed with 
the correct admission date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from September 25, 2022, to 
October 24, 2022.  
 
Please note that this decision is only in reference to the initial claim you submitted.  If you have submitted a 
corrected claim for these services, you must contact the Plan directly with any questions you may have about 
the corrected claim.