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

 
We decided that the Plan does not have to pay for paramedic intercept provided on January 7, 2023. 
 
 
 You asked the Plan to pay for the paramedic intercept. You say that your local ambulance provider was not 
available and you are being charged. The Plan denied your request. The Plan says advanced life support 
services delivered by paramedics that operate separately from the agency that provides the ambulance transport 
are not covered. 
 
The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by 
an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. 
Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area as 
defined above. It is noted that the only State in which these criteria are met is New York. 
 
The paramedic intercept services at issue in this appeal were not furnished in an area that is considered rural 
according to the Medicare definition. Therefore, we decided that the Plan does not have to pay for paramedic 
intercept provided on January 7, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oral/facial photographic images (D0350) provided on March 
15, 2023. 
 
You asked the Plan to pay for oral/facial photographic images. You say that this should be covered. The Plan 
denied your request. The Plan says this is not a covered service. 
 
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/facial 
photographic images (D0350) provided on March 15, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compressor device (E0652) to be provided 
by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve a pneumatic compressor device. You say that you would like the medical 
records to be reviewed and the authorization to be reconsidered and approved. The Plan denied your request. 
The Plan says the enrollee must use network providers to receive services/items. There are in-network 
providers that cab provide this item to the enrollee. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a pneumatic compressor device (E0652) to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic radiographic image (D3330), intraoral - 
periapical first radiographic image (D0220), each additional radiographic image (D0230), and limited oral 
evaluation - problem focused provided on February 6, 2023. 
 
You asked the Plan to pay for the panoramic radiographic image, intraoral - periapical first radiographic image, 
each additional radiographic image, and a limited oral evaluation. You say that you had pain in your tooth and 
could not manage the pain any further. You also say that you were out of town and called an out-of-network 
dentist who scheduled the root canal. The Plan denied your request. The Plan says the dental services were 
received from an out-of-network provider and are not covered by your 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 you 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 a panoramic radiographic image (D3330), intraoral - periapical first radiographic image (D0220), 
each additional radiographic image (D0230), and limited oral evaluation - problem focused provided on 
February 6, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral radiographic complete images (D0210) provided 
on January 5, 2023. 
 
You asked the Plan to pay for the dental service. You say that you never got asked what services you wanted 
and you only went there for a cleaning and a checkup. 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 the Plan paid for intraoral radiographic images (D0210) on February 14, 2023, which that claim was 
processed and paid prior to receiving the claim for January 5, 2023; therefore, your benefit for the requested 
item or service was exhausted on the date of service of February 14, 2023. Therefore, we decided that the Plan 
does not have to pay for the intraoral radiographic complete images (D0210) provided on January 5, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99291 for date of service January 19, 2023. 
 
You asked the Plan to pay for procedure code 99291. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that certain diagnosis codes have Excludes1 Notes. 
 
We looked at the file and Medicare rules. Review of the file shows that code 99291 was billed with diagnosis 
codes N49.2 (Inflammatory disorders of scrotum) and N45.4 (Abscess of epididymis or testis). Due to the 
Excludes1 Note, these two diagnosis codes should not be reported together. Based on this information, we 
decided that Medicare rules for coverage of procedure code 99291 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure code 99291 for date of service January 19, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a limited oral evaluation (D0140), the intraoral 
radiographic image (D0220), and a resin-based composite (D2335) for tooth #7 provided by an out-of-network 
provider on March 27, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you told the provider to call and verify if 
they were in-network and they never did. 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. 
 
  The total amount billed for the limited oral evaluation was $109 and the total allowed amount was $39 leaving 
a difference of $70 ($109 billed - $39 allowed). The total amount billed for the intraoral radiographic image 
was $47 and the total allowed amount was $15 leaving a difference of $32 ($47 billed - $15 allowed). The total 
amount billed for the resin-based composite was $374 and the total allowed amount was $156 leaving a 
difference of $218 ($374 billed - $156 allowed). The total difference amount for the dental services was $320 
($70 difference + $32 difference + $218 difference). 
 
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 (D0140), the 
intraoral radiographic image (D0220), and a resin-based composite (D2335) for tooth #7 provided by an out-of-
network provider on March 27, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs LTACH level of care 
is the only option for a safe discharge due to the need for frequent nursing and respiratory care, daily physician 
management by several specialties, telemetry, continuous pulse oximetry, IV antibiotic and medication 
administration, frequent vitals, daily labs, new hemodialysis, and physical, occupational and speech therapy. 
The Plan denied your request. The Plan says the enrollee is receiving appropriate in-patient acute care and is 
currently unstable for transfer to an LTACH. 
 
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 there are no services available at the LTACH that the enrollee requires that are not 
available at the current health care setting being offered by the health plan. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for resin-based composite - one surface, posterior (D2391) and 
resin-based composite - three surfaces, posterior (D2393) provided on April 14, 2022, and August 25, 2022. 
 
You asked the Plan to pay for the dental services. You say that you do not agree with the denial because you 
thought it is 2 fillings per year or per 12 months. You did not realize it was 12 consecutive months. 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. This benefit includes the 
requested item or service but is limited to fillings: $0 copayment - 2 restorations per 12-month period 
(combined with D2140, D2150, D2160, D2161, D2330, D2331, D2332, D2335, D2391, D2392, D2393, 
D2394). 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows you received covered resin-based composite - two surfaces, anterior (D2331) and resin-based composite 
- three surfaces, posterior (D2393) on date of service October 6, 2021. Although D2331 and D2391 are two 
different services, they fall within the same category in your Evidence of Coverage and are subject to the same 
frequency limitations. Therefore, these benefits have been exhausted. Therefore, we decided that the Plan does 
not have to pay for resin-based composite - one surface, posterior (D2391) and resin-based composite - three 
surfaces, posterior (D2393) provided on April 14, 2022, and August 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the deep sedation/general anesthesia first 15 minutes 
(D9222) and deep sedation/general anesthesia each subsequent 15-minute increment (D9223 x 3) provided on 
July 12, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are appealing the denial. The Plan denied 
your request. The Plan says these services are not covered under the Plan's 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 the deep 
sedation/general anesthesia first 15 minutes (D9222) and deep sedation/general anesthesia each subsequent 15-
minute increment (D9223 x 3) provided on July 12, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for inpatient hospital services provided on July 5, 2022 to July 
14, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
service was billed with the correct DRG. The Plan denied your request. The Plan says DRG 640 is more 
appropriate for the billed services. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 871. 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 inpatient hospital services at the DRG originally billed. Our reviewer says 
that the DRG billed is not supported. Our physician reviewer found while the patient had elevated white blood 
cell count and hypoxia, he did not have fever or a documented source of infection. There is no clear evidence 
of sepsis, therefore DRG code 871 is not supported.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on July 5, 2022 to July 14, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture treatments (97810, 97811) provided on 
January 5, 2023. 
 
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 at issue are not payable as the 
provider is not enrolled in the Medicare program.  
 
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. 
 
A 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 acupuncture treatments (97810, 
97811) provided on January 5, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiotherapy services (77427) provided on March 1, 2023. 
 
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 note how 
many fractions are being billed. 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 March 1, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6530. 
 
You asked the Plan to pre-approve the compression stockings. You say that you need the compression 
stockings or else you will lose your toes. You also say that you are diabetic and need these stockings to keep 
your legs from retaining fluids and swelling. The Plan denied your request. The Plan says this service is not 
covered by Medicare. 
 The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6530.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on March 20, 
2023. 
 
You asked the Plan to pay for the dental service. You say that you had to see a specialist because a general 
dentist could not help you so the evaluation 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 on the date of service of February 13, 2023. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on 
March 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve three (3) office visits with a specialist to be provided by 
an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve office visits. You say that you disagree with the denial and request 
reconsideration. The Plan denied your request. The Plan says the enrollee must receive her care from a network 
provider. There are in-network providers who can provide these services. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
three (3) office visits with a specialist to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CT scan provided on January 27, 2023, by an OON 
provider.  
 
You asked the Plan to pay for the CT scan. You say that you are appealing the claim payment denial. The Plan 
denied your request. The Plan says the services were provided out-of-network and were not approved in 
advanced. 
 
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 the CT scan provided on January 27, 2023, by an 
OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve maxillary partial denture and mandibular partial denture 
(D5213, D5214). 
 
You asked the Plan to pre-approve 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 on date of service September 16, 2021. 
Therefore, we decided that the Plan does not have to pre-approve maxillary partial denture and mandibular partial denture (D5213, D5214).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that you would like to continue staying at the skilled 
nursing facility. The Plan denied your request. The Plan says the enrollee is no longer having a consistent, 
meaningful benefit from skilled services. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. Your current function is at or near your prior level of 
function and you can safely be discharged to a lower level of care for further 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.