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

 
We decided that the Plan does not have to pay for procedure code 99223 provided on April 3, 2023. 
 
You asked the Plan to pay for procedure code 99223. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says you billed this service with an incorrect POS 
code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must bill the appropriate POS code for 
services. POS code 21 indicates that the services were performed in an inpatient hospital setting. POS code 22 
indicates that the services were performed in an outpatient hospital setting. 
 
In this case, you billed the claim for these services with POS code 21. However, the documentation shows that 
the patient was in an observation status. Observation is an outpatient status, so POS code 22 should have been 
used on the claim instead. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99223 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99223 provided on April 3, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home visit provided on January 27, 2023, to February 03, 
2023. 
 
You asked the Plan to pay for home visit. You say that you are appealing the claim payment denial. 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 home visit provided on 
January 27, 2023, to February 03, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve CT scan, thorax to be provided by an OON provider.  
 
You asked the Plan to pre-approve CT scan, thorax. You say that you do not agree with the denial of the 
requested service. The Plan denied your request. The Plan says the service can be provided by an in-network 
provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to 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 
CT scan, thorax to be provided by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral-complete series of radiographic images (D0210) 
provided on April 13, 2023.  
 
You asked the Plan to pay for this dental service. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says your benefit for the service provided 
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 service provided was exhausted on date of service June 30, 2022.  
  
 
 
 
Specifically, the Plans contract states that one intraoral-complete series of radiographic images is covered 
every three years. You previously received this service on June 30, 2022, less than three years prior, which was 
paid for by the Plan. Therefore, you have exhausted the allowable benefit for this service. Therefore, we 
decided that the Plan does not have to pay for the intraoral-complete series of radiographic images (D0210) 
provided on April 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 20 additional routine transportation trips (A0100). 
 
You asked the Plan to pre-approve the additional transportation trips. You say that you need the 20 additional 
trips for orthopedic appointments. The Plan denied your request. The Plan says the plan only allows 30 one-
way trips which have already been used for 2023. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 30 trips per year.  
 
We looked at your request, the records in the case file, and the rules. You asked the Plan to approve 20 
additional routine transportation trips for medical appointments. Based on this information, we decided that 
you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided 
that the Plan does not have to pre-approve 20 additional routine transportation trips (A0100).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for limited oral evaluation  problem focused (D0140) provided 
on April 13, 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 on date of service January 3, 2023, and 
January 10, 2023. Therefore, we decided that the Plan does not have to pay for limited oral evaluation  
problem focused (D0140) provided on April 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for dental services provided on March 1, 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 March 1, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the topical application of fluoride varnish (D1206) provided 
on April 17, 2023. 
 
You asked the Plan to pay for the dental service. You say that the treatment was performed because you have 
exposed roots, and you would like the Plan to reverse the denial. The Plan denied your request. The Plan says 
the denial of payment for this service is correct, because the topical application of fluoride varnish is not 
covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
topical application of fluoride varnish (D1206) provided on April 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on March 6, 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 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 dental services provided on March 6, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the compression stockings identified with code A6530 that 
were issued on January 27, 2023. 
 
You asked the Plan to pay for the compression stockings. You say that you are requesting a reconsideration of 
the Plan's denial for payment. The Plan denied your request. The Plan says this item is not a covered benefit.  
  
 
 
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 pay for the compression 
stockings identified with code A6530 that were issued on January 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit for observation (D9430) provided on October 11, 
2022. 
 
You asked the Plan to pay for office visit for observation. You say that this should be covered. The Plan denied 
your request. The Plan says this code is only payable when performed by the contracted dentist.  
 
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 office 
visit for observation (D9430) provided on October 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oral hygiene instructions (D1330) provided on April 18, 
2023, to May 8, 2023. 
 
You asked the Plan to pay for oral hygiene instructions. 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 
hygiene instructions (D1330) provided on April 18, 2023, to May 8, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the protective restoration (D2940) provided on March 23, 
2023. 
 
You asked the Plan to pay for this dental service. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says this service is not covered 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 service provided is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the protective 
restoration (D2940) provided on March 23, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2740) provided on November 8, 2022. 
 
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 on date of service December 10, 2019. 
Therefore, we decided that the Plan does not have to pay for a crown (D2740) provided on November 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repair upper false teeth (D5730). 
 
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 January 18, 2023. 
Therefore, we decided that the Plan does not have to pre-approve repair upper false teeth (D5730).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for panoramic radiographic image (D0330) provided on January 
26, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were not given a choice by the provider. 
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 January 12, 2021. Therefore, we decided that the Plan does not have to pay for panoramic radiographic image (D0330) provided 
on January 26, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve maxillary partial denture (D5211), mandibular partial 
denture (D5212) and an extraction, erupted tooth or exposed root (D7140). 
 
You asked the Plan to pre-approve maxillary partial denture, mandibular partial denture and an extraction. 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 pre-approve 
maxillary partial denture (D5211), mandibular partial denture (D5212) and an extraction, erupted tooth or exposed root (D7140).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure (64628, 64629). 
 
You asked the Plan to pre-approve an Intracept procedure. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no magnetic resonance imaging (MRI) showing only modic changes without 
facet degenerative joint disease (DJD) or foraminal stenosis. The cause of the pain is not clear. 
 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure (64628, 64629).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility visit provided on December 06, 2022. 
 
You asked the Plan to pay for nursing facility visit. You say that you are appealing the claim payment denial. 
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 nursing facility visit 
provided on December 06, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) stay from 
January 1, 2023, to February 7, 2023. 
 
You asked the Plan to waive the copayment for the SNF stay. You say that you assumed the SNF services 
would be covered in full without a copay as long as you were on the intravenous treatment. 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 
copayment of $196 for days 21-39 in a SNF setting.  Days 1-20: $0 copay per day per admission, Days 21-100: 
$196 copay per day per admission. Days 21-39 is 19 days ($196 x 19 = $3,724) for skilled nursing facility 
(SNF) care.  
 
You have been asked to pay a copayment of $196 for days 21-39 in a SNF setting. Days 1-20: $0 copay per day 
per admission, Days 21-100: $196 copay per day per admission. Days 21-39 is 19 days ($196 x 19 = $3,724) 
for skilled nursing facility (SNF) care. This item/service falls within the skilled nursing facility (SNF) 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 copayment the skilled nursing facility (SNF) 
stay from January 1, 2023, to February 7, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99214 billed with diagnosis codes M54.12 
and M51.16 provided on February 17, 2023. 
 
You asked the Plan to pay for procedure code 99214. 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. The rules say that health plans, physicians, hospitals, and other health 
care providers must comply with the Official International Classification of Disease, 10th Edition, Clinical 
Modification (ICD-10-CM) Coding Guidelines. 
 
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 M54.12 and M51.16 should not be reported together. Therefore, we decided that the Plan does 
not have to pay for procedure code 99214 billed with diagnosis codes M54.12 and M51.16 provided on 
February 17, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Optimizer Smart Implantable Pulse Generator 
(0408T). 
 
You asked the Plan to pre-approve an Optimizer Smart Implantable Pulse Generator. You say that the services 
are necessary. The Plan denied your request. The Plan says medical necessity has not been established. 
Therefore, coverage criteria have not been met. 
 
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 Optimizer Smart Implantable Pulse 
Generator. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found while the clinical studies led to FDA approval in 2019, 
cardiac contractility modulation (CCM) remains the subject of multiple studies examining long-term efficacy, as well as randomized, controlled, double-blinded trials to quantify clinical efficacy. Until such statistically 
rigorous studies are completed, it is premature to presume clinical outcomes and benefit. At the current time, 
the CCM system is not medically necessary in this enrollee. 
 
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 Optimizer Smart Implantable Pulse Generator have not been met. Therefore, 
we decided that the Plan does not have to pre-approve an Optimizer Smart Implantable Pulse Generator 
(0408T).