Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99215) provided on February 4, 2022. 
 
You asked the Plan to pay for the physician service. You say that this should be covered. The Plan denied your 
request. The Plan says the corrected claim was not submitted within 1 calendar year of the initial determination. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a corrected claim for the physician service was not filed until May 3, 2023. This means 
that more than one calendar year from the date of the initial determination had passed before a corrected claim was filed. Therefore, we decided that the Plan does not have to pay for the office visit (99215) provided on 
February 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150) to be provided 
by an out-of-network provider. 
 
You asked the Plan to pre-approve the dental service. You say that the requested dentist is your long-time 
dentist, and the provider accommodates your medical needs. The Plan denied your request. The Plan says 
dental services from an out-of-network provider 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. 
 
  You are requesting 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 pre-approve a 
comprehensive oral evaluation (D0150) to be provided by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the progressive lenses, the tint, the anti-reflective coating, 
and the polycarbonate lens provided on July 31, 2023. 
 
You asked the Plan to pay for the progressive lenses, the tint, the anti-reflective coating, and the polycarbonate 
lens. You say that you were not aware of the added cost. You say you thought it services were included. 
 The Plan denied your request. The Plan says the services are not covered benefits. 
 
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 standard frames and lenses. 
 
We looked at the file and the Plan's rules. Specifically, the services are considered upgrades, which are not 
covered benefits. Based on this information, we decided that the Plan's rules for coverage of the progressive 
lenses, the tint, the anti-reflective coating, and the polycarbonate lens have not been met. Therefore, we decided 
that the Plan does not have to pay for the progressive lenses, the tint, the anti-reflective coating, and the 
polycarbonate lens provided on July 31, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140), and intraoral - periapical 
first radiographic image (D0220) provided on August 22, 2023. 
 
You asked the Plan to pay for the dental services. You say that the dental visit and service provided was for 
treatment of gum abscess not surrounding or specific to any tooth. The Plan denied your request. The Plan says 
your benefit for the requested services 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 services was exhausted on date of service March 28, 2023. Therefore, we 
decided that the Plan does not have to pay for the limited oral evaluation (D0140), and intraoral - periapical 
first radiographic image (D0220) provided on August 22, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on May 31, 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 $2,000 annual maximum 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 $2,000 annual maximum was exhausted. Therefore, we decided that the Plan does not have to pay 
for dental services provided on May 31, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics.  
 
You asked the Plan to pre-approve foot orthotics. You say that your foot hurts every time you step, and the 
orthotics are medically necessary after you stopped using a boot. The Plan denied your request. The Plan says 
this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
  Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for occlusion analysis - mounted case (D9950) provided on 
March 24, 2023. 
 
You asked the Plan to pay for occlusion analysis - mounted case. 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 occlusion 
analysis - mounted case (D9950) provided on March 24, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a SNF stay provided from July 1, 2023, to 
July 26, 2023. 
 
You asked the Plan to waive the copayment for a SNF stay. You say that you should not be responsible for the 
copayment applied due to the quality of care you received. 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 $0 
copayment for days 1 to 20 and a $188 copayment per day for days 21 to 100 for SNF care.  
 
You have been asked to pay a $940 copayment for a SNF stay ($188 per day x 5 days = $940). This 
item/service falls within the 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 for a 
SNF stay provided from July 1, 2023, to July 26, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on March 28, 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 $2,000 annual maximum 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 $2,000 annual maximum was exhausted. Therefore, we decided that the Plan does not have to pay 
for dental services provided on March 28, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient psychiatric hospital care provided from 
July 11, 2023, through July 12, 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 acute inpatient psychiatric hospital care 
provided was not medically necessary.  
  
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 these services. Our reviewer says that the 
acute inpatient psychiatric hospital care provided was not medically necessary. Our physician reviewer found 
that you were admitted for acute inpatient psychiatric hospitalization on July 7, 2023 with Schizophrenia 
Spectrum Disorder, Paranoid Type. Based upon the review of the records provided, it was not expected that 
you would improve in a reasonable period of time beyond the dates in question as you were not showing any 
dangerousness to self or others, did not have auditory or visual hallucinations, and you were without aggressive 
behaviors while not showing any acute threats to safety. It did not appear medically necessary and reasonable 
to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the 
dates in question as you did not have any suicidal or homicidal thoughts, auditory or visual hallucinations, or 
abnormal behaviors. The health plans denial of continued inpatient psychiatric services appears appropriate. 
You did not require inpatient mental health treatment beyond the dates in question as noted above as you were 
not a danger to yourself or others and did not have any delusions, or auditory and visual hallucinations. It did 
not appear that active treatment was taking place beyond the date in question. It did not appear that the services 
for the dates in question were reasonably expected or medically necessary to improve your condition or were 
for the purpose of a diagnosis. It appears that the services were supervised and evaluated by a physician. Based 
upon the review of the records provided, you do not meet the criteria for coverage of the acute inpatient mental 
health treatment provided beyond the date in question of July 11, 2023 forward and could have been treated in 
a lesser restrictive setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the acute inpatient psychiatric hospital care provided from July 11, 2023, through July 12, 
2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for dates of service May 21, 
2023, to June 17, 2023. 
 
You asked the Plan to pay for procedure code S9328. You say that these services were medically necessary and 
were ordered by an in-network provider. The Plan denied your request. The Plan says the billed code is invalid 
for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for dates of service May 21, 2023, to June 17, 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) 
provided on June 21, 2023. 
 
You asked the Plan to pay for the limited oral evaluation - problem focused. You say that your old dentist was 
retiring and you needed a new dentist. You also say that you attended the new dentist as your molar needed 
attention. The Plan denied your request. The Plan says your benefit for the requested limited oral evaluation - 
problem focused 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 service was exhausted on dates of service June 3, 2023, and June 6, 2023. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation - problem focused 
(D0140) provided on June 21, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a consultation (D9310) provided on August 10, 2023. 
 
You asked the Plan to pay for a consultation. 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 a 
consultation (D9310) provided on August 10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical placement of implant body: endosteal implant 
(D6010), custom fabricated abutment  includes placement (D6057), and abutment supported 
porcelain/ceramic crown (D6058). 
 
You asked the Plan to pre-approve the dental services. You say that you would like the procedures approved. 
The Plan denied your request. The Plan says these services are not covered under your benefit 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 services are not among 
those covered under this benefit.  Therefore, we decided that the Plan does not have to pre-approve surgical placement of implant body: 
endosteal implant (D6010), custom fabricated abutment  includes placement (D6057), and abutment 
supported porcelain/ceramic crown (D6058).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve alveoloplasty with extractions (D7311) (x2). 
 
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. Therefore, we decided that the Plan does 
not have to pre-approve alveoloplasty with extractions (D7311) (x2).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 continuous glucose monitor (CGM).  
You asked the Plan to pre-approve a CGM. You say that testing your sugar traditionally causes you pain. The 
Plan denied your request. The Plan says the medical criteria for a CGM have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin. 
Based on this information, we decided that Medicare rules for coverage of a CGM have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 2 continuous glucose 
monitor (CGM).
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 you are requesting reconsideration of the 
denied LTACH admission. The Plan denied your request. The Plan says the patient 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 the patient is medically unstable for transfer due to abnormal chest x-ray finding with 
high FiO2 demand. There are no services available at the LTACH that the patient requires that are not available 
at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the patient and able to be furnished 
safely and effectively only on an inpatient basis. 
 
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 LTACH services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, advanced life support and ground 
mileage provided on February 13, 2023. 
 
You asked the Plan to pay for the ambulance services. You say that we transported this patient twice on the 
same date of service. You also say that this claim is for the first transport of the day.  The Plan denied your request. The Plan says on this date of service, the enrollee was registered as an inpatient 
hospital status therefore transportation services are not separately payable from the payment to the inpatient 
institution. 
 
The Plan must follow Medicare rules. Medicare rules say that once a beneficiary is admitted to a hospital it 
may be necessary to transport the beneficiary to another hospital or other site temporarily for specialized care 
while the beneficiary maintains inpatient status with the original provider.  
 
We looked at the file and Medicare rules. The records provided demonstrate that the enrollee was receiving 
inpatient hospital care at the time of the transport. This means that the transportation service furnished to the 
enrollee while they were admitted as inpatient would be covered as an inpatient hospital and not paid for 
separately under Part B. Based on this information, we decided that Medicare rules for coverage of the 
ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for ambulance 
service, advanced life support and ground mileage provided on February 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for a medical eye examination (92002) provided on May 
28, 2023. 
 
You asked the Plan to reimburse for a medical eye examination (92002). You say that since the store/vendor 
was listed as in-network, the provider should be in-network as well. The Plan denied your request. The Plan 
says the benefit Plan does not cover this out-of-network vision care service/material. 
 
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 you obtain your vision services through a Plan vision vendor or 
provider. 
 
We looked at the file and the Plan's rules. The Plan rules say that non-Medicare-covered routine eye 
examinations and eyewear must be obtained from a provider in the Plan's vision vendor network. Services 
obtained from vendors outside this network are not covered. Based on this information, we decided that the 
Plan's rules for coverage of a medical eye examination (92002) have not been met. Therefore, we decided that 
the Plan does not have to reimburse for a medical eye examination (92002) provided on May 28, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740) for tooth #31. 
 
You asked the Plan to pre-approve the dental services. You say that if you do not have this crown done you 
will have to have your tooth extracted. 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 July 13, 2021. Therefore, 
we decided that the Plan does not have to pre-approve a crown (D2740) for tooth #31.