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

 
We decided that the Plan does not have to pay for inpatient hospital care provided on November 15, 2021, to 
December 23, 2021. 
 
You asked the Plan to pay for the inpatient hospital care provided. You say that the claim was billed correctly 
and should be paid. The Plan denied your request. The Plan says this is a hospital claim audit, documentation is 
required. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment.  
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the inpatient hospital care provided 
have been met. Specifically, there is no itemized bill summary provided for review of the inpatient services 
provided. Therefore, we decided that the Plan does not have to pay for inpatient hospital care provided on 
November 15, 2021, to December 23, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76881 billed for date of service September 
16, 2022. 
 You asked the Plan to pay for procedure code 76881. You say that the claim was billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 76881 is bundled into payment for code 
93971. 
 
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, we have confirmed that code 76881 
is a column II code to column I code 93971. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 76881 billed for date of service September 16, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve interim partial denture (including retentive/clasping 
materials, rests, and teeth), mandibular (D5821). 
 
You asked the Plan to pre-approve dental services. You say that you do not agree with the service being denied. 
The Plan denied your request. The Plan says this service is not covered under your Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. Interim partial denture 
(including retentive/clasping materials, rests, and teeth), mandibular (D5821) is not covered under the Plans 
dental benefits. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D5821 is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve interim 
partial denture (including retentive/clasping materials, rests, and teeth), mandibular (D5821).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service December 5, 
2022. 
 You asked the Plan to pay for procedure code 76641. You say that the member had multiple exams on this date 
of service. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
Based on this information, we decided that Medicare rules for coverage of procedure code 76641 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 76641 billed for date of 
service December 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and infusion services provided on September 
8, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an office visit and infusion services. You say that these services are supported in 
the records. The Plan denied your request. The Plan says these services were not authorized. 
 
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 an office visit and infusion services provided on 
September 8, 2022, by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided on December 5, 2022. 
 
You asked the Plan to pay for physical therapy services. You say that this was medically necessary. The Plan 
denied your request. The Plan says this was not authorized. 
 
The Plan must follow Medicare rules. Medicare rules say that Health Maintenance Organizations (HMOs) may 
offer a Point of Service (POS) option as a mandatory or optional supplemental benefit and may either require or waive prior authorization rules for obtaining POS services. The Plan contract says that outpatient 
rehabilitation services require prior authorization. 
 
We looked at the file and Medicare rules. The physical therapy services at issue were not authorized. Based on 
this information, we decided that Medicare rules for coverage of physical therapy services have not been met. 
Therefore, we decided that the Plan does not have to pay for physical therapy services provided on December 
5, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided on October 20, 2022, billed with 
code 70450-26. 
 
You asked the Plan to pay for the imaging services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim 
and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on November 16, 2022. Comparison of the two claims shows these are exact duplicates. There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for the imaging services provided have not been 
met. Therefore, we decided that the Plan does not have to pay for imaging services provided on October 20, 
2022, billed with code 70450-26.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service January 27, 
2023. 
 You asked the Plan to pay for procedure code 70450. You say that the claim was billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for code 
70496. 
 
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, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service January 27, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the arthrocentesis provided on November 
25, 2022. 
 
You asked the Plan to waive the copayment for the arthrocentesis. You say that you were not told about this 
copayment and would not have received this service if you had been told. 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 $275 
copayment for outpatient surgery at an outpatient hospital. 
 
You have been asked to pay a $275 copayment for the arthrocentesis. This item/service falls within the 
outpatient surgery at an outpatient hospital 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. According to Medicare, an arthrocentesis (code 20610) is considered 
outpatient surgery. However, since the allowed amount is less than the standard copayment, you only owe 
$256.87. Therefore, we decided that the Plan does not have to waive the copayment for the arthrocentesis 
provided on November 25, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided on December 7, 2022. 
 
You asked the Plan to pay for physical therapy services. You say that this was medically necessary. The Plan 
denied your request. The Plan says this was not authorized. 
 
The Plan must follow Medicare rules. Medicare rules say that Health Maintenance Organizations (HMOs) may 
offer a Point of Service (POS) option as a mandatory or optional supplemental benefit and may either require or waive prior authorization rules for obtaining POS services. The Plan contract says that outpatient 
rehabilitation services require prior authorization. 
 
We looked at the file and Medicare rules. The physical therapy services at issue were not authorized. Based on 
this information, we decided that Medicare rules for coverage of physical therapy services have not been met. 
Therefore, we decided that the Plan does not have to pay for physical therapy services provided on December 
7, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services provided by an out-of-network 
(OON) provider on January 3, 2023. 
 
You asked the Plan to pay for psychotherapy services. You say that you have been seeing this provider for 
years. The Plan denied your request. The Plan says this was not authorized. 
 
The Plan must follow Medicare rules. Medicare rules say that Health Maintenance Organizations (HMOs) may 
offer a Point of Service (POS) option as a mandatory or optional supplemental benefit and may either require 
or waive prior authorization rules for obtaining POS services. The Plan contract says that authorization rules 
apply to out-of-network outpatient mental health services covered under the Point-of-Service option. 
 
We looked at the file and Medicare rules. The mental health service at issue was not authorized. Based on this 
information, we decided that Medicare rules for coverage of psychotherapy services have not been met. 
Therefore, we decided that the Plan does not have to pay for psychotherapy services provided by an out-of-
network (OON) provider on January 3, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided on October 17, 2022, billed with 
code 71045. 
 
You asked the Plan to pay for the imaging services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim 
and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on December 28, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. Based on this information, we decided that the Medicare rules for the imaging services provided have not been 
met. Therefore, we decided that the Plan does not have to pay for imaging services provided on October 17, 
2022, billed with code 71045.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre 14-day sensor kit. 
 
You asked the Plan to pre-approve a FreeStyle Libre 14-day sensor kit. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested 
device. 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who meet certain criteria. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee for whom a CGM is 
being prescribed, to improve glycemic control, meets at least one of the criteria below: 
The beneficiary is insulin-treated; or, 
The beneficiary has a history of problematic hypoglycemia with documentation of at least one of the following: 
Recurrent (more than one) level 2 hypoglycemic events (glucose less than 54mg/dL (3.0mmol/L)) that persist 
despite multiple (more than one) attempts to adjust medication(s) and/or modify the diabetes treatment plan; or, 
a history of one level 3 hypoglycemic event (glucose less than 54mg/dL (3.0mmol/L)) characterized by altered 
mental and/or physical state requiring third-party assistance for treatment of hypoglycemia 
Based on this information, we decided that Medicare rules for coverage of a FreeStyle Libre 14-day sensor kit 
have not been met. Therefore, we decided that the Plan does not have to pre-approve a FreeStyle Libre 14-day 
sensor kit.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for clinical crown lengthening (D4249) provided on December 
19, 2022. 
 
You asked the Plan to pay for clinical crown lengthening. 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 clinical 
crown lengthening (D4249) provided on December 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral radiographic images (D0220 and D0230), a 
cone beam (D0380), an unspecified preventive procedure (D1999), a prefabricated post and core (D2954), an 
anterior root canal (D3310), retreatment therapy (D3346), and a consultation (D9310) provided by an out-of-
network provider on September 28, 2022. You asked the Plan to pay for the dental services. You say that you were told you would get reimbursed for 
half of what you paid. The Plan denied your request. The Plan says the intraoral radiographic images, the 
prefabricated post and core, the root canal, and the retreatment therapy were received from an out-of-network 
provider and are not covered by your supplemental benefits. Also, the cone beam and the unspecified 
preventive procedure are 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. 
 
The record shows you received the intraoral radiographic images, the prefabricated post and core, the root 
canal, and the retreatment therapy 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. The cone beam and the unspecified preventive procedure are not covered 
under the Plans dental benefit. Therefore, we decided that the Plan does not have to pay for the intraoral 
radiographic images (D0220 and D0230), a cone beam (D0380), an unspecified preventive procedure (D1999), 
a prefabricated post and core (D2954), an anterior root canal (D3310), retreatment therapy (D3346), and a 
consultation (D9310) provided by an out-of-network provider on September 28, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
July 17, 2022, to July 20, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you cannot afford 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). Your contract with the Plan clearly says that you must pay a $295 
copayment each day, for days 1 to 5 and $0 copayment for additional days for Medicare-covered hospital care.  
 
 
 You have been asked to pay a $295 copayment per day, for days 1 to 3 of the inpatient hospital stay. You have 
been asked to pay a total of $885 ($295 copayment x 3 days = $885). You have not been charged for any 
additional days. This item/service falls within the inpatient hospital 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 the inpatient hospital stay provided from July 17, 2022, to July 20, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on December 13, 
2022. 
 
You asked the Plan to pay for the dental service. You say that it was necessary to go to the dentist office since 
your crown fell off and you expected it to be covered by the Plan. 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 August 12, 2022. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on 
December 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids (V5260) purchased on  
July 19, 2022. 
 
You asked the Plan to issue reimbursement for these items. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says these items are not payable as 
they were purchased from an out-of-network provider. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when purchased through the Plans select hearing aid provider.  
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically the Plans contract states that coverage is provided for 
hearing aids only when purchased through the Plans select hearing aid provider. However, the hearing aids in 
this case were purchased from an out-of-network provider. Therefore, we decided that the Plan does not have to 
issue reimbursement for the hearing aids (V5260) purchased on July 19, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary. The Plan denied 
your request. The Plan says that the admission to a SNF is not medically necessary. 
 
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 the enrollee no longer requires daily skilled nursing and/or skilled therapy 
services.  The enrollee could benefit from continued intermittent services at a lower level of care. Although the 
enrollee made slow progress with therapy, her functional improvement has plateaued, there is no indication that 
transfer to a skilled nursing facility is required. The enrollee can continue to receive skilled rehabilitation 
services at the current inpatient rehabilitation facility or be stepped down to a lower level of care. 
 
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 SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics. 
 
You asked the Plan to pay for foot orthotics. You say that these inserts help keep your knee straight. 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 pay for foot orthotics.