Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for periodontal root scaling and planing, 
adjunctive pre-diagnostic test, localized delivery of antimicrobial agents, gingival irrigation, and drugs or 
medicaments dispensed in the office (D4342, D4921, D4381, D0431, D9630) provided on April 24, 2023. 
 
You asked the Plan to waive the coinsurance for the dental services. You say that the services should be 
covered as you disagree with the denial and charges. The Plan denied your request. The Plan says the cost-
sharing for periodontal scaling and root planing services applied correctly based on the services provided. 
Additionally, coverage for the adjunctive pre-diagnostic tests, localized delivery of antimicrobial agents, 
gingival irrigation, and drugs or medicaments dispensed in the office denied correctly as they do not fall within 
your 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. 
 
You have been asked to pay a 50% coinsurance for periodontal scaling and root planing (D4342 x2). This 
item/service falls within the Dental Services 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, adjunctive pre-diagnostic tests, 
localized delivery of antimicrobial agents, gingival irrigation, and drugs or medicaments dispensed in the office 
are not among those covered under this benefit. Therefore, we decided that the Plan does not have to waive the 
coinsurance for periodontal root scaling and planing, adjunctive pre-diagnostic test, localized delivery of 
antimicrobial agents, gingival irrigation, and drugs or medicaments dispensed in the office (D4342, D4921, 
D4381, D0431, D9630) provided on April 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 96365, 96366, and 96521 billed for date of 
service April 17, 2023. 
 
You asked the Plan to pay for the billed services. You say that the enrollee was seen for problems with 
diabetes. The Plan denied your request. The Plan says the billed codes are not supported. 
 
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 codes 96365, 96366, and 96521 are not supported in the medical record. The file shows that 
the enrollee received outpatient intravenous insulin therapy (OIVIT), billed with codes 96365 and 96366. 
OIVIT is not covered by Medicare or the Plan. The file shows that orders were placed for code 96521, the 
refilling and maintenance of a portable pump. The records do not show that these services were provided on the 
date of service at issue. Based on this information, we decided that Medicare rules for coverage of the billed 
services have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 
96365, 96366, and 96521 billed for date of service April 17, 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 services are medically necessary for 
your wound care needs. The Plan denied your request. The Plan says your medical needs are being met in the 
current setting. 
 
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 you are receiving appropriate care in the current acute care setting as provided by the 
Plan. Documentation does not support that LTACH services are medically appropriate at this time. 
 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 4 additional home health skilled nursing visits. 
 
You asked the Plan to pre-approve home health services. You say that this is medically necessary. The Plan 
denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found clinical 
documentation shows that you have multiple medical comorbidities however it does not specify any acute 
clinical concern, medication change, or clinical assessment need thus 4 additional home health skilled nursing 
visits are not medically necessary. The records do not show that 4 additional skilled nursing visits in the home 
setting would be required to effectively provide treatment, care, and/or services in order to improve your 
condition, or to establish/perform a maintenance program to maintain your condition and/or prevent 
deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 4 additional home health skilled nursing visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (E0675) provided on 
January 18, 2023, through February 6, 2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that the item was medically 
necessary. The Plan denied your request. The Plan says this is not a covered item. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for the pneumatic compression device (E0675) provided on January 18, 2023, through February 6, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lightweight wheelchair (K0003). 
 
You asked the Plan to pre-approve a lightweight wheelchair. You say that the item is medically necessary. The 
Plan denied your request. The Plan says the item is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that A lightweight wheelchair (K0003) is covered when a 
beneficiary meets both criteria (1) and (2): 
 
    1. Cannot self-propel in a standard wheelchair in the home; and 
 
    2. The beneficiary can and does self-propel in a lightweight wheelchair. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a lightweight wheelchair. Our reviewer 
says that the item is not medically necessary. Our physician reviewer found the record does not address the 
enrollee's ability to manage a lightweight wheelchair. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a lightweight wheelchair have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a lightweight wheelchair (K0003).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a stair lift or glide.  
 
You asked the Plan to pay for a stair glide. You say that you would like reconsideration because the requested 
stair lift or glide is medically necessary. The Plan denied your request. The Plan says this item is not a covered 
benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pay for a stair lift or glide.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) care provided 
on July 3, 2022, to July 5, 2022. 
 
You asked the Plan to waive the copayment for skilled nursing facility (SNF) care SNF care. You say that you 
were never made aware of the additional stay co-payments. The Plan denied your request. The Plan says this 
cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay Days 1  20: $0 copay per day, Days 21  47: $188 copay per day, Days 48  100: $0 copay per day 
for Skilled nursing facility (SNF) care ($188 x 3 = $564). 
 
 The enrollee has been asked to pay $188 a day co-payment for days 21  23 ($188 x 3 = $564) for SNF care. 
This item/service falls within the Skilled nursing facility (SNF) care benefit category. This means that the 
enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a 
contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for skilled nursing facility (SNF) care provided on July 3, 2022, to July 
5, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray services provided on January 18, 2023, by an OON 
provider.  
 
You asked the Plan to pay for the x-ray services. You say that authorization is not required for these services. 
The Plan denied your request. The Plan says the 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 Plan contract says the enrollees POS benefit only applies to 
covered routine dental services. 
 
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 x-ray services provided on January 18, 2023, 
by an OON provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional rides. 
 
You asked the Plan to pre-approve additional rides. You say that you do not know how you can get to your 
appointments, as you cannot take the bus and there is no one else who can transport you. The Plan denied your 
request. The Plan says this request exceeds the limit of the supplemental benefit and does not meet the criteria 
for coverage.  
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 24 one-way non-emergency transportation trips per year.  
 
We looked at your request, the records in the case file, and the rules. 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 additional rides.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure (64628, 64629). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this is medically necessary. The Plan 
denied your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the 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 showing only modic changes without other 
degenerative joint disease. The cause of 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 the Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure (64628, 64629).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional mileage. 
 
You asked the Plan to pre-approve additional mileage. You say that you need this ride to your thyroid surgery 
for your cancer treatment. You also say that you do not understand why the surgery procedure was approved, 
but the transportation was denied. The Plan denied your request. The Plan says the requested transportation 
exceeds the limit of the supplemental benefit.  
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 routine transportation when each one-way trip does not exceed 50 miles. 
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Specifically, you have requested 
to be transported more than 50 miles one-way, which is not covered under your plan. Therefore, we decided 
that the Plan does not have to pre-approve additional mileage.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary to give the 
enrollee the proper level of care needed to ensure an optimal recoevery and prevent further decline. The Plan 
denied your request. The Plan says the enrollee does not meet the criteria for admission to an IRF.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
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 the enrollee needs can be met at a lower 
level of care. The Plan denied your request. The Plan says an LTACH admission is not medically necessary.  
 
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 that continued care in the short-term acute hospital is appropriate until the enrollee is 
stable to transfer to a lower level of care such as an inpatient rehabilitation facility, a sub-acute rehabilitation 
facility or a skilled nursing facility. 
 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the ambulance services and inpatient 
hospital services provided from May 1, 2023, to May 8, 2023. 
 
You asked the Plan to waive the copayments for the ambulance services and inpatient hospital services. You 
say that you were not told your options of being transported to rehabilitation. You also say that you were put in 
a room in the hospital for seven days and they would not let you move. The Plan denied your request. The Plan 
says the cost sharing will be applied according to the Plan contract. 
 
 
 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 $225 
copayment for ambulance services, a $95 copayment per visit for emergency care and a $250 copayment per 
day for days 1 to 6 per admission, up to a $1,500 maximum copayment per admission for inpatient hospital 
care. 
 
You have been asked to pay a $225 copayment for the ambulance services, a $95 copayment for the emergency 
care, and a $1,500 copayment for the inpatient stay. These services fall within the ambulance services benefit 
category, emergency care benefit category, and 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 copayments for the ambulance services and inpatient hospital services provided 
from May 1, 2023, to May 8, 2023.  
 
Your complaint about your unhappiness with the treatment you received in the hospital and your financial 
responsibility for the ambulance transportation is not a valid appeal for medical coverage. This part of your 
complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision 
about these types of complaints.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cerapedics I-Factor allograft (20930), and continuous 
intraoperative neurophysiology monitoring (95941). 
 
You asked the Plan to pre-approve Cerapedics I-Factor allograft, and continuous intraoperative 
neurophysiology monitoring. You say that this is medically necessary. The Plan denied your request. The Plan 
says the clinical value and effectiveness of Cerapedics I-Factor allograft in the setting of cervical radiculopathy 
have not been demonstrated in the peer-reviewed literature. In addition, a review of coding guidelines 
documents CPT code 95941 is a status I code which is not valid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. Medicare rules say that providers must report services correctly. Providers must 
report services with the appropriate procedure code. 
 
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 Cerapedics I-Factor allograft, and 
continuous intraoperative neurophysiology monitoring. Our reviewer says that the requested items/services are 
not considered medically reasonable and necessary in this case. Our physician reviewer found there is limited 
published, large-scale, long-term peer-reviewed literature that shows this requested allograft to be an effective 
and/or safe treatment for the noted pathology. Further studies are needed to demonstrate this request has 
beneficial outcomes compared with conventional treatment. There is no compelling rationale presented, or 
extenuating circumstances noted to support the medical necessity of this request as an exception. 
 
We looked at this physician's review, the file, and Medicare rules. Additionally, we find that procedure code 
95941 has a Status Indicator of I on the Physician Fee Schedule. This means that procedure code 95941 is not 
valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of 
Cerapedics I-Factor allograft, and continuous intraoperative neurophysiology monitoring have not been met. 
Therefore, we decided that the Plan does not have to pre-approve Cerapedics I-Factor allograft (20930), and 
continuous intraoperative neurophysiology monitoring (95941).