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

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from May 13, 2023, through 
May 18, 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 that the acute inpatient hospital care provided 
was not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not provided medical records to support their denial 
issued in this case. The Plan has stated that they did not receive medical records with your appeal request. 
However, the Plan has an obligation to request medical records when none have been provided. The Plan has 
not provided documentation to our organization of their attempts to request the medical records that pertain to 
this case. The Plan has not substantiated their denial; therefore, we must find in your favor. Therefore, we 
decided that the Plan has to pay for the acute inpatient hospital care provided from May 13, 2023, through  
May 18, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64447 billed for date of service June 26, 
2023.  
 
You asked the Plan to pay for procedure code 64447. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code 64447 is bundled into payment for code 01402. 
 
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 64447 is a column two code to column one code 01402 with a modifier indicator of 0. The column two code is 
therefore not payable. 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 64447 billed for date of service June 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit provided on June 16, 2023. 
 
You asked the Plan to pay for a home visit. You say that the services were medically necessary. 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 a home visit provided on 
June 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drugs or medicaments dispensed in the office for home 
use (D9630) and the consultation-diagnostic service provided by a dentist or physician other than requesting 
dentist or physician (D9310) on June 15, 2023 and July 7, 2023. 
 
You asked the Plan to pay for the dental items/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 dental items/services provided 
are 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 items/services provided are not 
among those covered under this benefit.   
 
Therefore, we decided that the Plan does not have to pay for the drugs or medicaments dispensed in the office 
for home use (D9630) and the consultation-diagnostic service provided by a dentist or physician other than 
requesting dentist or physician (D9310) on June 15, 2023 and July 7, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) provided 
on September 13, 2023. 
 
You asked the Plan to pay for this 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 March 17, 2022.  
  
Specifically, the Plans contract states that one comprehensive oral evaluation is covered every three calendar 
years. You previously received this service on March 17, 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 comprehensive periodontal evaluation (D0180) provided on  
September 13, 2023.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for tomographic (SPECT) myocardial perfusion imaging provided on 
August 24, 2023. 
 
You asked the Plan to pay for tomographic (SPECT) myocardial perfusion imaging. You say that the service 
was medically necessary. The Plan denied your request. The Plan says that this service was not authorized. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for tomographic (SPECT) myocardial perfusion imaging by a contract provider. The file 
does not show that the Plan provided notice that tomographic (SPECT) myocardial perfusion imaging would 
not be covered prior to the service being rendered. Under Medicare rules, this means tomographic (SPECT) 
myocardial perfusion imaging is considered approved by the Plan. Therefore, we decided that the Plan has to 
pay for tomographic (SPECT) myocardial perfusion imaging provided on August 24, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the foot orthotics (L3000) purchased on 
June 5, 2023 and July 3, 2023.  
 
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 a covered 
benefit for your condition. 
 
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. Additionally, Medicare rules say that with the exception of the situations described, orthopedic 
footwear billed using code L3000 will be denied as noncovered. Therefore, we decided that the Plan does not 
have to issue reimbursement for the foot orthotics (L3000) purchased on June 5, 2023 and July 3, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service September 6, 
2023. 
 You asked the Plan to pay for procedure code 70450. You say that the claim 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 September 6, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the tetanus, diphtheria toxoids and acellular pertussis vaccine 
(Tdap) (90715), and administration (90471) provided on August 10, 2023. 
 
You asked the Plan to pay for the vaccine services. You say that you were told you were due for this vaccine. 
You say that you, nor your provider, were aware that this would not be covered. You also say that you would 
have elected not to receive it had you known it would not be covered. The Plan denied your request. The Plan 
says this is not covered under Medicare Part B. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine services. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the vaccine 
services. Therefore, we decided that the Plan does not have to pay for the tetanus, diphtheria toxoids and 
acellular pertussis vaccine (Tdap) (90715), and administration (90471) provided on August 10, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing provided on March 15, 2023. 
 
You asked the Plan to pay for the drug testing. You say that this testing was medically necessary. 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 the drug testing 
provided on March 15, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from July 15, 2022, to August 
11, 2022. 
 You asked the Plan to pay for home health services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the NOA was not received timely. As such, this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is June 15, 2022. The NOA was not received by the Plan until December 13, 
2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from July 15, 2022, to August 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental cleaning (D1110) provided on August 14, 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 May 22, 2023. Specifically, the 
Plans contract states that two dental cleanings are covered per calendar year.  
  
 
You previously received two dental cleanings on January 30, 2023 and May 22, 2023 accordingly, less than 
one year prior, which were 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 dental cleaning (D1110) provided on 
August 14, 2023.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the outpatient office visit (99214), fundus photography (99250), 
scanning computerized ophthalmic diagnostic imaging (92134), and blood glucose (82947) provided on 
September 11, 2023. 
 
You asked the Plan to pay for the outpatient office visit, fundus photography, diagnostic imaging, and blood 
glucose. The Plan denied your request. The Plan says that the services provided were billed with medical codes 
and are not covered by the vision plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. We find that the records do not support the Plan's denial in this case. This means 
that the Plan has not provided a valid reason for denying payment of the outpatient office visit, fundus 
photography, diagnostic imaging, and blood glucose. It is the burden of the Plan to substantiate their denial 
with evidence. In this case, the denial has not been substantiated. Therefore, we decided that the Plan has to pay 
for the outpatient office visit (99214), fundus photography (99250), scanning computerized ophthalmic 
diagnostic imaging (92134), and blood glucose (82947) provided on September 11, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ocular prosthesis (V2627, L8499) provided on August 23, 
2023. 
 
You asked the Plan to pay for the ocular prosthesis. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the provider is not eligible for payment. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for an ocular prosthesis (V2627, L8499) 
provided on August 23, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for astigmatism correcting lenses provided on August 2, 2023, to 
August 16, 2023. 
 
You asked the Plan to pay for astigmatism correcting lenses. You say that if you were told it wasn't covered 
you wouldn't have had it done. The Plan denied your request. The Plan says this is not a covered service. 
 
The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives an A-C IOL 
during cataract surgery, the enrollee will be responsible for the difference in cost between the A-C IOL and a 
conventional IOL.  
 
While an A-C IOL may be appropriate for you, neither the Plan nor Medicare covers the astigmatism-
correcting feature of an IOL. Therefore, we decided that the Plan does not have to pay for astigmatism 
correcting lenses provided on August 2, 2023, to August 16, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on June 30, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that this testing was medically necessary. 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 the laboratory services 
provided on June 30, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture treatments (97810, 97811) and the 
unclassified drugs (J3490) provided on February 21, 2023. 
 
You asked the Plan to pay for these items/services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says you do not meet criteria for coverage of 
the items/services provided in this case.  
  
 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the acupuncture services in this case were not 
rendered on the basis of a diagnosis for chronic low back pain. Therefore, we decided that the Plan does not 
have to pay for the acupuncture treatments (97810, 97811) and the unclassified drugs (J3490) provided on 
February 21, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the pontic - porcelain/ceramic tooth #'s 3 and 5 
(D6245), and retainer crown - porcelain/ceramic tooth #'s 2, 4, and 6 (D6740). 
 
You asked the Plan to pre-approve the dental services. You say that these services are medically necessary as 
this situation is affecting your health when eating and your physical environment when speaking. 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 25, 2022. Therefore, we 
decided that the Plan does not have to pre-approve the pontic - porcelain/ceramic tooth #'s 3 and 5 (D6245), 
and retainer crown - porcelain/ceramic tooth #'s 2, 4, and 6 (D6740).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental services (D2751 and D4341). 
 
You asked the Plan to pre-approve the dental services (D2751 and D4341). You say that you would like to 
request reconsideration of the denied claim and that the services requested are medically necessary. 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 August 28, 2019 (D2751), and June 2, 2022 (D4341). Therefore, we decided that the Plan does not have to pre-approve the 
dental services (D2751 and D4341).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care. provided on September 07, 2023. 
 
You asked the Plan to pay for nursing facility care.. You say that you would like reconsideration based on the 
records submitted. 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 care. 
provided on September 07, 2023.