Persius/hicric huggingface dataset:
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on January 13, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you would 
like the service to be reconsidered. The Plan denied your request. The Plan says these services are not a 
covered benefit.  
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on January 13, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on January 13, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay on September 01, 
2022, to September 04, 2022.  
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that you have a bill for staying 
at the facility when you did not want to. 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 $175 
copayment per day for days 1-6 for inpatient hospital care. There were 3 days. 3 x $175 = $525. Therefore, 
results in the total cost sharing amount of $525. 
 
 You have been asked to pay a $175 copayment for per day inpatient hospital stay. 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 inpatient 
hospital stay on September 01, 2022, to September 04, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an unspecified preventive procedure and clinical crown 
lengthening services (D1999, D4249) provided on January 31, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services 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. 
 
  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 an 
unspecified preventive procedure and clinical crown lengthening services (D1999, D4249) provided on January 
31, 2023.
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 IRF is necessary for recovery care. The Plan denied 
your request. The Plan says the denial of IRF care is correct. 
 
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 complexity of the enrollee's nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation. While the enrollee 
may benefit from physical and/or occupational therapy, the enrollee's needs can be met in a lower intensity 
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 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral - periapical first radiographic image (D0220), 
each additional radiographic image (D0230), and consultation - diagnostic service provided by dentist or 
physician other than requesting dentist or physician (D9310) provided on January 20, 2023. 
 
You asked the Plan to pay for the dental services represented by codes D0220, D0230 and D9310. You say that 
you contacted the Plan prior to the services and was advised that the Plan would pay for 30% of the visit. The 
Plan denied your request.  The Plan says your benefit for the intraoral - periapical first radiographic image (D0220), each additional 
radiographic image (D0230) has already been exhausted. The Plan also says the consultation - diagnostic 
service provided by dentist or physician other than requesting dentist or physician (D9310) is not covered 
under the Plans 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the intraoral - periapical first radiographic image (D0220), and each additional 
radiographic image (D0230) on date of service January 26, 2023. The consultation - diagnostic service 
provided by dentist or physician other than requesting dentist or physician (D9310) is not among those covered 
under this benefit. Therefore, we decided that the Plan does not have to pay for an intraoral - periapical first 
radiographic image (D0220), each additional radiographic image (D0230), and consultation - diagnostic service 
provided by dentist or physician other than requesting dentist or physician (D9310) provided on January 20, 
2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the services are medically necessary for the 
enrollee's care. The Plan denied your request. The Plan says the enrollee is at baseline level of functioning. 
 
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 the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prolonged services (procedure code 99356) rendered on 
November 10, 2022. 
 
You asked the Plan to pay for the services. You say that you disagree with this denial. The Plan denied your 
request. The Plan says the documentation provided shows a total of 35 minutes spent caring for the patient. 
 
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, the CPT Code Manual definition of code 99356 is Prolonged service in the inpatient or 
observation setting, requiring unit/floor time beyond the usual service; first hour (List separately in addition to 
code for inpatient or observation Evaluation and Management service). 
 
We asked our coder 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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that to report this code, the service must extend at least 30 beyond the normal time of the evaluation and management code. In this case, CPT 
99356 is not support as it is used to report the first hour of prolonged service on a given time. The procedure 
report only documents 30 minutes of chart review and discussion. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for prolonged services (procedure code 99356) rendered on November 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve resin-based composites (D2391/D2330). 
 
You asked the Plan to pre-approve D2391 and D2330. You say that you would like the Plan to approve and pay 
for these services. The Plan denied your request. The Plan says the requested dental service is not a covered 
benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
resin-based composites (D2391/D2330).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation - established patient (D0120) 
provided on October 24, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were informed by the dentist's office that 
they are required by the law to perform an examination with each cleaning. You also say that since cleaning is 
covered two times per year, and since examination is required by law with each cleaning, you are requesting 
that the plan cover the additional cleaning charge of $55.00.  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 periodic oral evaluation - established patient was exhausted on date of service April , 
2022. Therefore, we decided that the Plan does not have to pay for a periodic oral evaluation - established 
patient (D0120) provided on October 24, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

? 
We decided that the Plan has to pre-approve complete upper and lower dentures. 
 
You asked the Plan to pre-approve complete upper and lower dentures. You say that this is medically 
necessary. The Plan denied your request. The Plan says that these services were already provided in 2019 and 
are only covered once every 60 months. 
 
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. The Plan says dentures were previously paid for in 2019 and that services were 
authorized in 2022. The Plan has not provided proof that dentures were already paid for or that the dentures 
were the service that was already authorized. It is the burden of the Health Plan to substantiate their denial with 
evidence. In this case, the denial has not been substantiated so we must find in your favor. Therefore, we 
decided that the Plan has to pre-approve complete upper and lower dentures.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for custom fabricated abutments (D6057) and abutments 
supported crowns (D6058) for tooth #3 and #19 provided on December 21, 2022. 
 
You asked the Plan to pay for then dental services. You say that your dental plan says that implants are a 
covered procedure, and you would like to have it covered up to your annual maximum. The Plan denied your 
request. The Plan says the denial of payment for these services is correct, because the custom fabricated 
abutments and abutments supported crowns 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. 
 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 custom 
fabricated abutments (D6057) and abutments supported crowns (D6058) for tooth #3 and #19 provided on 
December 21, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drugs (J1745) provided on December 21, 2022. 
 
You asked the Plan to pay for the drugs. You say that this service was medically necessary. The Plan denied 
your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted for treatment of pyoderma 
gangrenosum with coexisting inflammatory bowel disease must be submitted with a primary and a secondary 
ICD-10-CM code. If both the primary and secondary ICD-10-CM codes are not indicated on the claim, the 
service will be denied. 
 
We looked at the file and Medicare rules. The claim did not include a primary and secondary diagnosis code. 
Based on this information, we decided that Medicare rules for coverage of the drugs have not been met. 
Therefore, we decided that the Plan does not have to pay for drugs (J1745) provided on December 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic radiographic image (D0330) provided on 
January 31, 2023. 
 
You asked the Plan to pay for the dental service. You say that in order for the tooth to be extracted a panoramic 
radiographic image was carried out so there would be no damage to the nerves or bone tissue. The Plan denied 
your request. The Plan says your benefit for the panoramic radiographic image (D0330) has already been 
exhausted. Per your claim history, payment was issued for service (D0210) from the in-network provider on 
November 17th, 2022. 
 
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 panoramic radiographic image (D0330) was exhausted on date of service November 
17, 2022. Therefore, we decided that the Plan does not have to pay for a panoramic radiographic image 
(D0330) provided on January 31, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on November 17, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport . You say that the 
medical bill should not have been billed. The Plan denied your request. The Plan says these services are not a 
covered benefit.  
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on November 17, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on November 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ultrasound image-guided radiation therapy (IGRT). 
 
You asked the Plan to pre-approve IGRT. You say that you are appealing this denial. 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 IGRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case.  Our physician 
reviewer found using ultrasound on a daily basis is not unreasonable to offer but is not necessary. Daily 
performance of IGRT would not be furnished in accordance with accepted standards of medical practice. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IGRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve ultrasound image-guided radiation therapy (IGRT).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids (V5253) purchased on 
December 6, 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 from 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 says that hearing aids are covered 
only when purchased from 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 (V5253) purchased on December 6, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve Intracept. You say that the enrollee has tried and failed conservative 
treatment without relief. The Plan denied your request. The Plan says this is not appropriate for the enrollee's 
clinical situation. 
 
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 Intracept. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case.  Our physician 
reviewer found magnetic resonance imaging (MRI) shows spinal stenosis. The cause of the enrollee's back 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 Intracept have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Intracept procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an in-network intermittent urinary catheter 
provided on January 18, 2023. 
 
You asked the Plan to waive the coinsurance for an in-network intermittent urinary catheter. You say that the 
previous charge for this were less than this charge. This is too much for what you have 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 a 20% 
coinsurance for durable medical equipment (DME) and related supplies. The allowable amount of this item is 
$208.50, resulting in a $41.70 coinsurance ($208.50 x 20% = $41.70). 
 You have been asked to pay a $41.70 coinsurance for an in-network intermittent urinary catheter. This 
item/service falls within the durable medical equipment (DME) and related supplies 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 coinsurance for an in-network intermittent urinary catheter provided on 
January 18, 2023.