Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on March 29, 2023, by an out-
of-network (OON) provider.  
 
You asked the Plan to pay for home health services. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider is out-of-network and prior authorization is 
required for an out-of-network visit. 
 
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 home health services provided on March 29, 2023, 
by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 27506 rendered on June 14, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that the records do not support the services billed. 
 
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 27506 is "Open treatment of femoral shaft fracture, with or without external fixation, with insertion of 
intramedullary implant, with or without cerclage and/or locking screws." 
 
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 supported by the medical records. Our reviewer found that the enrollee was being treated for a 
displaced comminuted fracture of shaft of left femur. He underwent a revision of distal fixation, left femur, and 
antegrade intramedullary nailing of the left femur on 6/14/23. The procedure details note that the proximal end 
of the plate was repaired. There was also an indication of the placement of wires, nails, and interlocking screws 
were utilized in the greater trochanter. There was documentation supporting that the femoral shaft fracture was 
repaired via an open approach and intramedullary nail insertion. Therefore, the documentation does support 
that CPT 27506 (open treatment of femoral shaft fracture, with or without external fixation with insertion of 
intramedullary implant, with or without cerclage and/or locking screws) was performed in this case. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
procedure code 27506 rendered on June 14, 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ED services provided on March 24, 2023. 
 
You asked the Plan to pay for the ED services. You say that this should be covered. The Plan denied your 
request. The Plan says Medicare payment cannot be made to this type of provider. 
 
The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare. 
However, during the COVID-19-PHE, such providers were allowed to enroll as temporary hospitals and could 
be paid for services during this period.  
We looked at the file and Medicare rules. We find that the provider at issue has not enrolled as a temporary 
hospital as allowed during the PHE. As such, this provider is not eligible for Medicare payment. Therefore, we 
decided that the Plan does not have to pay for the ED services provided on March 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve porcelain or ceramic pontics (D6245) and porcelain or 
ceramic crowns (D2740). 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing with supporting records. 
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 Plan's 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 this authorization. 
Therefore, we decided that the Plan does not have to pre-approve porcelain or ceramic pontics (D6245) and 
porcelain or ceramic crowns (D2740).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from May 2, 2023, through 
May 4, 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 inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for these services. Our reviewer says that the 
documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer 
found that the documentation indicates that the enrollee was evaluated in the Emergency Department (ED) on  
May 2, 2023 and was afebrile with stable vital signs. He was admitted and seen by speech-language pathology 
and cleared for a regular diet with thin liquids. The Psychology Department was consulted due to concerns 
regarding the psychological component for the etiology of weight loss. The enrollee was diagnosed with 
adjustment disorder and was recommended consideration of the medication Remeron at bedtime for appetite. 
An outpatient psychology follow-up was also recommended. He was discharged home when considered 
medically stable on May 4, 2023. The review has determined that the record showed that at the time of the 
inpatient admission it was reasonable for the admitting physician to expect that the enrollees necessary 
hospital care (including earlier ED and/or observation care) would span two midnights with supporting 
documentation of the enrollees history and comorbidities, signs and symptoms, current medical needs, and risk 
of an adverse event. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to pay for 
the acute inpatient hospital care provided from May 2, 2023, through May 4, 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 pre-approve custom shoe supports (A5500, A5512) to be provided 
by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve custom shoe supports to be provided by an OON provider. You say that the 
items are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to 
provide these services. Therefore, coverage criteria have not been met. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
custom shoe supports (A5500, A5512) to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for unspecified endodontic procedure (D3999) provided on 
September 12, 2023. 
 
You asked the Plan to pay for unspecified endodontic procedure. 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 
unspecified endodontic procedure (D3999) provided on September 12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive oral evaluation (D0150) and intraoral-
complete series of radiographic images (D0210) provided on August 1, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says your 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 June 14, 2023. Therefore, we decided that the Plan does not have to pay for comprehensive oral evaluation (D0150) and intraoral-
complete series of radiographic images (D0210) provided on August 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided by a chiropractor on August 18, 
2023. 
 
You asked the Plan to pay for the office visit. You say that your husband has Parkinson's disease, and you help 
them move around. You say that you help your husband do manual lifting to help them get around day to day, 
which puts a strain on your back and because of that you need regular maintenance. The Plan denied your 
request. The Plan says the only covered chiropractic service is manual manipulation of the spine. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit provided by a chiropractor on August 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for routine eye examination (92014), non-standard lenses 
(S0581), sphere trifocal lenses (V2300), anti-reflective coating (V2750), and polycarbonate lenses (V2784) 
provided on August 9, 2023. 
 
You asked the Plan to pay for routine eye examination, non-standard lenses, sphere trifocal lenses, anti-
reflective coating, and polycarbonate lenses. You say that you went to this provider through the Plan vision for 
your glasses and paid for them at that time. You also say this needs to be covered, also. The Plan denied your 
request. The Plan says the Plan requires you to use network providers for routine eye examination (92014). The 
Plan also says that you pay 100% of the cost for any upgraded materials. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these routine eye examinations when they obtained through a Plan vision network 
provider. The Plan also covers standard lenses. Upgrades are 100% paid by the member. 
 
We looked at the file and the Plan's rules. The Plan rules say that you must use network providers to get routine 
eye examinations. The Plan rules also say that you pay 100% of the cost for any upgraded materials. The lenses 
purchased were upgrades materials. Based on this information, we decided that the Plan's rules for coverage of 
routine eye examination, non-standard lenses, sphere trifocal lenses, anti-reflective coating and polycarbonate 
lenses have not been met. Therefore, we decided that the Plan does not have to pay for routine eye examination 
(92014), non-standard lenses (S0581), sphere trifocal lenses (V2300), anti-reflective coating (V2750), and 
polycarbonate lenses (V2784) provided on August 9, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an extraction, erupted tooth or exposed 
root (D7140) provided on August 11, 2023. 
 
You asked the Plan to waive the coinsurance for an extraction, erupted tooth or exposed root. You say that due 
to cracks in your tooth, it could not be saved. You also say that you had an oral surgeon extract the tooth 
because you were in pain. 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 50% 
coinsurance after a $100 deductible for class 3 major services which includes surgical extractions.  
 
 You have been asked to pay $71.80. You pay a 50% coinsurance after $100 deductible for class 3 major 
services. The 50% coinsurance for the service is $59.18, additionally you had a remaining $12.62 deductible to 
be applied, which is 50% of the allowed amount for an extraction of an erupted tooth or exposed ($59.18 + 
$12.62 = $71.80). This service falls within the class 3 major 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. Therefore, we decided that the Plan 
does not have to waive the coinsurance for an extraction, erupted tooth or exposed root (D7140) provided on 
August 11, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive oral evaluation (D0150) provided on April 
10, 2023. 
 
You asked the Plan to pay for the dental services. You say that you thought you have 2 visits for 
comprehensive oral evaluation for the year. 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 February 2, 2023. 
Therefore, we decided that the Plan does not have to pay for comprehensive oral evaluation (D0150) provided 
on April 10, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan has to provide coverage for acute inpatient rehabilitation facility (IRF) admission and
services for the enrollee.

You asked the Plan to provide coverage for IRF care. You say that this admission is medically necessary. The
Plan denied your request. The Plan says that Medicare coverage criteria were not met.

The Plan must follow Medicare rules. The rules say that IRF admission is covered 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 found to be
medically reasonable and necessary for this enrollee. Our physician reviewer found based on
documentation, the enrollee requires an intensive rehabilitation program of 3 hours of therapy a day for a
minimum of 5 days per week. She will require multiple specialists, including physical and occupational therapy
as well as speech therapy. She will require coordination of multiple disciplines under direction of rehab
physician to attain maximal level of progression prior to discharge. There is a reasonable expectation that this
enrollee will be able to fully participate and benefit from an intensive rehabilitation therapy program. 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 been met. Therefore, we decided that the Plan has to provide
coverage for acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.

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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Strata Select test (0391U) provided on September 10, 
2023. 
 
You asked the Plan to pay for the Strata Select test. You say that the services were provided, and payment 
should be rendered. The Plan denied your request. The Plan says the claim for this molecular pathology testing 
did not include the required unique identifier. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the Strata Select test 
have not been met. Therefore, we decided that the Plan does not have to pay for the Strata Select test (0391U) 
provided on September 10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intravenous sedation. 
 
You asked the Plan to pre-approve the dental services. You say that you need to be put under because 
Novocain is not strong enough for these extractions. The Plan denied your request. The Plan says the request is 
not medically necessary. 
 
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. Additionally, the services you are asking the Plan to pre-approve 
involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting 
your teeth. These are dental services that are not covered under your medical benefit or paid for by Medicare. 
Therefore, we decided that the Plan does not have to pre-approve intravenous sedation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental service (D0274) on August 28, 2023. 
 
You asked the Plan to pay for the dental service (D0274). You say that you were unaware the service was not 
covered. The Plan denied your request. The Plan says your benefit for the requested item or service has already 
been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service February 27, 2023. 
Therefore, we decided that the Plan does not have to pay for the dental service (D0274) on August 28, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral x-ray, comprehensive oral evaluation, 
comprehensive periodontal evaluation, and cleaning (D0180, D0150, D1110, D0210) provided on August 7, 
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 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 29, 2023 (D0210) 
and September 28, 2023. Therefore, we decided that the Plan does not have to pay for an intraoral x-ray, 
comprehensive oral evaluation, comprehensive periodontal evaluation, and cleaning (D0180, D0150, D1110, 
D0210) provided on August 7, 2023.