Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each physical therapy (PT) visit provided 
on October 03, 2022, to November 23, 2022. 
 
You asked the Plan to waive the copayment for each physical therapy (PT) visit. You say that you were 
unaware there was still a balance remaining and you need help to pay for the cost share because you are on a 
fixed income. 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 
copayment for outpatient rehabilitation services. 
 
You have been asked to pay a $20 copayment for each physical therapy (PT) visit. This item/service falls 
within the outpatient rehabilitation 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. The total copayment you owe is $320 for PT visits ($20 per visit x 16 visits 
= $320). Therefore, we decided that the Plan does not have to waive the copayment for each physical therapy 
(PT) visit provided on October 03, 2022, to November 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pontic (D6245). 
 
You asked the Plan to pre-approve the dental service. You say that you need the pontic approved so you can 
have your bridge constructed so you can properly chew. The Plan denied your request. The Plan says the denial 
of authorization for this service is correct, because the pontic is 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 item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
pontic (D6245).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for adjust complete denture - maxillary (D5410) provided on 
May 25, 2023. 
 
You asked the Plan to pay for adjust complete denture - maxillary . You say that this should be covered. The 
Plan denied your request. The Plan says adjustments made in the first 6 months after getting dentures are part 
of the cost of the denture. 
 
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 adjust 
complete denture - maxillary (D5410) provided on May 25, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral - periapical each additional image (D0230 x2) 
provided on March 23, 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 March 23, 2023. 
Therefore, we decided that the Plan does not have to pay for intraoral - periapical each additional image 
(D0230 x2) provided on March 23, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the admission to an IRF is not medically necessary. 
 
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 that the complexity of the enrollee's documented nursing, medical, and rehabilitation 
needs would not be expected to require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. The clinical documentation shows that the enrollee requires ongoing physical therapy and 
occupational therapy but does not support an intensive rehabilitation regimen in an IRF 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 IRF admission and services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that the enrollee is weak and unable to walk and needs 
physical therapy and occupational therapy to return to their status prior to being hospitalized. The Plan denied 
your request. The Plan says the enrollee does not meet Medicare guidelines for services in a SNF. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the clinical documentation does not specify any daily inpatient therapy goals. 
The documentation does not specify any daily skilled nursing needs. The documentation does not support daily 
skilled services on an inpatient basis in a skilled nursing facility are necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown - porcelain fused to high noble metal tooth #27 
(D2750) provided on April 5, 2023. 
 
You asked the Plan to pay for the crown. You say that you are asking for a reconsideration for the denied code. 
The Plan denied your request. The Plan says per the enrollee's claim history, the $1,500 benefit maximum was 
met before the processing of this 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, certain limitations apply. The record 
shows the benefit for the requested service has been exhausted. The Plan has provided evidence of having 
made payments totaling $1,500 towards the cost of dental services provided in 2023. Therefore, we decided 
that the Plan does not have to pay for a crown - porcelain fused to high noble metal tooth #27 (D2750) 
provided on April 5, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6530. 
 
You asked the Plan to pre-approve the compression stockings. You say that you need the compression stocking 
to cover your joint and to prevent varicose veins. The Plan denied your request. The Plan says this item is not 
covered. 
 The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6530.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on June 12, 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 March 27, 2023. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on 
June 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for an injection and a specialist visit provided 
on March 13, 2023. 
 
You asked the Plan to waive the cost share for an injection and a specialist visit. You say that you have never 
had a cost share for previous injections. 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 20% 
coinsurance for Medicare Part B prescription drugs and a $30 copayment for each specialist visit.  You have been asked to pay $292.56 for an injection and a specialist visit. This total includes $279.57 
coinsurance, which is 20% of the allowed amount for a Medicare Part B drug injection ($1,397.86 allowed x 
20% = $279.57) and a $12.99 copayment, which is less than the standard amount for a specialist visit. The 
injection falls within the Medicare Part B prescription drugs benefit category. The specialist visit falls within 
the physician/practitioner 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 cost share for an 
injection and a specialist visit provided on March 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the retainer crown-porcelain fused to high noble metal for 
tooth number 20 (D6750) provided on March 21, 2023. 
 
You asked the Plan to pay for this dental item. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the enrollee's benefit for the item 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 dental item provided was exhausted on date of service October 16, 2019.   
 
 
 
 
 
Specifically, the Plans contract states that a dental crown is covered once every 60 months per tooth. The 
enrollee previously received a dental crown for tooth number 20 on October 16, 2019, less than 60 months 
prior, which was paid for by the Plan. Therefore, the enrollee has exhausted the allowable benefit for the dental 
item provided in this case. Therefore, we decided that the Plan does not have to pay for the retainer crown-
porcelain fused to high noble metal for tooth number 20 (D6750) provided on March 21, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 180 units of code 01402-AA and 1 unit of 64450-59 
provided on March 29, 2023. 
 
You asked the Plan to pay for 180 units of code 01402-AA and 1 unit of 64450-59. You say that this is 
supported in the records. The Plan denied your request. The Plan says these services were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules also say that providers must report the 
actual number of units provided for each procedure code.  
In this case, the CPT Code Manual definition of code 01402 is anesthesia for open or surgical arthroscopic 
procedures on knee joint; total knee arthroplasty. The definition of 64450 is injection(s), anesthetic agent(s) 
and/or steroid; other peripheral nerve or branch.  
 
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 180 units of code 01402-AA and 1 unit of 
64450-59 Our reviewer says that the billed units and codes are not supported. Our physician reviewer found the 
records document 172 minutes of anesthesia time. For code 1402, each unit represents 15 minutes, meaning 
180 units are not supported. While the procedure report describes post-operative injection for post-operative 
pain, the anesthesia service provided is not supported and code 64450 cannot be paid. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 180 units of code 01402-AA and 1 unit of 64450-59 have not been met. 
Therefore, we decided that the Plan does not have to pay for 180 units of code 01402-AA and 1 unit of 64450-
59 provided on March 29, 2023.
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 you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says the coverage criteria has not been met. 
 
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 the enrollee appears to be improving with current treatment and should only 
require short-term acute care services that can safely be completed at the current facility until more stable and 
appropriate for transfer to a lower level of care soon. The enrollee does not require services at the LTACH that 
are not already available at the current 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transport provided on April 18, 
2023. 
 
You asked the Plan to waive the copayment for the ambulance transport. You say that your provider called 
someone to verify a price for the ambulance services and told you it was free of charge. 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 $290 
copayment  per date of service regardless of the number of trips provided in and out-of-network for ground and 
air ambulance.  
 You have been asked to pay a $290 copayment for the ambulance transport. This service falls within the 
ambulance 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 copayment for ambulance transport 
provided on April 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown for tooth #30 (D2750) provided on April 19, 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 September 22, 2022. 
Therefore, we decided that the Plan does not have to pay for a crown for tooth #30 (D2750) provided on April 
19, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 14 additional routine transportation trips (A0120). 
 
You asked the Plan to pre-approve the additional trips. You say that the 14 additional transportation trips are 
needed for medical appointments to continue with your rehabilitation/therapy sessions. The Plan denied your 
request. The Plan says you currently have 2 trips remaining and you will have exceeded your benefit limit. 
 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 trips per year.  
 
We looked at your request, the records in the case file, and the rules. You asked the Plan to pre-approve the 
additional transportation trips for your medical needs. 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 14 additional routine transportation trips (A0120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids (V5298) purchased on 
March 28, 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 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 states 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 (V5298) purchased on March 28, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for deluxe frames (V2025) provided on May 11, 2023. 
 You asked the Plan to pay for deluxe frames (V2025). You say that covered services include one pair of 
eyeglasses or contact lens after each cataract surgery. The Plan denied your request. The Plan says they applied 
the contractual $45 copayment and denied the deluxe frames (V2025). 
 
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 says there is a $45 copayment for one pair of Medicare-covered standard glasses or contacts 
after each cataract surgery. 
 
We looked at the file and the Plan's rules. The rules say there is a $45 copayment for one pair of Medicare-
covered standard glasses or contacts after each cataract surgery. The rules also say they cover standard frames 
and standard lenses. The record shows you purchased deluxe frames (V2025). Based on this information, we 
decided that the Plan's rules for coverage of deluxe frames (V2025) have not been met. Therefore, we decided 
that the Plan does not have to pay for deluxe frames (V2025) provided on May 11, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the screening mammogram (77067) and the screening digital 
breast tomosynthesis (77063) provided on March 7, 2023. 
 
You asked the Plan to pay for the screening services. You say that the procedure was rendered in an outpatient 
setting and was clinically necessary. The Plan denied your request. The Plan says Z diagnostic codes can only 
be reported as a principal diagnosis in an inpatient setting. 
 
The Plan must follow Medicare rules. Medicare rules say that Z diagnostic codes can be used in any healthcare 
setting but can only be reported as a principal diagnosis in an inpatient setting. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the screening services have not been met. The claim shows diagnosis code, Z12.3, as the principal 
diagnosis. The claim also shows that the Place of Service (POS) code billed was 23, which indicates the services were rendered in an emergency room/outpatient hospital. Therefore, we decided that the Plan does not 
have to pay for the screening mammogram (77067) and the screening digital breast tomosynthesis (77063) 
provided on March 7, 2023.