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

 
We decided that the Plan does not have to waive the coinsurance for a comprehensive periodontal evaluation - 
new or established patient (D0180), prophylaxis - adult ( D1110), comprehensive oral evaluation - new or 
established patient (D0150), and periodontal maintenance (D4910) provided on May 12, 2022, to February 8, 
2023. 
 You asked the Plan to waive the coinsurance for the dental services represented by codes D0180, D1110, 
D0150, and D4910. You say that you do not feel you should be responsible for the cost share for the out-of-
network provider. 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 50% of 
the approved amount for covered services provided out-of-network.  
 
You have been asked to pay a 50% coinsurance for the dental services represented by codes D0180, D1110, 
D0150, and D4910. These services fall within the dental services out-of-network 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 a comprehensive periodontal evaluation - new or established patient 
(D0180), prophylaxis - adult ( D1110), comprehensive oral evaluation - new or established patient (D0150), 
and periodontal maintenance (D4910) provided on May 12, 2022, to February 8, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit provided on August 16, 2022. 
 
You asked the Plan to pay for a home visit. You say that this is supported in the records. 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 
August 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a compression sleeve identified with code A6549. 
 
You asked the Plan to pre-approve this item. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says the requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 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 a compression 
sleeve identified with code A6549.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for standby services billed with code 99360 for date of service 
June 21, 2022. 
 
You asked the Plan to pay for code 99360. You say that these services were medically necessary and reduced 
the probability of an injury occurring. The Plan denied your request. The Plan says standby services are not 
covered. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare does not pay for standby services, as 
they are bundled or included in another service's basic allowance.  

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 99360 have not been met. Therefore, we decided that the Plan does not have to pay for 
standby services billed with code 99360 for date of service June 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided on September 07, 2022. 
 
You asked the Plan to pay for physical therapy services. You say that these 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 physical therapy 
services provided on September 07, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of a left atrial appendage closure device 
(LAAC). 
 
You asked the Plan to pre-approve placement of a LAAC. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that the Centers for Medicare & Medicaid Services 
(CMS) covers percutaneous LAAC for non-valvular atrial fibrillation (NVAF) through Coverage with 
Evidence Development (CED) with certain conditions. 
 
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 placement of a LAAC. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found there has been no 
documentation of consultation with an independent, non-interventional physician. As such, guidelines would 
not support implantation of a LAAC in this setting. In summary, LAAC placement would not be considered 
reasonable or medically necessary in this enrollees clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of placement of a LAAC have not been met. Therefore, we decided that the Plan 
does not have to pre-approve placement of a left atrial appendage closure device (LAAC).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95819 billed for date of service October 10, 
2022. 
 
You asked the Plan to pay for procedure code 95819. You say that this service is supported in the medical 
record. The Plan denied your request. The Plan says this service is not supported as billed, and there is a more 
appropriate code to report the service provided. 
 
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 95819 is electroencephalogram (EEG); including recording awake and asleep. 
 
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 procedure code 95819. Our reviewer says that the service 
provided is not most accurately reported with code 95819. Our reviewer found the procedure report documents 
a 21-channel routine digital EEG recording obtained according to standard-technique capturing portions of 
wakefulness and drowsiness. In this case, there is a more appropriate code to report for service documented. 
Code 95819 cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 95819 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 95819 billed for date of service October 10, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided on September 9, 2022. 
 
You asked the Plan to pay for the medication. You say that you can't afford the cost of the medication. The 
Plan denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs provided 
on September 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an upper partial denture (D5225) and a lower partial 
denture (D5214). 
 
You asked the Plan to pre-approve these dental items. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says the requested items are 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 are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an upper 
partial denture (D5225) and a lower partial denture (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scaling and root planing-four or more teeth 
per quadrant (D4341), an upper partial denture (D5211), and a lower partial denture (D5212). 
 
You asked the Plan to pre-approve these items/services. You say that you are requesting a reconsideration of 
the Plan's denial. The Plan denied your request. The Plan says the requested items/services are 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 and services are 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
periodontal scaling and root planing-four or more teeth per quadrant (D4341), an upper partial denture 
(D5211), and a lower partial denture (D5212).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 25600 billed for August 4, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 25600 is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 25600 is closed treatment of distal radial fracture (eg, 
Colles or Smith type) or epiphyseal separation, includes closed treatment of fracture of ulnar styloid, when 
performed; without manipulation.  

We find that CPT code 25600 is not supported in the medical record. Specifically, there is no documentation of 
a closed treatment of distal radial fracture or epiphyseal separation was performed. Based on this information, 
we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 25600 billed for August 4, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acute inpatient psychiatric care provided from December 20, 
2022, to December 23, 2022. 

You asked the Plan to pay for acute inpatient psychiatric care. You say that the enrollee was informed her 
husband died on December 19, 2022, and the additional days were medically necessary. The Plan denied your 
request. The Plan says that the enrollee was medically ready to be discharged on December 19, 2022. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 acute inpatient psychiatric care. Our 
reviewer says that the coverage criteria has not been met. Our physician reviewer found that the records 
provided for the admission of the enrollee does not meet the criteria for psychiatric care from December 20, 
2022, to December 23, 2022, as the enrollee was not shown to be a danger to themselves or others. The 
enrollee did not have noted auditory or visual hallucinations. The enrollee was cooperative and compliant with 
treatment while not showing any threats. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient psychiatric care have not been met. Therefore, we decided that 
the Plan does not have to pay for acute inpatient psychiatric care provided from December 20, 2022, to 
December 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a vision exam provided on October 24, 
2022. 
 
You asked the Plan to waive the copayment for a vision exam. You say that you are disputing the share cost. 
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 $35 
copayment for Vision care. 
 
You have been asked to pay a $35 copayment for a vision exam. This item/service falls within the Vision 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 a vision exam provided on 
October 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service code as 87150,87798, 87481, 87801 
provided November 15, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that your lab performed all the tests that were 
ordered by the referring physician. The Plan denied your request. The Plan says the Medicare criteria for 
coverage has not been met. 
 
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 pay for the laboratory service. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case.  Our 
physician reviewer found the review indicates that the enrollee underwent lab testing. There was no 
documentation or clinical information provided to indicate medical necessity for the codes 87150,87798, 
87481, 87801. Given the documentation provided for review, the review has determined that the items/services 
at issue in this case are not medically reasonable or 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 the laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pay for the laboratory service code as 87150,87798, 87481, 87801 provided November 15, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve shock absorbers for an approved manual wheelchair 
(E1015). 
 
You asked the Plan to pre-approve the shock absorbers. You say that these features are medically necessary. 
The Plan denied your request. The Plan says this accessory is for use outdoors and is therefore non-covered. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home.  Therefore, we decided that the Plan does 
not have to pre-approve shock absorbers for an approved manual wheelchair (E1015).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental services. 
 
You asked the Plan to pre-approve the dental services. You say that you would like to request reconsideration 
of the denied authorization. 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 January 11, 2023. 
Therefore, we decided that the Plan does not have to pre-approve the dental services.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you want to get to the rehabilitation facility because 
you need more therapy to get better and stronger.  The Plan denied your request. The Plan says that the medical 
records do not document that you have complex medical, nursing or rehabilitation needs that require an acute 
hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found you require ongoing physical therapy and occupational therapy. Per American stroke association, an 
intensive rehabilitation program is recommended for patients after acute stroke for optimal functional outcome. 
You have good participation in therapy evaluations and documented good prognosis per evaluating therapists 
thus you would be expected to participate and significantly benefit from an intensive rehabilitation program. 
The preadmission screen states that you require an intensive rehabilitation program with documented risks if 
you would transition to a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have been met. Therefore, we decided that the Plan has to pre-approve 
acute IRF admission and services.  
 
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 Freestyle Libre 2 sensors. 
 
You asked the Plan to pre-approve the Freestyle Libre 2 sensors. You say that the enrollee has re-occurring 
episodes and the glucometer is hard for her to use with her hands. You also say that the Libre will greatly 
benefit the patient. The Plan denied your request. The Plan says the enrollee is not using any insulin. 
 The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
the Freestyle Libre 2 sensors have not been met. Therefore, we decided that the Plan does not have to pre-
approve Freestyle Libre 2 sensors.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 99214-25 provided on October 18, 2022. 
 
You asked the Plan to pay for procedure code 99214-25. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says that the services are not covered as 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 99214 is Office or other outpatient visit for the evaluation and management of an established patient, 
which requires a medically appropriate history and/or examination and moderate level of medical decision 
making. When using time for code selection, 30-39 minutes of total time is spent on the date of the encounter. 
 
We find that CPT code 99214 is supported in the medical record. Specifically, the records document that an 
office visit for the evaluation and management of the enrollee included a medically appropriate history and 
examination and moderate level of medical decision making on October 18, 2022, the same day as the 
ultrasound guided injection of Synojoynt-Hyaluronic Acid (20610) provided by the same provider. Based on 
this information, we decided that Medicare rules for coverage of procedure code 99214-25 have been met. 
Therefore, we decided that the Plan has to pay for procedure code 99214-25 provided on October 18, 2022.  
 
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.