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

 
We decided that the Plan does not have to pay for an emergency department visit (procedure 99284) provided 
on April 16, 2023. 
 
You asked the Plan to pay for an emergency department visit (procedure 99284). You say that procedure code 
99284 is appropriate based on the services performed. The Plan denied your request. The Plan says the records 
do not support the services at issue in this case. 
 
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 99284 is emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and moderate 
level of medical decision making. 
 
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 an emergency department visit (procedure 99284). Our 
reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer 
found the documentation submitted supports a medically appropriate history or examination but does not 
support a moderate level of decision making. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an emergency department visit (procedure 99284) have not been met. 
Therefore, we decided that the Plan does not have to pay for an emergency department visit (procedure 99284) 
provided on April 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), intraoral-
comprehensive series of radiographic images (D0210), and the porcelain/ceramic dental crown (D2740) 
rendered by the out-of-network (OON) provider on July 7, 2023.  
 
You asked the Plan to pay for these items/services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says the items/services were rendered by an 
out-of-network provider, without prior authorization. 
 
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 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 
items/services 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 the comprehensive oral evaluation (D0150), 
intraoral-comprehensive series of radiographic images (D0210), and the porcelain/ceramic dental crown 
(D2740) rendered by the out-of-network (OON) provider on July 7, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for limited oral evaluation (D0140) and intraoral first x-ray 
(D0220) provided on August 21, 2023. 
 
You asked the Plan to pay for the dental services. You say that your teeth are loosening on top and giving you 
pain. You also say they had to x-ray and look to see what is going on. 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 intraoral first x-ray (D0220) was exhausted on date of service April 13, 2023. The 
record also shows that limited oral evaluation (D0140) is excluded from this benefit. Therefore, we decided 
that the Plan does not have to pay for limited oral evaluation (D0140) and intraoral first x-ray (D0220) 
provided on August 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit provided on July 06, 2023. 
 
You asked the Plan to pay for a home visit. You say that you are requesting reconsideration for the denied 
claim. 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 
July 06, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bone replacement graft for ridge preservation (D7953) 
provided on February 14, 2023. 
 
You asked the Plan to pay for bone replacement graft for ridge preservation. You say that you are appealing 
with supporting records. The Plan denied your request. The Plan says your Plan will only cover dental services 
in a hospital setting or from injury to natural teeth. 
 
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 bone 
replacement graft for ridge preservation (D7953) provided on February 14, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator (E0466). 
 
You asked the Plan to pre-approve a ventilator. 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 must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and necessary. 
 
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 a ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the enrollee does not have indication per 
documentation provided for home ventilator. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator (E0466). 
 
You asked the Plan to pre-approve a ventilator. 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 must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and necessary. 
 
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 a ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the enrollee has restrictive lung disease 
from kyphoscoliosis, however, there is no data to support the need or requirement for home ventilator at this 
time. A trial of bilevel positive airway pressure (BIPAP) can be considered. Hence, no indication for a home 
ventilator. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for tympanometry and reflex threshold measurements, 
comprehensive audiometry threshold evaluation and speech recognition and distortion product evoked 
otoacoustic emissions provided on March 16, 2021. 
 
You asked the Plan to pay for tympanometry and reflex threshold measurements, comprehensive audiometry 
threshold evaluation and speech recognition and distortion product evoked otoacoustic emissions. You say that 
the claim was submitted timely. The Plan denied your request. The Plan says the claim was untimely, and the 
submission did not meet the exception criteria guidelines outlined in 42 CFR Section 424.4. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 The record shows that a claim for tympanometry and reflex threshold measurements, comprehensive 
audiometry threshold evaluation and speech recognition and distortion product evoked otoacoustic emissions 
was not filed until May 22, 2023. This means that more than one calendar year from the date of service had 
passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for tympanometry 
and reflex threshold measurements, comprehensive audiometry threshold evaluation and speech recognition 
and distortion product evoked otoacoustic emissions provided on March 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for telehealth services provided on July 28, 2023. 
 
You asked the Plan to pay for telehealth services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the member must use a network provider who offers the service by 
telehealth. 
 
The Plan contract covers certain telehealth services. If the enrollee chooses to get one of these services by 
telehealth, the enrollee must use a network provider who offers the service by telehealth. 
 
We looked at the file and the Plans rules. The file shows that the provider is not a network provider who offers 
the service by telehealth. Based on this information, we decided that the Plans rules for coverage of telehealth 
services have not been met. Therefore, we decided that the Plan does not have to pay for telehealth services 
provided on July 28, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the COVID-19 tests provided on October 13, 2022. 
 
You asked the Plan to pay for the COVID-19 tests. You say that you billed the correct diagnosis, and the 
COVID-19 tests were done during the public health emergency The Plan denied your request. The Plan says 
that the tests are considered non-diagnostic. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. We find that the enrollee's diagnosis shows that this test would be considered 
medically necessary. The enrollee's diagnosis shows possible exposure to COVID-19. Therefore, we decided 
that the Plan has to pay for the COVID-19 tests provided on October 13, 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.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (80053, 83970, 84100) provided June 
24, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the diagnosis codes should not be reported together which is based on the 
Excludes1 Notes instructions in the ICD-10-CM Official Guidelines for Coding and Reporting. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the laboratory services have not been met. The diagnosis codes 
associated to it, E83.52 (Hypercalcemia) and E21.3 (Hyperparathyroidism, unspecified), should not be reported 
together, per our policy, which is based on the Excludes1 Notes instructions in the ICD-10-CM Official 
Guidelines for Coding and Reporting. Therefore, we decided that the Plan does not have to pay for the 
laboratory services (80053, 83970, 84100) provided June 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for eyeglasses (V2799) provided on August 23, 2023.  
You asked the Plan to reimburse for eyeglasses. You say that you called the Plan, and the Plan assured you 
they would offer a reimbursement for the eyeglasses. The Plan denied your request. The Plan says they do not 
cover these services when you see an out-of-network provider. 
 
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 services when the eyewear is provided by a Plan vision network provider. 
 
We looked at the file and the Plan's rules. The Plan rules say that covered services include eyeglass lenses and 
eyeglass frames when performed by a Plan routine vision care provider. Based on this information, we decided 
that the Plan's rules for coverage of eyeglasses have not been met. Therefore, we decided that the Plan does not 
have to reimburse for eyeglasses (V2799) provided on August 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for telehealth services provided on August 25, 2023. 
 
You asked the Plan to pay for the telehealth services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says telehealth is covered only in-network. 
 
The Plan contract covers certain telehealth services. If the enrollee chooses to get one of these services by 
telehealth, the enrollee must use a network provider who offers the service by telehealth. 
 
We looked at the file and the Plans rules. The file shows that the provider is not a network provider who offers 
the service by telehealth. Based on this information, we decided that the Plans rules for coverage of the 
telehealth services have not been met. Therefore, we decided that the Plan does not have to pay for telehealth 
services provided on August 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the massage therapy (97124) billed for date of service 
August 24, 2023. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says that payment for code 97124 is bundled into 
payment for code 98940. 
  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 97124 
is a column II code to column I code 98940. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the massage therapy (97124) billed for date of service August 24, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital inpatient or observation care provided on 
August 15, 2023. 
 
You asked the Plan to pay for initial hospital inpatient or observation care. You say that the services were 
medically necessary. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for initial hospital inpatient 
or observation care provided on August 15, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive series of intraoral x-rays (D0210) provided 
on September 13, 2023. 
 
You asked the Plan to pay for 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 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 14, 2023. 
Therefore, we decided that the Plan does not have to pay for comprehensive series of intraoral x-rays (D0210) 
provided on September 13, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from 
March 13, 2023, to March 15, 2023. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the treating practitioner, upon 
evaluation of the entire clinical picture, determined that inpatient admission was necessary and reasonable. The 
Plan denied your request. The Plan says the inpatient admission 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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found that the record did not show that at the time of inpatient admission it was reasonable 
for the admitting physician to expect that the patient's necessary hospital care (including earlier emergency 
department and/or observation care) would span two midnights with supporting documentation of the patients 
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 acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided from March 13, 2023, to  
March 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on October 4, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the physician service. You say that you want to appeal this denial. You also say 
that you want to find a provider in-network so your claims will get paid. The Plan denied your request. The 
Plan says prior authorization was not obtained. 
 
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 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 the office visit provided on October 4, 2023, by an 
out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for panoramic radiographic image (D0330) and bitewings-four 
radiographic images (D0274) provided on August 25, 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 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 June 8, 2023. Therefore, 
we decided that the Plan does not have to pay for panoramic radiographic image (D0330) and bitewings-four 
radiographic images (D0274) provided on August 25, 2023.