Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99214) provided on May 12, 2023. 
 
You asked the Plan to pay for office visit. You say that this was billed with modifier -25 to support separate 
payment. The Plan denied your request. The Plan says this code was not billed with the -25 modifier to support 
separate payment. 
 
The Plan must follow Medicare rules. Medicare rules say that modifier -25 is used to facilitate billing of 
evaluation and management services on the day of a procedure for which separate payment may be made.  
 
We looked at the file and Medicare rules. This evaluation and management service was billed on the same date 
of service as surgical code 20610. Although you claim that this code was billed with modifier -25, the claim 
form submitted clearly shows that this code was not billed with modifier -25. Therefore, separate payment may 
not be facilitated at this time. Based on this information, we decided that Medicare rules for coverage of office 
visit have not been met. Therefore, we decided that the Plan does not have to pay for an office visit (99214) 
provided on May 12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal maintenance (D4910). 
 
You asked the Plan to pre-approve the dental services. You say that you need this cleaning. 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 April 7, 2023, and 
October 9, 2023. Therefore, we decided that the Plan does not have to pre-approve periodontal maintenance 
(D4910).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). You asked the Plan to pre-approve the CGM. You say that you have diabetes and the CGM is necessary. The 
Plan denied your request. The Plan says the Medicare criteria was not met. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the CGM. Our reviewer says that the 
CGM coverage criteria was not met. Our physician reviewer found that the coverage criteria for a CGM 
requires insulin use or low blood sugars. This enrollee is not taking insulin and we are not told of any low 
blood sugars nor is the enrollee on medications that typically cause low blood sugars. Although the CGM may 
help the enrollee control their blood sugar levels and diet, coverage criteria are not met. 
 
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 CGM have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a continuous glucose monitor (CGM).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an over-the-counter (OTC) COVID-19 test provided on July 
3, 2023. 
 
You asked the Plan to pay for the OTC COVID-19 test. The Plan denied your request. The Plan says OTC 
COVID-19 tests are not covered by Medicare after May 11, 2023. 
 
The Plan must follow Medicare rules. Medicare rules say that starting April 4, 2022, and continuing until the 
COVID-19 public health emergency (PHE) ends, people with Medicare Part B can get up to eight free over-
the-counter tests for the month of April any time before April 30th and can then get another set of eight free 
over-the-counter tests during each subsequent calendar month through the end of the COVID-19 PHE. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the OTC COVID-19 test have not been met. Therefore, we decided that the Plan does not have to 
pay for an over-the-counter (OTC) COVID-19 test provided on July 3, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral radiographic images (D0220 and D0230), a 
resin-based composite (D2335) for tooth #8, the core buildup (D2950) for tooth #8, a splint (D4323) for tooth 
#6, #7, #8, #9, #10, and #11, the tooth reimplantation (D7270) for tooth #8 and #9, and the palliative treatment 
of dental pain (D9110) provided on June 13, 2022, September 12, 2022, and October 18, 2022. 
 
You asked the Plan to pay for the dental services. You say that the treatment was due to a traumatic fall and 
you are entitled to medical coverage for the surgery to repair the bones. The Plan denied your request. The Plan 
says the denial of payment for these services is correct, because dental services are not covered by the Plan or 
Medicare. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
  The requested intraoral radiographic images, a resin-based composite, the core buildup, a splint, the tooth 
reimplantation, and the palliative treatment of dental pain in dispute meets the Medicare definition of dental, 
since it is a service which involved the care and treatment of teeth or structures directly supporting the teeth. 
The intraoral radiographic images, a resin-based composite, the core buildup, a splint, the tooth reimplantation, 
and the palliative treatment of dental pain does not fall under any of Medicare exceptions for coverage of non-
routine dental care. These are dental services that are not covered or paid for by Medicare. Therefore, we 
decided that the Plan does not have to pay for the intraoral radiographic images (D0220 and D0230), a resin-
based composite (D2335) for tooth #8, the core buildup (D2950) for tooth #8, a splint (D4323) for tooth #6, #7, 
#8, #9, #10, and #11, the tooth reimplantation (D7270) for tooth #8 and #9, and the palliative treatment of 
dental pain (D9110) provided on June 13, 2022, September 12, 2022, and October 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on June 15, 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 $2,000 annual maximum 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 $2,000 annual maximum was exhausted. Therefore, we decided that the Plan does not have to pay 
for dental services provided on June 15, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a heavy duty wheelchair provided on 
February 25, 2023. 
 
You asked the Plan to waive the coinsurance for a heavy duty wheelchair. You say that you were not aware that 
this was a rental. 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 in-network durable medical equipment (DME) and related supplies. 
 
You have been asked to pay 20% coinsurance for a heavy duty wheelchair. This item/service falls within the 
in-network durable medical equipment (DME) and related supplies benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. The total you owe is $9.84 ($49.18 allowed 
amount x 20% = $9.84 rounded up). Therefore, we decided that the Plan does not have to waive the 
coinsurance for a heavy duty wheelchair provided on February 25, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral- periapical each additional radiographic image 
(D0230) provided on June 19, 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 19, 2023. Therefore, 
we decided that the Plan does not have to pay for intraoral- periapical each additional radiographic image 
(D0230) provided on June 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on April 18, 2023. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the provider was not aware that an 
authorization was needed. 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 subsequent nursing 
facility care provided on April 18, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing billed for date of service May 19, 2023. 
 
You asked the Plan to pay for the billed testing. You say that the codes are approved by Medicare. The Plan 
denied your request. The Plan says the billed codes cannot be verified. The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. In this case, there are no medical records from the treating physician 
that documents a need or the intent for these tests to be provided for a specific medical problem. Based on this 
information, we decided that the Medicare rules for coverage have not been met. Therefore, we decided that the 
Plan does not have to pay for the lab testing billed for date of service May 19, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiology services provided on May 31, 2023. 
 
You asked the Plan to pay for the radiology services. You say that you are requesting reconsideration of 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 the radiology services 
provided on May 31, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and the trimming procedure provided on 
December 05, 2022. 
 
You asked the Plan to pay for the office visit and the trimming procedure. You say that you are requesting 
reconsideration of 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 the office visit and the 
trimming procedure provided on December 05, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 83880 billed for date of service April 18, 
2023. 
 
You asked the Plan to pay for the billed service. You say that physicians send specimens for testing. The Plan 
denied your request. The Plan says the billed code cannot be verified. The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or 
provider must corroborate the documentation in the beneficiary's medical documentation.  
 
We find that CPT code 83880 is not supported in the medical record. The medical documentation provided 
does not show that the lab testing was provided by the provider at issue. Additionally, the referring provider on 
the claim does not match the physician information in the records. Based on this information, we decided that 
Medicare rules for coverage of the billed service have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure code 83880 billed for date of service April 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the cone beam CT capture and interpretation with field 
of view of both jaws; with or without cranium (D0367). 
 
You asked the Plan to pre-approve the cone beam CT capture and interpretation. You say that you need the CT 
scan. The Plan denied your request. The Plan says this service is not covered in your dental 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 service is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the cone 
beam CT capture and interpretation with field of view of both jaws; with or without cranium (D0367).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a new patient office visit, and related services provided on 
May 25, 2023. 
 
You asked the Plan to pay for a new patient office visit, and related services. You say that you think that the 
prior authorization request should be waived. 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 new patient office 
visit, and related services provided on May 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lesion destruction procedures and an office visit provided 
on June 30, 2023. 
 
You asked the Plan to pay for the lesion destruction procedures and an office visit. You say that you are 
requesting reconsideration of 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 the lesion destruction 
procedures and an office visit provided on June 30, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on August 31, 2022, to 
September 5, 2022, at the DRG originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that 
diagnosis code J96.21 was appropriately assigned and the DRG should remain 177. The Plan denied your 
request. The Plan says diagnosis code J96.21 is not supported, which resulted in a DRG change. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services with diagnosis code J96.21, defined as acute and chronic 
respiratory failure with hypoxia. 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 inpatient 
hospital services at the DRG originally billed. Our reviewer says that billing of diagnosis code J96.21 is not 
supported. Our physician reviewer found the enrollee was treated for pneumonia in the setting of known 
asthma and chronic bronchitis. It was suspected that the enrollee likely had chronic obstructive pulmonary 
disease and bronchiectasis. The enrollee also had a cough and mild hypoxia, but there is no evidence that the 
enrollee had acute respiratory failure.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on August 31, 2022, to September 5, 2022, at the DRG originally 
billed.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like to request reconsideration of the 
denied IRF services and that the services requested are medically necessary. The Plan denied your request. The 
Plan says the inpatient rehabilitation facility (IRF) services you are requesting do not meet the requirements for 
approval. 
 
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 the complexity of the enrollees nursing medical and rehabilitation needs does require an acute hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee required surgery on 
November 13, 2023, and is weight bearing as tolerated in the right lower extremity. The enrollee was also 
treated for atrial fibrillation and rapid ventricular response. They are noted to have had an elevated troponin 
level, likely secondary to demand ischemia and has a history of coronary artery disease with a prior left heart 
catheterization on November 17, 2023. Other medical issues include hyperkalemia. Given the complexity of 
their medical issues they would benefit from the oversight of a rehabilitation physician as well as rehabilitation 
nursing care. Their medical and rehabilitation needs do require the intensive interdisciplinary approach 
provided on acute inpatient rehabilitation. 
 
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 inpatient rehabilitation facility (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.