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

 
We decided that the Plan does not have to pre-approve additional mileage. 
 
You asked the Plan to pre-approve the additional mileage. You say that you do not agree with the 
determination and are requesting additional mileage. The Plan denied your request. The Plan says the requested 
transportation in each direction has exceeded the mileage 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 50 miles 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 mileage. 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 
additional mileage.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on November 
18, 2022. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you say that you were 
advised that you would only be billed once for ambulance services. The Plan denied your request. The Plan 
says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 
copayment for ambulance services. 
 
You have been asked to pay a $50 copayment for ambulance services. This item/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 services 
provided on November 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on June 
12, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were dissatisfied with the first dentist. You 
also say you found another dentist and will use his service going forward. 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 12, 2023. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) 
provided on June 12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a retainer crown (D6740) and a pontic (D6245). 
 
You asked the Plan to pre-approve the dental services. You say that it hurts to eat, and you need this. 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 7, 2022. 
Therefore, we decided that the Plan does not have to pre-approve a retainer crown (D6740) and a pontic 
(D6245).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral radiographic images (D0230), localized delivery of 
antimicrobial agents (D4318) and gingival irrigation with a medicinal agent  per quadrant (D4921) provided 
on May 3, 2023, and May 12, 2023. 
 
You asked the Plan to pay for the dental services. You say that this is medically necessary. The Plan denied 
your request. The Plan says your benefit for the intraoral radiographic images 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 intraoral radiographic images was exhausted on date of service May 3, 2023, and May 12, 2023. Therefore, we decided that the Plan does not have to pay for intraoral radiographic images 
(D0230), localized delivery of antimicrobial agents (D4318) and gingival irrigation with a medicinal agent  
per quadrant (D4921) provided on May 3, 2023, and May 12, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care (99232 x9) provided from May 
5, 2023, to May 16, 2023. 
 
You asked the Plan to pay for the subsequent hospital care. The Plan denied your request. The Plan says the 
billed services were 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 99232 is Subsequent hospital inpatient or observation 
care, per day, for the evaluation and management of a patient, which requires a medically appropriate history 
and/or examination and moderate level of medical decision making. When using total time on the date of the 
encounter for code selection, 35 minutes must be met or exceeded. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the subsequent hospital care. Our reviewer found the 
documentation from May 05, 2023, through May 16, 2023, followed the patient being stabilized with 
nephrostomy/stenting and describe the patient as stable hemodynamically, improving kidney function and 
requiring antibiotics and nephrostomy care without major changes in the treatment plan. Our reviewer also 
found that the documentation does not sufficiently support the code, 99232, for these dates because the 
documentation does not describe a moderate level of decision making or provide a duration of time spent for 
each encounter lasting 35 minutes or more.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the subsequent hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the subsequent hospital care (99232 x9) provided from May 5, 2023, to May 16, 
2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a syringe (A4657), an epoetin alfa injection (Q4081) and an 
iron sucrose injection (J1756) related to end-stage renal disease (ESRD) provided on April 4, 2023, to April 20, 
2023. 
 
You asked the Plan to pay for the ESRD-related services. You say that you are requesting payment for these 
services. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related 
services. 
 
The Plan must follow Medicare rules. Medicare rules state that all ESRD-related injectable drugs and 
biologicals and oral equivalents of those injectable drugs and biologicals are included in the ESRD PPS. No 
other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for a 
syringe (A4657), an epoetin alfa injection (Q4081) and an iron sucrose injection (J1756) related to end-stage 
renal disease (ESRD) provided on April 4, 2023, to April 20, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown- porcelain/ceramic (D2740). 
 
You asked the Plan to pre-approve 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 December 16, 2021. 
Therefore, we decided that the Plan does not have to pre-approve a crown- porcelain/ceramic (D2740).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the respiratory assist device provided on February 28, 2023, 
by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the respiratory assist device. You say that when you went to request 
authorization it comes back as no authorization or referral required. The Plan denied your request. The Plan 
says the equipment is available in network.  
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the respiratory assist device provided on February 
28, 2023, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes A4550, 64483, 64484, J0702 and Q9967 for date of 
service May 26, 2023. 
 
You asked the Plan to pay for codes A4550, 64483, 64484, J0702 and Q9967. You say that you disagree with 
the Plan's denial. The Plan denied your request. The Plan says the codes are not payable 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 64483 is injection(s), anesthetic agent(s) and/or steroid; 
transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, single level. 
The CPT Code Manual definition of code J0702 is Injection, betamethasone acetate 3 mg and betamethasone 
sodium phosphate 3 mg. 

The CPT Code Manual definition of code Q9967 is low osmolar contrast material, 300-399 mg/ml iodine 
concentration, per ml. 
 
 
We find that CPT codes 64483, 64484, J0702 and Q9967 are not supported in the medical record. Specifically, 
the medical records do not include a procedure note to indicate that injection, anesthetic agent and/or steroid; 
transforaminal epidural, with imaging guidance, lumbar or sacral, single level was performed; therefore, code 
64483 cannot be verified. 
 
The medical records submitted did not include a procedure note to indicate that injection, anesthetic agent 
and/or steroid; transforaminal epidural, with imaging guidance, lumbar or sacral, single level was performed; 
therefore, code 64484 cannot be verified. 
 
The submitted medical records do not indicate that injection, betamethasone acetate 3 mg and 
betamethasone sodium phosphate 3 mg was administered; therefore, code J0702 cannot be verified. 
 
The medical claim form submitted doesn't include a National Drug Code (NDC) number, quantity, or measure 
of units for the billed drug; this means code Q9967 cannot be verified. 
 
We find that procedure code A4550 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code A4550 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of codes A4550, 64483, J0702 and Q9967 have not been met. Therefore, we decided that the Plan 
does not have to pay for codes A4550, 64483, 64484, J0702 and Q9967 for date of service May 26, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pneumatic propulsion tire, any size (E2211) insert for 
pneumatic propulsion tire (removable), any type (E2213) push handles (K0108) push tracker (K0108). 

You asked the Plan to pre-approve the wheelchair accessories. You say that you are appealing on the grounds 
that this is not a request to repair to a back-up chair. The Plan denied your request. The Plan says pneumatic 
tires are primary for outdoor use. Push handles and push tracker are convenience items and are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Pneumatic tires are needed for outdoor use. The approved wheelchair 
comes with tires that are suitable for indoor use. Push handles are for caretaker convenience. A push tracker to 
tract how much you pushed is not medically related. Based on this information, we decided that Medicare rules 
for coverage of the wheelchair accessories have not been met. Therefore, we decided that the Plan does not 
have to pre-approve pneumatic propulsion tire, any size (E2211) insert for pneumatic propulsion tire 
(removable), any type (E2213) push handles (K0108) push tracker (K0108).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 20936 billed for date of service December 
20, 2021. 
 
You asked the Plan to pay for procedure code 20936. You say that the claim should be reviewed and 
reconsidered for payment. The Plan denied your request. The Plan says procedure code 20936 is considered 
bundled and not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 20936 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 20936 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 20936 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 20936 billed for date of service December 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ConfirmMDx testing billed with code 81551. 
 
You asked the Plan to pay for ConfirmMDx. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the services rendered are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that ConfirmMDx is only covered for certain indications. 
 
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 ConfirmMDx. Our reviewer says that the 
documentation does not support that the services rendered were medically reasonable or necessary. Our 
physician reviewer found the enrollee has an elevated prostate specific antigen (PSA). There is no family 
history of prostate cancer. Magnetic resonance imaging (MRI) of the prostate on January 16, 2023, showed 
enlarged prostate, no focal lesion to suggest clinically significant malignance. Per NCCN guidelines for 
Prostate Cancer Early Detection, it is recommended other biomarkers be done to further evaluate the risk if the biopsy is negative. In this case, criteria are not met for ConfirmMDx as the enrollee was not being considered 
for a repeat biopsy due to persistent risk factors such as elevated/rising PSA and/or abnormal DRE by repeat 
testing. Therefore, the enrollee did not meet criteria for the testing rendered. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ConfirmMDx have not been met. Therefore, we decided that the Plan does not 
have to pay for ConfirmMDx testing billed with code 81551.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for re-cement or re-bond crown (D2920) provided on May 30, 
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 January 25, 2022. 
Therefore, we decided that the Plan does not have to pay for re-cement or re-bond crown (D2920) provided on 
May 30, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the extraction (D7140) for tooth #8 and #11 and to pay 
for the bone replacement graft (D7953) for tooth #8 and #11 provided by an out-of-network provider on May 
17, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you were told you could go to any doctor 
and if you were told you had to pay you would not have got your mouth fixed. The Plan denied your request. 
The Plan says you are responsible for any charged amount above the Plans cost-sharing amount when your 
services are received from an out-of-network provider. The bone replacement graft is not covered by the Plan. 
Also, prior to the date of service it was verified you were told the provider was an out-of-network provider. 
 
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. The total amount billed for the extraction for tooth #8 was $280 and the total allowed amount was $74 leaving 
a difference of $206 ($280 billed - $74 allowed). The total amount billed for the extraction for tooth #11 was 
$280 and the total allowed amount was $74 leaving a difference of $206 ($280 billed - $74 allowed). 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. The 
bone replacement graft is not covered under the Plans dental benefit. Therefore, we decided that the Plan does 
not have to pay more for the extraction (D7140) for tooth #8 and #11 and to pay for the bone replacement graft 
(D7953) for tooth #8 and #11 provided by an out-of-network provider on May 17, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric services for October 5, 2023. 
 
You asked the Plan to pre-approve inpatient psychiatric services for October 5, 2023. You say that it is of the 
opinion of the admitting physician and the professional staff at the hospital that the enrollee meets admission 
and continued stay criteria for inpatient care. The Plan denied your request. The Plan says based on Medicare 
guidelines, the request for a continued stay at the inpatient behavioral health level of care is not approved. 
 
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 pre-approve inpatient psychiatric services for 
October 5, 2023. Our reviewer says that the enrollee does not meet the Medicare criteria for continued inpatient 
psychiatric care beyond October 4, 2023. Our physician reviewer found as of October 5, 2023, the enrollee was 
reported to be improved with no aggressive, agitated outbursts and was not heavily sedated. Records document 
that social services had secured placement at a nursing facility. Our reviewer also found that the provided 
medical records do not document that further psychiatric follow-up care in the nursing facility was appropriate 
as of October 5, 2023.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric services for October 5, 2023 have not been met. Therefore, 
we decided that the Plan does not have to pre-approve inpatient psychiatric services for October 5, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services and supplies and materials provided by a 
chiropractor on January 5, 2023. 
 
You asked the Plan to pay for lab services and supplies and materials. The Plan denied your request. The Plan 
says the only covered chiropractic service is manual manipulation of the spine. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for lab services and supplies and materials provided by a chiropractor on January 
5, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an extraction of an erupted tooth (D7140) 
provided on April 17, 2023. 
 
You asked the Plan to waive the coinsurance for an extraction of an erupted tooth (D7140). You say that there 
was an infection, so you had no choice but to pull the tooth. The Plan denied your request. The Plan says this 
cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 50% 
coinsurance after a $100 deductible for class 3 major dental services.  
 
 
  You have been asked to pay $55.39, which is 50% of the allowed amount for an extraction of an erupted tooth 
(D7140) ($110.78 x 50% = $55.39). This item/service falls within the class 3 major dental services benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the coinsurance for an extraction of an erupted tooth (D7140) 
provided on April 17, 2023.