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

We decided that the Plan does not have to pay for two fillings provided on February 4, 2020.
You asked the Plan to pay for two fillings. The Plan denied your request. The Plan says that they have already
paid for two fillings this year.
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. The Plan covers two fillings
per calendar year.
We looked at the file and Plan rules. The file indicates the Plan has already covered two fillings for the same
date of service. Based on this information, we decided that the Plan's rules for coverage of two fillings have not
been met. Therefore, we decided that the Plan does not have to pay for two fillings provided on February 4,
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for periodontal maintenance (D4910) provided February 17,
2020.
You asked the Plan to pay for the dental services. You say that please accept this appeal on the basis that
periodontal prophylaxis is a precautionary method as to not have further more expensive problems. The Plan
denied your request. The Plan says this service is not covered under the plan benefits.
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. Services not listed under the
description of benefits is not covered by the plan.
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
periodontal maintenance (D4910) provided February 17, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy rendered on September 18, 2019.
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 the services are not covered.
The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be
covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The
Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies.
We looked at the file and Medicare and the Plan's rules. Based on this information, we decided that Medicare
and the Plan's rules for coverage of these services have not been met.
Therefore, we decided that the Plan does not have to pay for the home infusion therapy rendered on September
18, 2019.
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D
benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the ExoDx Prostate Intelliscore (EPI) testing rendered on
January 7, 2020.
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 the testing is not covered.
The Plan must follow Medicare rules. The rules say that biomarkers (specifically, EPI, MiPS, and SelectMDx)
are deemed investigational.
The testing at issue is the ExoDx Prostate Intelliscore (EPI) test. This test is considered investigational by
Medicare and is therefore not covered.
Therefore, we decided that the Plan does not have to pay for the ExoDx Prostate Intelliscore (EPI) testing
rendered on January 7, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services rendered from June 20, 2019 to
August 17, 2019.
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 the claims were not billed correctly.
The Plan must follow Medicare rules. The rules say that HH PPS claims must report a 0023 revenue code line
on which the first four positions of the HIPPS code match the code submitted on the RAP.
We looked at the file and Medicare rules. The file shows that the claims were not submitted with the required
RAP. 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 the home health services rendered from June
20, 2019 to August 17, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a screening mammogram (77063, 77067) provided
December 2, 2019.
You asked the Plan to pay for the screening mammogram. You say that the services were medically necessary
and the claim was denied in error. The Plan denied your request. The Plan says the referring provider is
excluded from the Medicare program.
The Plan must follow Medicare rules. Medicare rules say that no Federal health care program payment may be
made for any items or services furnished by an excluded person or at the medical direction or on the
prescription of an excluded person.
We looked at the file and Medicare rules. The record shows the referring provider listed on the claim submitted
is excluded from Medicare participation. Based on this information, we decided that Medicare rules for
coverage of the screening mammogram have not been met. Therefore, we decided that the Plan does not have
to pay for a screening mammogram (77063, 77067) provided December 2, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from November 16,
2019 to November 27, 2019.
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee's
care could safely be provided at a custodial level of care by the extended care facility custodial level of care as
it had been prior to the SNF admission.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed above are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pay for the skilled nursing services. Our reviewer
says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the
enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment
of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily
skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the skilled nursing services have not been met. Therefore, we decided that the
Plan does not have to pay for the skilled nursing services provided from November 16, 2019 to November 27,
2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9328) provided from November 14,
2019 to December 12, 2019.
You asked the Plan to pay for home infusion therapy. You say that this should be reprocessed. The Plan denied
your request. The Plan says this code is not valid for Medicare purposes.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
We find that CPT code S9328 is not supported in the medical record. Specifically, this code has a status
indicator of "I." Medicare uses another code for reporting of, and payment for these services. Based on this
information, we decided that Medicare rules for coverage of home infusion therapy have not been met.
Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9328) provided from
November 14, 2019 to December 12, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the mandibular partial denture provided on January 31, 2019
by an OON provider.
You asked the Plan to pay for the mandibular partial denture. You say that you do not understand how the $100
deductible is applied because usually there is just a copay. You also say that you do not understand the way it
was figured out that you owe $575 as the patient responsibility. The Plan denied your request. The Plan says
$100 was applied to the deductible because your deductible had not been met prior to this service being
rendered. The Plan also says that the provider is OON and $575 was applied as the copayment.
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, you pay a $100 combined deductible
per calendar year. The record shows that you had not met the $100 deductible when the claim was received and
processed, which is why $100 was applied to the deductible for this service. The contract also says that after
you pay the $100 deductible, you are responsible for a 50% coinsurance of the comprehensive service per visit
when the services are received OON. Therefore, we decided that the Plan does not have to pay for the
mandibular partial denture provided on January 31, 2019 by an OON provider.
Your complaint about your dissatisfaction with how you were treated by the Plan is not a valid appeal for
medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does
not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve a general surgery consultation with a tertiary level of care
provider.
You asked the Plan to pre-approve a a consultation visit. You say that the enrollee was previously treated by
this provider and would like to get a second opinion with this provider. The Plan denied your request. The Plan
says that the denial of authorization for this service is correct, because tertiary level of care is not medically
necessary, and the enrollee can be treated by a community level provider.
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan
providers available to meet the enrollees' needs. The enrollee's contract with the Plan says that, with few
exceptions, enrollees must use contract providers for care.
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 consultation visit. Our reviewer says
that the enrollee meets the Medicare criteria for the requested tertiary level of care consultation. Our physician
reviewer found the enrollee has prior history of gastric cancer, now with cholecystostomy tube in place and
need for cholecystectomy. Given the history of prior infection, the surgical removal of the gallbladder can be
more complex. Given the enrollee's prior surgical history it would make sense for the original surgeons to
provide ongoing 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 consultation visit have been met. Therefore, we decided that the Plan has to preapprove
a general surgery consultation with a tertiary level of care provider.
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: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency room services provided July 29, 2017.
You asked the Plan to pay for the emergency room services. You say that the claim should be paid. The Plan
denied your request. The Plan says the claim was not correctly submitted within the allowable timeframe.
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 the emergency room services was not filed until December 23, 2019. 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 emergency room services provided July 29, 2017.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on January 29, 2020.
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 screening tests are not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed above, are not covered.
The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test
solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory
services rendered on January 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on January 16, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says nonemergent,
non-urgent services with out-of-network providers require 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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we
decided that the Plan does not have to pay for physician's services provided on January 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the implant /abutment supported removable mandibular
denture for edentulous arch (D6111) provided on January 6, 2020.
You asked the Plan to pay for the implant /abutment supported denture. You say that you believe this procedure
should have been coded as a complete mandibular denture (D5120) because you had already paid for the
hardware and procedures. The Plan denied your request. The Plan says this procedure is not listed as covered
by your plan.
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, 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 the
implant /abutment supported removable mandibular denture for edentulous arch (D6111) provided on January
6, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the sacroiliac joint.
You asked the Plan to pre-approve radiofrequency ablation. You say that you are appealing with supporting
documentation. The Plan denied your request. The Plan says the denial of authorization for this service is
correct, because this procedure is considered experimental/investigational.
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 pre-approve radiofrequency ablation. Our reviewer
says that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found this procedure is considered an experimental/investigational procedure because of the
wide variation in efficacy in peer-reviewed literature. Therefore, the request is considered not medically
reasonable and 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 radiofrequency ablation have not been met. Therefore, we decided that the Plan
does not have to pre-approve radiofrequency ablation (RFA) of the sacroiliac joint.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided to the enrollee from
November 14, 2019 to November 17, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that this care was medically necessary. The
Plan denied your request. The Plan says that that the notes did not show a medical reason for inpatient
admission.
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 supports that the criteria for inpatient payment are met in this case. The record
showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's
necessary hospital care (including earlier emergency department and/or observation care) would span two
midnights. Our physician reviewer found that the enrollee's condition met Medicare criteria for acute inpatient
hospital 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 acute inpatient hospital care have been met. Therefore, we decided that the Plan
has to pay for the acute inpatient hospital care provided to the enrollee from November 14, 2019 to November
17, 2019.
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for Apixiban and Lopressor provided on January 26, 2020 and
January 27, 2020.
You asked the Plan to pay for self-administered drugs. You say that the medication should be covered by the
insurance company. The Plan denied your request. The Plan says self-administered drugs are not covered under
your Part B benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Apixiban and Lopressor
provided on January 26, 2020 and January 27, 2020.
Benefits for self-administered drugs may be available under Medicare Part D. Contact the Plan that administers
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on January 5, 2016.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
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 the laboratory services was not filed until December 30, 2019. 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 the laboratory services provided on January 5, 2016.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH).
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says care can be safely received in another setting, such as a skilled nursing facility.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found you are currently undergoing treatment at an ACH for sacral osteomyelitis, severe peripheral vascular disease and overall failure to thrive. You are not intubated/ventilated. Your long-term prognosis is noted to be poor. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. You can remain at the current ACH until such time no acute services are required. You can then be transferred/discharged to a lower level of care for any ongoing long term care needs. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH).