Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy provided on March 3, 2022, by an OON 
provider. 
 
You asked the Plan to pay for physical therapy. The Plan denied your request. The Plan says the out-of-
network services were not authorized. 
 
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 physical therapy provided on March 3, 2022, by 
an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services you received on November 22, 2021. 
 
You asked the Plan to pay for the dental services. You say that you believe you were misinformed.  You 
believed that if you started the dental services in 2021 but paid for them in 2022 that the amount would be 
reimbursed under your 2022 benefits.  You stated that had you known it would not be covered, you would have 
waiting until 2022 to have the services. The Plan denied your request. The Plan says your benefit for the 
requested item or service has already been exhausted for 2021.  The bill for these services cannot be applied to 
your 2022 benefits because the services occurred in 2021. 
 
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 that you have already met the allowance maximum for 2021 for dental services.  The Plan is under no 
obligation to apply the payments you made in 2022 for services rendered in 2021 towards your 2022 benefits. 
Therefore, we decided that the Plan does not have to pay for dental services you received on November 22, 
2021.   
Your complaint about being misinformed about the year to which these dental benefits applied 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) and a panoramic x-ray 
(D0330) provided on May 2, 2022. 
 
You asked the Plan to pay for an evaluation and x-ray. You say that to have your hip replacement surgery you 
needed to have this x-ray done. The Plan denied your request. The Plan says a limited oral evaluation (D0140) 
is not covered by your supplemental dental benefits. The Plan also says your benefit for a panoramic x-ray 
(D0330) 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, a limited oral evaluation is not among 
those covered under this benefit. The record shows your benefit for a panoramic x-ray has been exhausted on 
date of service January 5, 2019. Therefore, we decided that the Plan does not have to pay for a limited oral 
evaluation (D0140) and a panoramic x-ray (D0330) provided on May 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the 2D oral/facial photographic images (code D0350) you 
received on June 6, 2022. 
 
You asked the Plan to pay for code D0350. You say that you had tooth pain and saw an in-network dentist, so 
this service should be covered. The Plan denied your request. The Plan says this service is not covered under 
your medical benefits. 
 
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 the 2D 
oral/facial photographic images (code D0350) you received on June 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an endosteal implant on tooth #20 (D6010) provided on June 
14, 2022. 
 
You asked the Plan to pay for an implant. You say that you did not know there was a waiting period otherwise 
you would have waited. The Plan denied your request. The Plan says you have not been continuously covered 
for more than 24 consecutive months and do not qualify for this service. 
 
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 before the waiting period ends. Therefore, we decided that the Plan 
does not have to pay for an endosteal implant on tooth #20 (D6010) provided on June 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services provided on March 21, 2022, and April 
25, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were told the provider was in-network. The 
Plan denied your request. The Plan says the dental services were received from an out-of-network provider and 
are not covered by your supplemental benefits. 
 
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 record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for the dental services provided on March 21, 2022, and April 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prophylaxis (D1110) provided by an out-of-network provider 
on May 18, 2022. 
 
You asked the Plan to pay for the dental services. You say that the Plan should pay for 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 maximum dental allowance amount was exhausted on date of service May 18, 2022. Therefore, we 
decided that the Plan does not have to pay for prophylaxis (D1110) provided by an out-of-network provider on 
May 18, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the LTACH is the most appropriate level 
of care for the enrollee. The enrollee's needs are too complex for skilled nursing. 
 The Plan denied your request. The Plan says the LTACH is not medically necessary, and the enrollee's needs 
can be met at the enrollee's current hospital setting. 
 
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 the enrollee was admitted with acute on chronic respiratory failure in the setting of 
COVID-19 infection. The record indicates that the enrollee continues to receive acute care services, and these 
have not been denied. 
 
 
 
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 long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are appealing the denial. The Plan denied your 
request. The Plan says the IRF care is not medically necessary, and the enrollee's needs can be met at a lower 
level of care such as a skilled nursing facility (SNF). 
 
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 not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee was admitted for infection of the left foot and had an above the knee amputation. The record shows the enrollee's medical problems are stable, and there are no complex nursing or 
rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record 
supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. 
 
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 not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of nivolumab.

You asked the Plan to pre-approve nivolumab. You say that you want to treat the enrollee with nivolumab. The
Plan denied your request. The Plan says nivolumab is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer
drugs if they are medically accepted as safe and effective or appropriate for the particular use.

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 nivolumab. Our reviewer says that the
enrollee does not meet the Medicare criteria for nivolumab. Our physician reviewer found the enrollee disease
has not been resected. Nivolumab is not Food & Drug Administration (FDA) approved for this indication. The
requested use is not supported by one of the major drug compendia or by clinical research appearing in a
Medicare-approved medical journal.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of nivolumab have not been met. Therefore, we decided that the Plan does not
have to pre-approve use of nivolumab.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you live alone and are unable to care for yourself 
after breaking your leg. You say that the rehabilitation has been slower than normal. The Plan denied your 
request. The Plan says the IRF care is not medically necessary, and your needs can be met at a lower level of 
care such as a skilled nursing facility (SNF). 
 
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 not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the patient was admitted for surgical repair of a hip fracture. Medical problems 
are stable. There are no complex nursing or rehabilitation needs.  
 
The patient does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. 
 
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 not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dentures you received from an out-of-network dentist on 
June 13, 2022. 
 
You asked the Plan to pay for the dentures. You say that the hospital lost your dentures, and you needed a new 
set to continue your treatment with an otolaryngologist. The Plan denied your request. The Plan says the 
dentures were received from an out-of-network provider and are not covered by your supplemental benefits. 
 
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 record shows you received the dentures from an out-of-network provider. Though the Plan offers a dental 
benefit in excess of Medicare coverage, the requested items or services are not covered under this benefit when 
received from an out-of-network provider. Therefore, we decided that the Plan does not have to pay for 
dentures you received from an out-of-network dentist on June 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on September 16, 2021, billed 
with codes 81408, 81407, 81302, 81345 and 81330. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was necessary and is 
supported in the medical record. The Plan denied your request. The Plan says this claim was not billed in 
accordance with Medicare rules. 
 The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
September 16, 2021, billed with codes 81408, 81407, 81302, 81345 and 81330.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on May 24, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
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 May 10, 2022. Therefore, 
we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on May 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pontic on tooth #13 (D6240) provided on December 6, 
2021. 
 
You asked the Plan to pay for a pontic. You say that this service was medically necessary. The Plan denied 
your request. The Plan says your annual allowance has been exhausted. 
 
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 this benefit includes 
coverage up to $3,000 for preventive and routine dental services. The record shows your annual dental allowance has been exhausted. You have been asked to pay for a pontic 
on tooth #13. This item/service falls within the 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 pay for a pontic on tooth #13 (D6240) provided on December 6, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 7, 2022. 
 
You asked the Plan to pay for the services provided. You say that the denial of payment is incorrect. The Plan 
denied your request. The Plan says the rules for payment have not been met. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We looked at the file and the rules. We find that the lab services were not billed with a modifier suitable for 
payment. Based on this information, we decided that Medicare rules for coverage of the services provided have 
not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on 
January 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral x-rays (D0210) provided on January 17, 2022, and 
core build up on tooth #11 (D2950) provided on January 31, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says your benefit for an intraoral x-ray has already been exhausted. The 
Plan also says that core build up (D2950) is not covered by your supplemental dental benefits. 
 
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. Core build up 
is not among those covered under this benefit. The record shows your benefit for the requested item or service was exhausted on date of service January 12, 2022. Therefore, we decided that the Plan does not have to pay 
for intraoral x-rays (D0210) provided on January 17, 2022, and core build up on tooth #11 (D2950) provided 
on January 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periapical x-ray (D0220) provided on August 3, 2022. 
 
You asked the Plan to pay for the dental services. You say that you thought dental services were covered at 
100%. 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 August 3, 2022. 
Therefore, we decided that the Plan does not have to pay for a periapical x-ray (D0220) provided on August 3, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service April 7, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that you disagree with the denial. The Plan 
denied your request. The Plan says procedure code 99100 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 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service April 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81345 billed for date of service February 28, 
2022. 
 You asked the Plan to pay for procedure code 81345. You say that you feel that this should be paid due to 
medical necessity. The Plan denied your request. The Plan says payment for code 81345 is bundled into 
payment for code 0089U. 
 
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 81345 
is a column II code to column I code 0089U. 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 procedure code 81345 billed for date of service February 28, 
2022.