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

 
We decided that the Plan does not have to pay for the subsequent nursing facility care (99309) provided on 
September 17, 2021. 
 
You asked the Plan to pay for the nursing facility care. You say that the provider rendered medically necessary 
services to the enrollee in good faith. The Plan denied your request. The Plan says the enrollees claim would 
be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of 
election until the last day of the month in which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage before rendering services and to know proper billing procedures 
for a Medicare Advantage member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the subsequent nursing facility care (99309) provided on 
September 17, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that based on the enrollee's current needs, they recommend care at home 
with home care or services in an office. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section 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 pre-approve SNF services. Our reviewer says that 
SNF services are not medically reasonable and necessary. The enrollee has no identifiable skilled nursing 
service needs. The enrollee has identifiable skilled therapy service needs. The beneficiary does not require 
skilled nursing or therapy services on a daily basis. This beneficiary does not meet severity of illness or 
intensity of service criteria for an inpatient basis in a skilled nursing facility setting. Our physician reviewer 
found that the enrollee's condition does not meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for extractions (dental code D7140) and immediate denture 
(dental code D5130) on tooth #7, #8, and #9 provided on February 23, 2022. 
 
You asked the Plan to pay for extractions and immediate denture. You say that these services were covered 
prior, and you were unaware that your dental benefits had changed. The Plan denied your request. The Plan 
says the denial of this service is correct because the service provided is not included in the covered dental 
benefits. The Plan also states the enrollee was notified of the dental plan changed on September 24, 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, 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 
extractions (dental code D7140) and immediate denture (dental code D5130) on tooth #7, #8, and #9 provided 
on February 23, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the duplex scan of extremity veins (93970) provided on 
December 8, 2021. 
 
You asked the Plan to pay for the duplex scan. You say that the service should be paid. The Plan denied your 
request. The Plan says the claim denied correctly. 
 
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. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the duplex scan of extremity veins 
(93970) provided on December 8, 2021. have been met. Specifically, the record shows that the Plan paid 1 unit of procedure code 93970. The provided documentation does not indicate that an additional unit of procedure 
code 93970 was rendered on the date of service in this case.. Therefore, we decided that the Plan does not have 
to pay for the duplex scan of extremity veins (93970) provided on December 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core buildup and crown - porcelain/ceramic services (D2740, 
D2950) provided on February 4, 2022. 
 
You asked the Plan to pay for the core buildup and crown - porcelain/ceramic services. You say that the 
services should be covered as you disagree with the charges. The Plan denied your request. The Plan says the 
services denied correctly as they do not fall within your 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, 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 core 
buildup and crown - porcelain/ceramic services (D2740, D2950) provided on February 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance (D4910), fluoride varnish (D1206), 
and additional periapical x-rays (D0230) provided on December 10, 2021. 
 
You asked the Plan to pay for the periodontal maintenance, fluoride, and x-rays. You say that the services were 
denied because the provider was out of network. The Plan denied your request. The Plan says periodontal 
maintenance (D4910) and fluoride varnish (D1206) are not covered by your supplemental dental benefits. The 
Plan also says that the benefit for the periapical x-rays (D0230) has been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the periodontal maintenance (D4910) 
and fluoride varnish (D1206) are not among those covered under this benefit. Additionally, the record shows 
that the Plan covered one periapical x-ray provided on December 10, 2021. Your dental benefit for periapical 
x-rays has now been exhausted. Therefore, we decided that the Plan does not have to pay for periodontal 
maintenance (D4910), fluoride varnish (D1206), and additional periapical x-rays (D0230) provided on 
December 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implant supported crown (D6066) provided by a 
participating provider. 
 
You asked the Plan to pre-approve an implant supported crown. You say that you would like the Plan to 
approve these services. The Plan denied your request. The Plan says dental implants and all associated services 
are not covered. 
 
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 pre-approve an 
implant supported crown (D6066) provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the add tooth to existing partial denture (D5650) provided 
February 10, 2022. 
 
You asked the Plan to pay for the add tooth to existing partial denture. You say that without the adjustment, 
you might have had to get a more costly new plate create. The Plan denied your request. The Plan says this 
service is not covered under your 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 add 
tooth to existing partial denture (D5650) provided February 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup (dental code D2950) for tooth #20 and #21 
provided on December 9, 2021. 
 
You asked the Plan to pay for the core buildup. You say that all the information was provided so the Plan can 
cover the service that was provided. The Plan denied your request. The Plan says the enrollee's supplementary 
benefits do not cover the service that was provided. 
 
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 core 
buildup (dental code D2950) for tooth #20 and #21 provided on December 9, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services provided to the enrollee 
from August 20, 2021, to October 1, 2021. 
 
You asked the Plan to pay for the services. You say that you rendered treatment in good faith that the service 
would be reimbursed. The Plan denied your request. The Plan says this provider is a non-network provider who 
does not work with the health plan. 
 
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 outpatient mental health services provided to the 
enrollee from August 20, 2021, to October 1, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital care provided from March 22, 2021, to 
March 26, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the clinical 
evidence does not support the diagnosis code. 
 
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 provided with secondary diagnosis G93.49, defined as other 
encephalopathy. 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 services provided. Our 
physician reviewer found that the enrollee presented to the emergency room with lethargy and being minimally 
responsive at the nursing home. A computed tomography (CT) scan of the head noted an acute on chronic 
subdural hematoma. While encephalopathy was documented, the clinical evidence in the medical record did 
not support the diagnosis.  In the emergency department, the enrollee was self-oriented and responded to 
commands.  Her altered mental status was not significantly worse than her baseline. The review has determined 
that the records did not show that the diagnosis at issue was supported.  
 
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 the inpatient hospital care provided from March 22, 2021, to March 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the neuromonitoring services provided on January 31, 2021. 
 
You asked the Plan to pay for the neuromonitoring services. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says this claim cannot be paid due to 
incorrect information listed in the claim form. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules say that if a claim is submitted with 
incomplete or invalid information, it may be returned to the 
submitter as unprocessable. 
 
We looked at the file and Medicare rules. In this case, the documentation indicates that the claim form was 
filled out with an incorrect date of birth.  Based on this information, we decided that Medicare rules for 
coverage of the neuromonitoring services have not been met. 
 
 
  
 Therefore, we decided that the Plan does not have to pay for the neuromonitoring services provided on January 
31, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a genicular nerve block (64454) provided on January 13, 
2022. 
 
You asked the Plan to pay for a genicular nerve block. You say that the services at issue were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met 
because the services at issue are 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 pay for a genicular nerve block. Our reviewer says 
that the services at issue are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that genicular nerve blocks are considered experimental/investigational as their role in the 
treatment of knee osteoarthritis is still being evaluated.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a genicular nerve block have not been met. Therefore, we decided that the Plan 
does not have to pay for a genicular nerve block (64454) provided on January 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for replacement of semi-precision attachment (dental code 
D5867) and custom fabricated abutment (dental code D6057) for teeth #22 and #26 provided on February 8, 2022. 
 
You asked the Plan to pay for replacement of semi-precision attachment and custom fabricated abutment. You 
say that you were having problems with your implants and the provider suggested removable dentures and you 
would like the claim to be covered. The Plan denied your request. The Plan says they paid for the dentures and 
the codes that were billed by the provider are not a covered benefit under the supplementary benefit category; 
therefore, the claim was processed correctly. 
 
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 
replacement of semi-precision attachment (dental code D5867) and custom fabricated abutment (dental code 
D6057) for teeth #22 and #26 provided on February 8, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve anesthesia for diagnostic or therapeutic nerve blocks 
and injections (01992) for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that the patient is in pain and in need of injection. 
The Plan denied your request. The Plan says that records do not document the rationale for anesthesia. 
 
The Plan must follow Medicare rules. Medicare rules say that general anesthesia is considered not medically 
reasonable and necessary for facet joint interventions absent any unique circumstances.  
 
We looked at the file and Medicare rules. No rare or unique circumstance has been presented for the medical 
necessity of the requested general anesthesia in conjunction with the facet joint injections. 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 pre-approve anesthesia for diagnostic or therapeutic nerve blocks and 
injections (01992) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve replacement dentures. 
 
You asked the Plan to pre-approve replacement dentures. You say that the original dentures did not fit correctly 
and the provider who made the dentures said there was nothing they could do. The Plan denied your request. 
The Plan says the denial of the authorization for this service is correct because the documentation indicates that 
the members current dentures are less than 60 months old therefore, replacement dentures is not a covered 
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. The plan covers replacement 
dentures once every 60 months. 
 
  We looked at the file, the Plans rules, and Medicare rules. You previously received a dentures on July 9, 2020; 
therefore, the replacement benefit would not be covered until July 9, 2025. Therefore, we decided that the Plan 
does not have to pre-approve replacement dentures.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on 
February 7, 2022. 
 
You asked the Plan to pay for an oral evaluation. You say that you were traveling and needed emergency dental 
services. The Plan denied your request. The Plan says this service is covered by the Plan's dental benefits; 
however, your benefit for one procedure every three plan years has been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers one 
comprehensive oral evaluation (D0150) once every three plan years. 
 
We looked at the case file, the Plan's rules, and Medicare rules. The record shows the Plan paid for a 
comprehensive oral evaluation on February 15, 2021; therefore, the benefit for a comprehensive oral 
evaluation has been exhausted. Therefore, we decided that the Plan does not have to pay for a 
comprehensive oral evaluation (D0150) provided on February 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for (D5650) adding a tooth to existing partial denture performed 
on January 18, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental coverage. 
 
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 (D5650) 
adding tooth to existing partial denture provided on January 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve deep medicated filling in tooth (dental code D3120) for 
teeth #18, #29, and #31. 
 
You asked the Plan to pre-approve deep medicated filling in tooth. You say that the caps should be covered by 
the dental coverage. The Plan denied your request. The Plan says the code is not listed in the coverage; 
therefore, it is excluded and there is no exception to approve the dental code. 
 
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 pre-approve deep 
medicated filling in tooth (dental code D3120) for teeth #18, #29, and #31.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an occlusal guard (D9944) provided on February 15, 2022. 
 
You asked the Plan to pay for a guard. You say that you believed this should be covered at 50% for the cost of 
manufacturing and fitting the device. The Plan denied your request. The Plan says that an occlusal guard 
(D9944) is not covered by your Plan's dental 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. 
 
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 an 
occlusal guard (D9944) provided on February 15, 2022.