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

 
We decided that the Plan does not have to pay for the coronavirus testing (U0003, U0005) provided on August 
24, 2021. 
 
You asked the Plan to pay for the laboratory testing. You say that the services should be covered. 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 coronavirus testing (U0003, U0005) provided on August 
24, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Laboratory services provided on December 21, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for Laboratory services. You say that you would like to appeal the denial of the 
claim. The Plan denied your request. The Plan says prior authorization is required for an out-of-network visit. 
 
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 Laboratory services provided on December 21, 
2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic interventions that focus on cognitive function 
provided on February 26, 2020. 
 
You asked the Plan to pay for therapeutic interventions that focus on cognitive function. The Plan denied your 
request. The Plan says experimental services 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 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 therapeutic interventions that focus on 
cognitive function. Our reviewer says that the requested therapeutic interventions that focus on cognitive 
function are not considered medically reasonable and necessary in this case. Our physician reviewer found that 
based on the medical records provided and review of the current medical literature on cognitive training there is 
no documentation that the therapeutic interventions that focus on cognitive function (97129, 97130) at issue in 
this case meet Medicare criteria for medically reasonable and necessary. Present studies do not show a lasting 
therapeutic or preventive benefit for cognitive decline or dementia for cognitive training programs outside of 
one study (the ACTIVE trial) and further follow-up is needed on this study as well; the services provided to the 
enrollee on February 26, 2020 do not appear to be consistent with the training program described in the 
ACTIVE trial.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of therapeutic interventions that focus on cognitive function have not been met. 
Therefore, we decided that the Plan does not have to pay for therapeutic interventions that focus on cognitive 
function (97129, 97130) provided on February 26, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Trinity Evolution Allograft (20930). 
 
You asked the Plan to pre-approve Trinity Evolution Allograft (20930). You say that the requested Trinity 
Evolution Allograft (20930) is medically necessary. The Plan denied your request. The Plan says the requested 
Trinity Evolution Allograft (20930) is not medically necessary. 
 
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 Trinity Evolution Allograft (20930). 
Our reviewer says that the requested Trinity Evolution Allograft (20930) is not medically necessary. Our 
physician reviewer found Trinity allograft is experimental in spine surgery. Iliac crest bone graft is the gold 
standard. The requested Trinity Evolution Allograft (20930) is not medically necessary in this case. 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Trinity Evolution Allograft (20930) have not been met. Therefore, we decided 
that the Plan does not have to pre-approve Trinity Evolution Allograft (20930).
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99204) and destruction of benign lesions 
(17110) provided on November 8, 2021. 
 
You asked the Plan to pay for the office visit and destruction of benign lesions. You say that you would like 
reconsideration because these services were not related to the enrollee's hospice diagnosis. The Plan denied 
your request. The Plan says the enrollee was enrolled in hospice on the billed date of service. 
 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 office visit (99204) and destruction of benign lesions 
(17110) provided on November 8, 2021.
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 this is medically necessary. The Plan denied your 
request. The Plan says the enrollee would be more appropriately placed in a subacute rehabilitation setting, 
where standard nursing care, supportive custodial care, and ongoing therapy can be received until safe for 
discharge to the home setting. 
 
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 has lumbar spinal stenosis and is status post spinal surgery. The enrollee 
does not meet the coverage criteria for this admission. On a review of the available records, the enrollee is 
medically stable, and does not need physician close supervision three times per week (at a minimum) for the 
ongoing management of any active or acute exacerbations of chronic medical conditions. There are no rehab 
nursing needs identified or documented in the record. At the current functional level, the enrollee does not need 
3 hours a day five days a week of IRF therapies with interdisciplinary management and the rehab needs can be 
met in an alternate and lower setting such as in a skilled nursing facility (SNF) with therapies as needed. IRF 
admission is not medically necessary based on medical stability, lack of medical complexity, and lack of rehab 
nursing needs and current functional level. The services can be safely provided at a lower intensity and 
alternate setting such as in an SNF or in-home with 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 pay for the home infusion therapy rendered on December 1, 2021 to 
December 7, 2021. 
 
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. The file shows that home infusion therapy services 
were rendered. 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 December 1, 2021 to December 7, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve the continuation of SNF care. You say that SNF care is medically 
reasonable and necessary. The Plan denied your request. The Plan says the criteria for SNF care are no longer 
met. 
 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 the continuation of SNF care. Our 
reviewer says that daily skilled services are not necessary. Our physician reviewer found there is no 
documentation that the patient requires skilled nursing services, i.e., the specialized skill, knowledge and 
judgment of a skilled professional nurse are not required to safely and effectively provide medically necessary 
and reasonable treatment. Records do not document the need for intravenous medications, new tube feeding or 
ostomy care or daily complex wound care. While this patient does require skilled therapy services, these 
services are not required on a daily basis. In conclusion, there is no documentation that the patient requires the 
services on an inpatient basis, only in a skilled nursing facility setting. Records do not document that services 
in the home with home health care or in a long-term care facility on a part time basis are not appropriate in this 
case. 
 
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 continuation of SNF care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fixed partial denture sectioning (D9120) provided on 
November 30, 2021. 
 
You asked the Plan to pay for the dental service. You say that you were advised you need an extraction and 
would require sectioning of a bridge. You say that you were advised the procedure would be covered at 100%. 
You also say that you were given misinformation regarding how much the service would cost you. The Plan 
denied your request. The Plan says fixed partial denture sectioning is not listed and therefore is not a covered 
service. 
 
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 fixed partial denture sectioning is 
not among those covered under this benefit.  
 
Therefore, we decided that the Plan does not have to pay for the fixed partial denture sectioning (D9120) 
provided on November 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the three removals of impacted teeth (D7220 x3) provided on 
October 29, 2021. 
 
You asked the Plan to pay for the removals of impacted teeth. You say that you contacted the Plan and were 
told extractions would be covered. The Plan denied your request. The Plan says this service is not a covered 
expense under your dental plan. The Plan says that neither you nor the provider contacted the Plan prior to the 
date of this service to verify benefits. The Plan also says that when you did previously contact the Plan on May 
17, 2021, you inquired about providers and were told that dentures would not be 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 pay for the three 
removals of impacted teeth (D7220 x3) provided on October 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for complete radiographic imaging (D0210) provided by a 
participating provider on January 25, 2022. 
 
You asked the Plan to pay for complete radiographic imaging. You say that you would like the Plan to pay for 
this. The Plan denied your request. The Plan says D0210 is not a covered dental benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for complete 
radiographic imaging (D0210) provided by a participating provider on January 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oncology (prostate), mRNA (81542) microdissection (ie, 
sample preparation of microscopically identified target) (88381) provided August 18, 2021.  
You asked the Plan to pay for the laboratory services. You say that you ask for review of all enclosed 
information and reconsider the payment, as well as application of in-network benefit design. The Plan denied 
your request. The Plan says the procedure/diagnosis is not correct for patient gender. 
 
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 find that CPT codes 81542 and 88381 are not supported in the medical record. Specifically, 
physicians and non-physician practitioners should use modifier KX with procedure codes that are gender 
specific in the particular cases of transgender, ambiguous genitalia, and hermaphrodite beneficiaries. Therefore, 
if a gender/procedure or gender/diagnosis conflict edit occurs, the KX modifier alerts the MAC that it is not an 
error and will allow the claim to continue with normal processing. Based on this information, we decided that 
Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pay for oncology (prostate), mRNA (81542) microdissection (ie, sample preparation of 
microscopically identified target) (88381) provided August 18, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xiidra 5% drops. 
 
You asked the Plan to pre-approve Xiidra. You say that this drug is medically necessary for the enrollee's 
condition. The Plan denied your request. The Plan says this drug is not covered under the enrollee's medical 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered 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 pre-approve Xiidra 5% drops.  
 
Benefits for Xiidra 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the 3 fillings provided on November 16, 2021. 
 
You asked the Plan to pay for the dental services. You say that you have dental insurance. You say that the 
dentist had to practically rebuild the whole tooth back. You say that your tooth was broken off down to the gum 
line. You also say that you lost the filling on your front tooth. The Plan denied your request. The Plan says the 
claim denied 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 and 1 filling is covered per calendar 
year, the frequency limit has been exceeded.  
 
The record shows that the Plan paid for a filling that you received on April 6, 2021. Therefore, we decided that 
the Plan does not have to pay for the 3 fillings provided on November 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the removal of torus mandibularis (D7473), extraction, 
erupted tooth requiring removal of bone (D7210), extraction, erupted tooth or exposed root (D7140), limited 
oral evaluation - problem focused (D0140), deep sedation/general anesthesia - first 15 minutes (D9222), deep 
sedation/general anesthesia - each subsequent 15 minute increment (D9223), alveoloplasty not in conjunction 
with extraction - per quadrant (D7320) provided June 12, 2021, and July 24, 2021. 
 
You asked the Plan to pay for the removal of torus mandibularis, tooth extractions, limited oral exam, general 
anesthesia and alveoloplasty. You say that you were told the cost of extraction and dentures would be covered. 
The Plan denied your request. The Plan says these services were denied 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. The Plan covers two oral 
surgeries and two oral exam per calendar year. This benefit includes a $3,000 dental annual maximum.  
 
We looked at the file and Medicare rules. The Plan provided documentation showing that they previously 
covered two oral surgeries and two oral exams. Based on this information, we decided that the two 
alveoloplasty on June 12, 2021, and the limited oral exam on July 24, 2021, have exceeded the frequency limits 
for these services. The removal of torus mandibularis is not listed as a covered service under your benefits. The 
Plan has also provided documentation explaining that your full $3,000 annual dental maximum has been 
applied to services provided to you on April 12, 2021, and June 12, 2021. Therefore, no additional payment 
from the Plan is due. Therefore, we decided that the Plan does not have to pay for the removal of torus 
mandibularis (D7473), extraction, erupted tooth requiring removal of bone (D7210), extraction, erupted tooth 
or exposed root (D7140), limited oral evaluation - problem focused (D0140), deep sedation/general anesthesia - 
first 15 minutes (D9222), deep sedation/general anesthesia - each subsequent 15 minute increment (D9223), 
alveoloplasty not in conjunction with extraction - per quadrant (D7320) provided June 12, 2021, and July 24, 2021.  
 
Your complaint about potentially receiving misinformation 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: Unfavorable

 
We decided that the Plan does not have to pre-approve the removal of a mass in the right cheek to be provided 
by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the OON removal of a mass in the right cheek. You say that the enrollee is 
going through infections and needs the service being requested. The Plan denied your request. The Plan says 
there are network providers within a reasonable distance from the enrollee's location that can provide the 
service being requested. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the removal of a mass in the right cheek to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on July 12, 2021. 
 
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 there is no valid physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 
We looked at the file and Medicare rules. The file does not contain documentation of an established 
relationship between the enrollee and the ordering provider. Without a record showing that this provider is 
treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the laboratory services rendered on July 12, 2021.