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

 
We decided that the Plan does not have to pay for an extraction, erupted tooth or exposed root (D7140) 
provided on July 26, 2022. 
 
You asked the Plan to pay for an extraction. You say that your face was swollen up to your eyes and the pain 
was extraordinary. You also say that you had to have the extraction done. The Plan denied your request. The 
Plan says an extraction (D7140) is not covered by 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, an extraction is not among those 
covered under this benefit.  Therefore, we decided that the Plan does not have to pay for an extraction, erupted 
tooth or exposed root (D7140) provided on July 26, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing provided on November 23, 2021, billed with codes 81206, 81210, 81235, 81275, 81276, 81292, 81295, 81298, 81301, 81317, 81401, 81194 and 81309.

You asked the Plan to pay for the genetic testing billed. You say that you would like this claim reprocessed based on the medical records. The Plan denied your request. The Plan says this claim has not been billed as required by Medicare billing regulations.

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 November 23, 2021, billed with codes 81206, 81210, 81235, 81275, 81276, 81292, 81295, 81298, 81301, 81317, 81401, 81194 and 81309.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical removal of implant body, tooth #27 (D6100). 
 
You asked the Plan to pre-approve the surgical removal of implant body, tooth #27 (D6100). You say that you 
are asking for a review and to reconsider the coverage. The Plan denied your request. The Plan says these 
services are not covered under the benefit package. 
 
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 
surgical removal of implant body, tooth #27 (D6100).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for apicoectomy  molar (first root) (D3425) and retrograde 
filling  per root (D3430) tooth #3 provided on April 28, 2022. 
 
You asked the Plan to pay for dental services. You say that you had the procedure done to help relieve sinus 
issues. This was done to help your medical health. The Plan denied your request. The Plan says this service is 
not covered under your Plan. 
 
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. Apicoectomy  molar (first 
root) (D3425) and retrograde filling  per root (D3430) are not covered under the Plans dental benefits. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested apicoectomy  molar 
(first root) (D3425) and retrograde filling  per root(D3430) tooth #3 are not among those covered under this 
benefit. Therefore, we decided that the Plan does not have to pay for apicoectomy  molar (first root) (D3425) 
and retrograde filling  per root(D3430) tooth #3 provided on April 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for adding a clasp to an existing partial denture on tooth #10 
provided on February 9, 2022. 
 
You asked the Plan to pay for adding a clasp to an existing partial denture on tooth #10. You say that you were 
told on February 9, 2022, that the requested code required a one-hundred eighty day waiting period. The Plan 
denied your request. The Plan says the claim was paid correctly as there is a $60.00 copayment for adding a 
clasp to an existing partial denture. 
 
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 adding a 
clasp to an existing partial denture on tooth #10 provided on February 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bone replacement graft (D7953) and non-intravenous 
conscious sedation (D9248) provided by a participating provider on April 26, 2022. 
 
You asked the Plan to pay for a bone replacement graft and non-intravenous conscious sedation. You say that 
the Plan should pay up to $2,000 for dental services. The Plan denied your request. The Plan says the rendered 
dental services are not covered 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 a bone 
replacement graft (D7953) and non-intravenous conscious sedation (D9248) provided by a participating 
provider on April 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a gingivectomy or gingivoplasty (D4212) provided on June 
23, 2022. 
 
You asked the Plan to pay for a gingivectomy or gingivoplasty (D4212). You say that you always let a doctor 
know to only do the procedure that your insurance is willing to pay for, nothing more. You also say you were 
surprised that you did not get an itemized breakdown of what your payment would be for this procedure. The 
Plan denied your request. The Plan says they do not include coverage for any services not specifically listed in 
the coverage information. 
 
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 a 
gingivectomy or gingivoplasty (D4212) provided on June 23, 2022.  
 Your complaint about the potentially poor customer services by the provider and his office 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 pre-approve a core buildup (D2740) and a porcelain/ceramic crown 
(D2950) on tooth #30. 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered. The Plan 
denied your request. The Plan says the enrollee does not have comprehensive dental benefits. The requested 
services are not covered under the basic dental package. 
 
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 a 
core buildup (D2740) and a porcelain/ceramic crown (D2950) on tooth #30.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for  the bath/shower chair, with or without wheels, any size 
(E0240) and shower hose (E1399) purchased March 25, 2022. 
 
You asked the Plan to pay for the shower chair and hose. You say that it was medically necessary for you to 
have this equipment after surgery. The Plan denied your request. The Plan says these are hygienic equipment 
and is not primarily medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pay for  the bath/shower chair, with or without wheels, any size (E0240) 
and shower hose (E1399) purchased March 25, 2022.
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 the reason for referral to IRF level of care was 
skilled therapy. The Plan denied your request. The Plan says the member does not meet the Medicare criteria 
for admission to an IRF. 
 
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 patient does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. Our physician reviewer also 
found that medically necessary care can be provided in a different level of 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 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve six physical therapy visits. 
 
You asked the Plan to pre-approve therapy visits. You say that the enrollee has not improved enough to 
discharge. The Plan denied your request. The Plan says that additional therapy is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that the enrollee has had prior therapy and the documentation does not 
reveal that the enrollee requires the unique skills of a professional therapist to provide treatment safely and 
effectively. The enrollee can transition to an independent home exercise program at this point. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of therapy visits have not been met. Therefore, we decided that the Plan does not 
have to pre-approve six physical therapy visits.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) admission provided 
September 8, 2021 
 
You asked the Plan to pay for the SNF admission. You say that the services you received were medically 
necessary and you had to be admitted. You were surprised to find that you were not covered. The Plan denied 
your request. The Plan says the enrollee did not meet all of the criteria for SNF admission. Prior authorization 
was required before services being rendered. 
 
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 skilled nursing facility (SNF) admission provided September 8, 2021 have been met. The Plan made multiple attempts to obtain the medical 
records without success. The Plan did not pre-approve the item/service at issue. Therefore, we decided that the 
Plan does not have to pay for the skilled nursing facility (SNF) admission provided September 8, 2021
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 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 care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found records do not document the need for intravenous medications, new tube feeding, 
ostomy care, daily complex wound care or respiratory care. There is no documentation that further daily skilled 
services are required. The enrollee is walking household distances with a wheeled walker with contact guard 
assistance and is contact guard assist for transfers. Provided records do not document a significant decline in 
the enrollees functional status to necessitate further daily inpatient skilled therapy services. The enrollee does 
not require the services on an inpatient basis, only in a skilled nursing facility setting. Records do not support 
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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair (E0240). 
 
You asked the Plan to pre-approve a shower chair. You say that you cannot function without a shower chair. 
You have cracked pelvic bones and will not fully heal without a shower chair. The Plan denied your request. 
The Plan says shower chairs are not covered because they are considered comfort or convenience 
items/hygienic equipment that is not primarily medical in nature. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair (E0240).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental services. 
 
You asked the Plan to pre-approve the dental services. You say that the services requested are medically 
necessary. The Plan denied your request. The Plan says the services requested are not covered 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 pre-approve the 
dental services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
June 15, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service June 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on March 28, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on March 
28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an electroencephalogram (EEG) (procedure code 95720) 
provided to the enrollee on March 18, 2022. 
 
You asked the Plan to pay for the EEG. You say that this should be paid for. The Plan denied your request. The 
Plan says the records do not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code  is "Electroencephalogram (EEG), continuous recording, 
physician or other qualified health care professional review of recorded events, analysis of spike and seizure 
detection, each increment of greater than 12 hours, up to 26 hours of EEG recording, interpretation and report 
after each 24-hour period; with video (VEEG)." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the EEG. Our reviewer says that the services at issue in this 
case were not supported by the medical records. Our reviewer found that procedure code 95720 is not 
documented in the records.  
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the EEG have not been met. Therefore, we decided that the Plan does not have 
to pay for an electroencephalogram (EEG) (procedure code 95720) provided to the enrollee on March 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on March 15, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the lab services. You say that you do not understand why these lab services were 
not covered. The Plan denied your request. The Plan says unauthorized, out-of-network services are not 
covered. 
 
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 lab you used in this case is not a network provider with the Plan. 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 lab services provided on March 15, 2022, by an 
out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
April 21, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service April 21, 2022.