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

 
We decided that the Plan does not have to pay for bitewings (D0270), intraoral imaging (D0220 and D0230), a 
crown (D2740), and a core build-up (D2950), provided by a participating provider on January 7, 2022. 
 
You asked the Plan to pay for bitewings, intraoral imaging, a crown, and a core build-up. You say that the Plan 
should pay for this. The Plan denied your request. The Plan says these services have been correctly denied. 
 
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 bitewings, 
intraoral imaging, a crown within limitations. 
 
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of bitewings, intraoral imaging, a crown have not been met. A core build-up is not a covered dental 
service. Therefore, we decided that the Plan does not have to pay for bitewings (D0270), intraoral imaging 
(D0220 and D0230), a crown (D2740), and a core build-up (D2950), provided by a participating provider on 
January 7, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the duplex scan (93976) provided on December 6, 2021. 
 
You asked the Plan to pay for code 93976. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered as 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, we have confirmed that code 93976 
is a column II code to column I code 76856. The medical records provided do not show that the service billed 
with the -59 modifier is a distinct procedural service.  Based on the claim submitted, Medicare billing criteria 
have not been met. Therefore, we decided that the Plan does not have to pay for the duplex scan (93976) 
provided on December 6, 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 specialists have stated that the enrollee needs IRF 
services for adequate treatment. The Plan denied your request. The Plan says the enrollee does not meet the 
requirements for approval. 
 
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 complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for an 
intensive rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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 the resin-based composite - two surfaces, anterior (D2331) 
and resin-based composite - two surfaces, posterior (D2392) provided January 5, 2022. 
 
You asked the Plan to pay for the resin-based fillings. You say that these services were medically necessary. 
The Plan denied your request. The Plan says these services are 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 resin-
based composite - two surfaces, anterior (D2331) and resin-based composite - two surfaces, posterior (D2392) 
provided January 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an out-of-network provider on 
January 12, 2022. 
 
You asked the Plan to pay for dental services. You say that this was preventative care. The Plan denied your 
request. The Plan says the claim has been processed correctly. 
 
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. 
 
We looked at the file and Medicare rules. When you see an out-of-network provider you may be billed more 
than what the Plan will pay. Based on this information, we decided that the Plan's rules for coverage of dental 
services have not been met. Therefore, we decided that the Plan does not have to pay for dental services 
provide by an out-of-network provider on January 12, 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 IRF care is medically necessary so the enrollee can 
return home and remain independent. The Plan denied your request. The Plan says criteria for admission to the 
IRF setting have not been met. 
 
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 complexity of the enrollees nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does 
support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-
disciplinary rehabilitation program. There is not a reasonable expectation that the enrollee will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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 a pre-diagnostic test (D0431) provided on February 11, 2022, 
and conscious sedation (D9248) provided on February 18, 2022. 
 
You asked the Plan to pay for testing and sedation. You say that you are on a fixed income and need the dental 
services. The Plan denied your request. The Plan says that a pre-diagnostic test (D0431) and conscious sedation 
(D9248) are not covered by your routine 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 a pre-
diagnostic test (D0431) provided on February 11, 2022, and conscious sedation (D9248) provided on February 18, 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 you need rehabilitation in order to function and 
complete daily activities on your own. The Plan denied your request. The Plan says you do not meet the 
requirements for approval. 
 
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 complexity of your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While you have a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. 
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the over the counter COVID-19 testing kits provided on 
January 27, 2022. 
 
You asked the Plan to pay for the over the counter COVID-19 testing kits. You say that the provided 
information says you can be reimbursed for the COVID-19 testing kits that you purchased. The Plan denied 
your request. The Plan says people with Medicare will not be eligible to be reimbursed for tests purchased 
before April 4, 2022. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare will only pay for claims with dates of 
service starting on or after April 4, 2022, through the last day of the COVID-19 public health emergency 
(PHE), and claims should be submitted to Original Medicare for patients enrolled in a Medicare Advantage 
(MA) plan.  
 
We looked at the file and Medicare rules. Over the counter (OTC) tests for dates of service April 4, 2022 and 
after are paid for. OTC tests before April 4, 2022 are only covered if the Plan has a supplemental benefit for 
them. Centers for Medicare & Medicaid Services (CMS) instructs that for a Medicare Advantage beneficiary, 
the claim for the test should be submitted to Original Medicare instead of the Plan. Therefore, we decided that 
the Plan does not have to pay for the over the counter COVID-19 testing kits provided on January 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81321, 81206, 81210, 81235, 81272, 
81275, 81276, 81292, 81301, and 81311) provided on April 19, 2021. 
 
You asked the Plan to pay for codes 81321, 81206, 81210, 81235, 81272, 81275, 81276, 81292, 81301, and 
81311. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your 
request. The Plan says the services are not covered as 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. 
 
We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT code 81479. Therefore, we decided that the Plan does not have 
to pay for the laboratory services (81321, 81206, 81210, 81235, 81272, 81275, 81276, 81292, 81301, and 
81311) provided on April 19, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve massage therapy. 
 
You asked the Plan to pre-approve massage therapy. You say that the services are necessary. The Plan denied 
your request. The Plan says the requested services are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore, 
we decided that the Plan does not have to pre-approve massage therapy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to for oral surgery provided on January 20, 2020. 
 
You asked the Plan to pay for oral surgery. You say that you feel the charges should be covered. The Plan 
denied your request. The Plan says the provider opted out of Medicare and is not eligible for payment. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for oral 
surgery provided on January 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cone beam CT image capture (D0383) provided by a 
participating provider on May 11, 2021. 
 
You asked the Plan to pay for a cone beam CT image capture. You say that the Plan should pay for this. The 
Plan denied your request. The Plan says the rendered dental work 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. 
 
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 cone 
beam CT image capture (D0383) provided by a participating provider on May 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an intraoral x-ray (D0220), additional 
intraoral x-ray (D0230), a limited oral evaluation (D0140) provided on December 13, 2021. 
 
You asked the Plan to waive the coinsurance for x-rays and an evaluation. You say that services were 
preventive and should have been covered at 100%. You also say this provider shows in-network on the website 
and provider handbook. The Plan denied your request. The Plan says you have been charged the correct cost 
sharing amount. 
 
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 you must pay 50% 
coinsurance of provider's billed charges for preventive and diagnostic dental services.  
 
The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay a 
total of $76.50, which is 50% coinsurance of provider's billed charges for x-rays and an evaluation. 
 
Code Billed Charges 50% Coinsurance 
D0220 $37 $18.50 
D0230 $28 $14 
D0140 $88 $44 
Total $153 $76.50 
 
Intraoral x-rays and an evaluation fall 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 waive the coinsurance for an intraoral x-ray (D0220), additional intraoral x-ray (D0230), a limited oral 
evaluation (D0140) provided on December 13, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary. The Plan 
denied your request. The Plan says an IRF admission is not medically necessary. 
 
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 complexity of your nursing, medical and rehabilitation needs does not require 
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
a fall, respiratory failure, and cord compression. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While you have a need for 
physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. 
 
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 IRF admission and services.
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 enrollee remains high risk for further 
decline and needs daily physician oversight with around the clock nursing and respiratory care. The Plan 
denied your request. The Plan says the enrollee is receiving appropriate inpatient care at the current hospital. 
 
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 does not require services at the LTACH that are not already available at 
the current facility. Transfer to LTACH is not medically necessary as it would not be clinically advantageous. 
Completion of treatment at the current facility is recommended. 
 
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: Testing
Decision: Favorable

 
We decided that the Plan has to pay for the head and neck ultrasound provided by the facility on February 16, 
2021, billed with code 76536. 
 
You asked the Plan to pay for the ultrasound services as billed. You say that these services are separately 
payable. The Plan denied your request. The Plan says that our records show procedure code 74177 was 
rendered in this facility on 02/16/2021 and paid. The appealed procedure code 76536 was rendered on the same 
date of service from this facility. Per Medicare Claims Processing Manual, Chapter 4 Sections 10.3 and 10.4, 
procedure code 76536 is considered included in allowable for 74177 and should not be separately reimbursed. 
 
The Plan must follow Medicare rules. Medicare rules say that OPPS packaging rules state that payment for 
certain types of procedures is included in payment for other services. One type of OPPS packaging is STV-
packaging. In this type, codes assigned status indicator (SI) Q1 are only separately payable if they are not billed 
with a code with an S, T, or V status indicator. Codes assigned status indicator Q3 are packaged into composite 
APC groups when billed with other Q3 procedures.  
 
We looked at the file and Medicare rules. In this case, the procedure billed on the claim being referenced by the 
Plan is 74177 which has an SI of Q1. This was billed on the same date of service as 76536 which does not have 
an SI of S, T, or V. This is a Q3 code, which means that neither of these codes would be packaged with the 
other. As such, both codes are separately payable per OPPS rules. Based on this information, we decided that 
Medicare rules for coverage of the ultrasound services as billed have been met. Therefore, we decided that the 
Plan has to pay for the head and neck ultrasound provided by the facility on February 16, 2021, billed with 
code 76536.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a shower chair provided on October 25, 2021. 
 
You asked the Plan to pay for a shower chair. You say that  The Plan denied your request. The Plan says this 
item is not a covered benefit. 
 
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 pay for a shower chair provided on October 25, 
2021.