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

 
We decided that the Plan does not have to pay for the genetic testing described by codes 81206 and 81321 
provided on September 7, 2021. 
 
You asked the Plan to pay for the genetic testing as billed. You say that this is medically necessary testing. The 
Plan denied your request. The Plan says this testing was performed without being ordered by the physician 
listed. Therefore, only 12 of the 14 billed line items are approved for payment. 
 
The Plan must follow Medicare rules. Medicare 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 is an NGS testing panel and 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 
as billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing 
described by codes 81206 and 81321 provided on September 7, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from June 11, 2021, to 
June 30, 2021. 
 
You asked the Plan to pay for the home health services. You say that the claim was submitted. The Plan denied 
your request. The Plan says the claim denied correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that all Home Health Agencies (HHAs) must submit 
a request for anticipated payment (RAP) within 5 calendar days after the start of care date for initial 30-day 
periods and within 5 calendar days after the from date for each subsequent 30-day period of care, which is set 
at 0 percent at the beginning of every 30-day period. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health services have not been met. Specifically, the record indicates the RAP was not 
submitted within 5 days of the from the start of care date, June 11, 2021. Therefore, we decided that the Plan 
does not have to pay for the home health services provided from June 11, 2021, to June 30, 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 the enrollee is receiving adequate and necessary intensive rehabilitation 
in the Inpatient Rehabilitation Facility. 
 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 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health physical therapy visits. 
 
You asked the Plan to pre-approve home health care. You say that you are appealing this denial. The Plan 
denied your request. The Plan says the denial of authorization for home health care is correct. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 
 
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 home health care. Our reviewer says 
that you do not meet the Medicare criteria for the requested home health. Our physician reviewer found you do 
not have documented home health physical therapy needs. You are functioning at a level commensurate with a 
lower level of care such as outpatient therapy or a home exercise program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health care have not been met. Therefore, we decided that the Plan does 
not have to pre-approve home health physical therapy visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional payment for the occlusal guard  hard appliance, 
full arch (D9944) provided January 27, 2022. 
 
You asked the Plan to provide additional payment for the bite guard. You say that the receptionist at the dental 
office said the bite guard would be covered in full. The Plan denied your request. The Plan says you have 
exhausted your dental benefit and no further payment is due. 
 
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 the bite guard 
up to a $1,000 allowance every year.  
 
We looked at the file and Medicare rules. The Plan provided documentation showing that at the time the claim 
processed you had $552 remaining in your annual dental allowance. This amount was applied to the claim. You 
have been asked to pay the remaining amount over the allowance ($167). Therefore, we decided that the Plan 
does not have to provide additional payment for the occlusal guard  hard appliance, full arch (D9944) 
provided January 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core build up (D2950) provided on December 28, 2021. 
 
You asked the Plan to pay for core build up. You say that you do not think you should be responsible for this 
claim since the provider was on the Plan's list of in-network providers. The Plan denied your request. The Plan 
says that core build up (D2950) 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, 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 build 
up (D2950) provided on December 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodic oral evaluation (D0120) and prophylaxis-adult 
(D1110) provided on December 30, 2021. 
 
You asked the Plan to pay for periodic oral evaluation (D0120) and prophylaxis-adult (D1110). You say that 
you did not realize there was a limit on how often you could have the evaluation and prophylaxis. The Plan 
denied your request. The Plan says the service is covered but limitations apply. 
 
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. Preventive dental services 
benefit includes periodic oral, limited oral evaluation, comprehensive oral exam - two every calendar year. 
 
We looked at the file, the Plan's rules, and Medicare's rules. You previously received covered periodic oral 
evaluations on January 7, 2021, and July 16, 2021, and received covered dental prophylaxis (cleanings) on 
January 7, 2021, and September 3, 2021. Therefore, these benefits were exhausted as of December 30, 2021. 
Therefore, we decided that the Plan does not have to pay for periodic oral evaluation (D0120) and prophylaxis-
adult (D1110) provided on December 30, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing care provided in the home on December 22, 
2021, billed with code S9123. 
 
You asked the Plan to pay for the nursing care as billed. You say that this should be paid due to medical 
necessity. The Plan denied your request. The Plan says this is not a valid code for home health billing. 
 
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 CPT code S9123 has a Status Indicator of I on the Physician Fee Schedule. This means that CPT 
code S9123 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the nursing care as billed have not been met. Therefore, we decided that the Plan does not have to 
pay for the nursing care provided in the home on December 22, 2021, billed with code S9123.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core build up on tooth #30 (D2950), porcelain crown on 
tooth #30 (D2740), and deep gum and root cleaning (D4341). 
 
You asked the Plan to pre-approve core build up, crown, and deep cleaning. You say that you need to continue 
with the dental care. The Plan denied your request. The Plan says that core build up (D2950), crown (D2740), 
and a deep cleaning (D4341) are 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 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 pre-approve core 
build up on tooth #30 (D2950), porcelain crown on tooth #30 (D2740), and deep gum and root cleaning (D4341).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve abutment supported cast metal crown (predominantly 
base metal) (dental code D6063) for teeth #6, #7, #8, #9, #10, #11, and #12. 
 
You asked the Plan to pre-approve abutment supported cast metal crown (predominantly base metal). You say 
that you started the process, and you need the coverage to be approved. The Plan denied your request. The Plan 
says The Plan says the denial of authorization for this service is correct, because abutment supported cast metal 
crown are not covered by the 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. 
 
  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 
abutment supported cast metal crown (predominantly base metal) (dental code D6063) for teeth #6, #7, #8, #9, 
#10, #11, and #12.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the complete lower denture (D5751) provided by an 
out-of-network provider on February 8, 2022. 
 
You asked the Plan to pre-approve the complete lower denture (D5751). You say that the denture adjustments 
are necessary because your gums have receded, and your dentures are loose causing mouth sores. The Plan 
denied your request. The Plan says the service 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 complete lower denture (D5751) is 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
the complete lower denture (D5751) provided by an out-of-network provider on February 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services provided on January 20, 2022. 
 
You asked the Plan to pay for anesthesia services. You say that you can't afford the out-of-pocket cost. The 
Plan denied your request. The Plan says the service is 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 anesthesia is not covered 
under this benefit as the extractions were not covered under Original Medicare. Therefore, we decided that the 
Plan does not have to pay for anesthesia services provided on January 20, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ascending aorta graft (33864) provided on December 29, 2021. 
 
You asked the Plan to pay for an ascending aorta graft. You say that you have provided medical records to 
support the service billed. The Plan denied your request. The Plan says rules for payment have not been met 
because the medical record does not support the service 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 33864 is "Ascending aorta graft, with cardiopulmonary 
bypass with valve suspension, with coronary reconstruction and valve-sparing aortic root remodeling 
(eg, David Procedure, Yacoub Procedure)." 
 
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 an ascending aorta graft. Our reviewer says that the CPT 
code at issue does not meet criteria for payment in this case. Our reviewer found that CPT code 33864 cannot 
be verified from the available medical record. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an ascending aorta graft have not been met. Therefore, we decided that the Plan 
does not have to pay for an ascending aorta graft (33864) provided on December 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a radiofrequency ablation procedure (64625). 
 
You asked the Plan to pre-approve the radiofrequency ablation procedure. You say that this procedure is 
medically necessary. The Plan denied your request. The Plan says this procedure is experimental and non-
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 pre-approve the radiofrequency ablation procedure. 
Our reviewer says that the requested services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the requested procedure is considered experimental because of the wide 
variation in efficacy reported in the literature. 
 
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 radiofrequency ablation procedure have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a radiofrequency ablation procedure (64625).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical assistant services for an instrumentation removal 
(22852-AS-59), spinal fusion exploration (22830-AS-XS), a transpedicular approach (63056-AS), and anterior 
instrumentation (22845-AS-59) provided on December 29, 2020. 
 
You asked the Plan to pay for surgical assistant services. You say that these services are documented. The Plan 
denied your request. The Plan says these codes are not supported. 
 
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 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 surgical assistant services. Our reviewer says that these codes 
are not supported as billed. Our reviewer found the submitted records do not specify what services the assistant 
participated on to support the AS modifier. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of surgical assistant services have not been met. Therefore, we decided that the 
Plan does not have to pay for surgical assistant services for an instrumentation removal (22852-AS-59), spinal 
fusion exploration (22830-AS-XS), a transpedicular approach (63056-AS), and anterior instrumentation 
(22845-AS-59) provided on December 29, 2020.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve deep gum and root cleaning  four quadrants. We also decided that 
the Plan does not have to pre-approve implant placement, abutment supported crown, custom abutment, tissue 
materials, and adding bone for teeth.  
 
You asked the Plan to pre-approve approve deep gum and root cleaning, implant placement, abutment 
supported crown, custom abutment, tissue materials, and adding bone for teeth. You say that you are in pain 
and when you eat you have difficulty chewing. The Plan denied your request. The Plan says implant placement, 
abutment supported crown, custom abutment, tissue materials, and adding bone for teeth are not covered under 
your benefit plan. The Plan also says that deep gum and root cleaning is not medically necessary. 
 
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 periodontal 
scaling and root planning when the services are medically necessary and reasonable. The Plan does not cover 
implant placement, abutment supported crown, custom abutment, tissue materials, and adding bone for teeth. 
 
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 periodontal scaling and root planning. 
Our physician reviewer found that the documentation provided meets the criteria for coverage for periodontal 
scaling and root planning in four quadrants. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of periodontal scaling and root planning in four quadrants have been met. 
Therefore, we decided that the Plan has to pre-approve approve deep gum and root cleaning  four quadrants 
(code D4341). We also decided the Plan does not have to pre-approve approve deep gum and root cleaning 
implant placement (code D6010), abutment supported crown (code D6059), custom abutment (code D6057), 
tissue materials to help healing (code D4265) and adding bone for teeth (code D4263).  
 
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 pre-approve the pneumatic compressor device and accessories to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the durable medical equipment. You say that this equipment is medically 
necessary. The Plan denied your request. The Plan says there are in-network providers who would be able to 
provide this equipment. 
 
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 pneumatic compressor device and accessories to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pulp vitality tests (D0460), and pulpal debridement 
(D3221), provided by a participating provider on November 11, 2021. 
 
You asked the Plan to pay for a pulp vitality tests and pulpal debridement. You say that you were not aware of 
these charges. The Plan denied your request. The Plan says the rendered dental 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 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 pulp 
vitality tests (D0460), and pulpal debridement (D3221), provided by a participating provider on November 11, 2021.  
 
The limited oral evaluation (D0140) that was provided is not being appealed due to being approved and paid.