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

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from May 10, 2021, to June 8, 2021. 
 You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says denial of the continued admission was appropriate, given the clinical scenario. 
 
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 pay for the services. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found there are no identifiable skilled therapy 
service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee 
does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 
setting. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for skilled nursing facility (SNF) services provided to the enrollee from May 10, 2021, to June 8, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on July 29, 2021. 
 
You asked the Plan to pay for the limited oral evaluation. You say that the initial plan was to perform sections. 
You say that the sectioning was not performed. You say that the dentist did extractions instead. You also say 
that you were not aware of the frequency limitations. The Plan denied your request. The Plan says 1 limited 
oral evaluation is covered per plan year. The Plan also says that the frequency limit has been exceeded. 
 
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 limited oral evaluation is listed as 
covered, the frequency limit of 1 per plan year has been exceeded. The record shows that the Plan paid for a 
limited oral evaluation that you received on May 11, 2021. Therefore, we decided that the Plan does not have 
to pay for the limited oral evaluation (D0140) provided on July 29, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee on June 24, 2021, to July 23, 2021. 
 You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says there was no daily skilled nursing or therapist need. 
 
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 pay for the services. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing 
service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled 
nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of 
service criteria for an inpatient basis in a skilled nursing facility setting. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for skilled nursing facility (SNF) services provided to the enrollee on June 24, 2021, to July 23, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the 5 extractions, initial 15 minutes of deep sedation, 
additional 15 minutes of deep sedation, and therapeutic parenteral drug provided on September 27, 2021. 
 
You asked the Plan to pay for the dental services. You say that you should not have to pay anything. The Plan 
denied your request. The Plan says there is an annual maximum benefit of $1,000 for dental services. The Plan 
also says that the annual maximum benefit has been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of the dental services have not been met. Specifically, the file shows that the annual maximum benefit 
of $1,000 has been exceeded.  The file shows that the Plan paid $1,000 for services that you received on May 3,2021. Therefore, we decided that the Plan does not have to pay for the 5 extractions, initial 15 minutes of deep sedation, additional 15 minutes of deep sedation, and therapeutic parenteral drug provided on September 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a wig purchased May 24, 2021, to August 30, 2021. 
 
You asked the Plan to pay for a wig. You say that you were losing your hair due to chemotherapy and this wig 
was medically necessary. The Plan denied your request. The Plan says wigs are not covered by the Plan or by 
Medicare. 
 
Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are 
ordered by a physician. The Plan follows these same rules. In this case, although the wig may be appropriate, it 
does not meet the definition of the above benefit categories. It is not considered DME because it does not 
directly treat a medical condition. It does not meet the Medicare definition of a prosthetic because it does not 
replace an internal body organ or attached tissue. As such, it is noncovered by Medicare. Furthermore, the Plan 
does not offer a supplemental benefit which would provide coverage for a wig. Therefore, we decided that the 
Plan does not have to pay for a wig purchased May 24, 2021, to August 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network services provided on November 18, 2021. 
 
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The 
Plan denied your request. The Plan says you did not have prior authorization for out of network care. 
 
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 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 out of network services provided on November 18, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the apicoectomy, first root (D3425), apicoectomy, each 
additional root (D3426), and retrograde filling, per root, (D3430 x 2) provided on October 5, 2021. 
 
You asked the Plan to pay for the dental services. You say that this was an emergency procedure that required 
surgery. You also say that you feel this should be covered. The Plan denied your request. The Plan says 
apicoectomies are not covered services. The Plan also says that retrograde fillings are not covered services.  
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 apicoectomies and retrograde 
fillings are not among those covered under this benefit. Additionally, the services you are asking the Plan to 
pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly 
supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we 
decided that the Plan does not have to pay for the apicoectomy, first root (D3425), apicoectomy, each 
additional root (D3426), and retrograde filling, per root, (D3430 x 2) provided on October 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cardiology services to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve OON services. The Plan denied your request. The Plan says the care you 
require can be provided by a network provider. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve 
cardiology services to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an annual wellness visit (G0439) provided October 1, 2021. 
 
You asked the Plan to pay for the annual wellness visit. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the benefit for this service was already exhausted. 
 
The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once 
every 12 months.  
 
Based on review of the file, an AWV was provided less than 12 months prior to the visit at issue in this case. 
Therefore, we decided that the Plan does not have to pay for an annual wellness visit (G0439) provided 
October 1, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that you are not able to walk yet and live alone. You 
say that you would be unable to get in and out of bed, or to the bathroom. You say that you could fall very 
easily and have open wounds. You say that a SNF is the appropriate next step in your care. The Plan denied 
your request. The Plan says the enrollee's needs may be more safely managed in the current inpatient 
rehabilitation facility (IRF) setting.  
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 
daily skilled services are not necessary. Our physician reviewer found no skilled nursing service needs have 
been identified. The enrollee may benefit from continued therapy services, but not they are not medically 
necessary on a daily basis. The enrollee does not require the necessary services on an inpatient basis in a SNF 
setting. 
 
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.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection (ESI). 
 
You asked the Plan to pre-approve an ESI. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that epidural steroid injections are covered when specific 
criteria are met. 
 
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 an ESI. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found in this case, the enrollee's bilateral lumbar 
transforaminal lumbar epidural steroid injection (TFESI) were performed less than one month ago. In addition, 
the records do not show that the repeat ESI will be performed using a different approach, level and/or 
medication. The requesting physician recommended that the enrollee undergo repeat bilateral lumbar TFESI at 
the same level to be performed using the same approach. The review has determined that the enrollee does not 
meet the coverage criteria detailed in the LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an ESI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an epidural steroid injection (ESI).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on 
November 10, 2021. 
 
You asked the Plan to pay for the dental service. You say that you moved to a new city. You say that you 
needed to find a new dentist. You say that your previous dentist retired. You also say that all of these 
circumstances should be considered, and the claim paid. The Plan denied your request. The Plan says 1 
comprehensive oral evaluation is covered every 3 plan years. The Plan also says that the frequency limit has 
been exceeded. 
 
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 the service is listed as covered, the 
frequency limit of 1 comprehensive oral evaluation every 3 plan years has been exceeded. The record shows 
that the Plan paid for a comprehensive oral evaluation that you received on September 8, 2020. Therefore, we 
decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on 
November 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral exam (D0140) and cone beam image capture 
(D0380) provided on October 20, 2021. 
 
You asked the Plan to pay for the limited exam and dental imaging. You say that these services were necessary 
as you needed a second opinion on a recurring issue. The Plan denied your request. The Plan says these 
services are not covered by your dental benefit. 
 
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 the 
limited oral exam (D0140) and cone beam image capture (D0380) provided on October 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services provided from January 22, 2020, to July 
29, 2020. 
 
You asked the Plan to pay for the dental services. You say that you were not aware that you had dental 
coverage through this plan until November 2021. The Plan denied your request. The Plan says this claim was 
received more than one year from the date of service. Claims that are filed after one year from the date of 
service will not be considered. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the dental services was not filed until November 2021. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for the dental services provided from January 22, 2020, to July 29, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided on August 16, 2021.
You asked the Plan to pay for the lab services. You say that this is a Medicare-covered service and should be
paid. The Plan denied your request. The Plan says these lab services were reported with an incorrect Place of
Service code.
The Plan must follow Medicare rules. Medicare rules say that only an independent lab that takes the sample
from the patient directly should use Place of Service (POS) 81. The POS should be reported where the face-toface
encounter with the patient occurred. In this case, the records do not show that the patient physically
presented to your lab to provide this specimen. Therefore, POS 81 should not have been used on the claim. We
looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage
of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services
provided on August 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on 
October 15, 2021. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
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 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 out of network physician services provided to the 
enrollee on October 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a resin-based composite (D2330) provided by an opt-out 
provider on July 12, 2021, to August 10, 2021. 
 
You asked the Plan to pay for a resin-based composite. You say that you were unaware that this dentist had 
opted-out of Medicare. The Plan denied your request. The Plan says this provider has opted-out of Medicare. 
 
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 until February 15, 2023. Therefore, we decided that the Plan does not 
have to pay for a resin-based composite (D2330) provided by an opt-out provider on July 12, 2021, to August 
10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pulpal debridement (D3221) provided on November 4, 2021. 
 
You asked the Plan to pay for the dental service. You say that you need a root canal. You say that this service 
was necessary to relieve pressure to make it more bearable to wait another month until the root canal. You also 
say that you were advised the services would be covered. The Plan denied your request. The Plan says pulpal 
debridement is not listed as 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 pulpal debridement is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the pulpal 
debridement (D3221) provided on November 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic consultation services (D9310) provided by an out-
of-network provider on August 17, 2021. 
 
You asked the Plan to pay for diagnostic consultation services. You say that this was a consultation 
appointment, and you do not feel like it is fair to be charged for this. The Plan denied your request. The Plan 
says the consultation that was provided 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 diagnostic 
consultation services (D9310) provided by an out-of-network provider on August 17, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 testing provided on June 28, 2021.
You asked the Plan to pay for the Guardant360 testing. You say that POS code 81 is correct for this testing. The Plan denied your request. The Plan says the billed POS code is not supported.
The Plan must follow Medicare rules. Medicare rules say that for lab services, the POS code must reflect the location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory directly.
We looked at the file and Medicare rules. The documentation does not indicate this sample was taken by the lab directly. As such, the use of POS code 81 is not supported. Based on this information, we decided that Medicare rules for coverage of the Guardant360 testing have not been met. Therefore, we decided that the Plan does not have to pay for the Guardant360 testing provided on June 28, 2021.