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

 
We decided that the Plan does not have to pre-approve prefabricated abutment  includes modification and 
placement (D6056) Tooth 5, 30 and abutment supported porcelain fused to metal crown (high noble metal) 
(D6059) Tooth 5, 30. 
 
You asked the Plan to pre-approve dental service. You say that you checked your coverages multiple times, so 
you don't understand why these items are not being covered. 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. Prefabricated abutment  
includes modification and placement (D6056) and abutment supported porcelain fused to metal crown (high 
noble metal) (D6059) are not covered under the Plans dental benefits. 
 
  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 
prefabricated abutment  includes modification and placement (D6056) Tooth 5, 30 and abutment supported 
porcelain fused to metal crown (high noble metal) (D6059) Tooth 5, 30.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for a colonoscopy (45385) and initial sedation services (G0500). We 
decided that the Plan does not have to pay for additional sedation services (99153).  
 
You asked the Plan to pay for a colonoscopy (45385), initial sedation services (G0500), and additional sedation 
services (99153) provided on April 29, 2022. You say that these services are supported in the records. The Plan 
says that code 99153 is not payable in the facility setting. and the other codes are being handled separately. 
 
We decided that the Plan has to pay for a colonoscopy (45385) and initial sedation services (G0500).  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan has not provided any information on their denial of these services or 
provided valid reasoning that they are exempt from the appeal process. Therefore, we decided that the Plan has 
to pay for a colonoscopy (45385) and initial sedation services (G0500).  
 
We also decided that the Plan does not have to pay for additional sedation services (99153). 
 
The Plan follows Medicare rules. Medicare rules say that the OPPS recognizes that CPT code 99153 is a PE 
only code and that PE are not payable to the physician for services provided in the facility setting.  
 
We find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment to the 
physician for CPT code 99153 when performed in the facility setting. Therefore, we decided that the Plan does 
not have to pay for additional sedation services (99153). 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on July 5, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the dental services were received from an out-of-
network provider and are not covered by your supplemental 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. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for the dental services on July 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prophylaxis - adult (D1110), and periodic oral evaluation - 
established patient (D0120) provided on August 1, 2022. 
 
You asked the Plan to pay for the dental services. You say that the Plan representative did not tell you the 
dentist was out-of-network. The Plan denied your request. The Plan says the dental services were received from 
an out-of-network provider and are not covered by your supplemental 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. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for prophylaxis - adult (D1110), and periodic oral evaluation - established patient (D0120) provided on 
August 1, 2022.  
 Your complaint about the Plan salesman 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: Testing
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 76641 billed for date of service August 29, 2022. 
 
You asked the Plan to pay for procedure code 76641. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the number of units billed exceeds the 
maximum allowed. 
 
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 76641 was billed with 1 unit of service with modifier RT on one claim line, and 1 unit 
of service and modifier LT on the second claim line. We also find that code 76641 has an MUE of 2, not 1. 
Based on this information, we decided that Medicare rules for coverage of the billed services have been met. 
Therefore, we decided that the Plan has to pay for procedure code 76641 billed for date of service August 29, 
2022.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on August 10, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service March 29, 2018. 
Therefore, we decided that the Plan does not have to pay for the dental services on August 10, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia (J0897). 
 
You asked the Plan to pre-approve Prolia. You say that the plan only covers one exam every 24 months. You 
say that you have not been able to have a recent one to show your current situation. You say that you are unable 
to obtain past medical records due to the office closing. You also say that this medication is medically 
necessary. The Plan denied your request. The Plan says the requested drug is not medically necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
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 Prolia. Our reviewer says that the 
requested drug, Prolia, is not medically necessary. Our physician reviewer found the record indicates that you 
have a stated diagnosis of age-related osteoporosis without pathologic fracture. The reviewer found that the 
provided documentation indicates that you had a normal bone density study in April 2021. The reviewer found 
that the provided documentation does not support the diagnosis of osteoporosis. Therefore, the reviewer found 
that the requested drug, Prolia, is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia (J0897).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a brand specific walker with seat, brakes and
accessories.
You asked the Plan to provide coverage for this equipment. You say that the requested walker was medically
necessary. The Plan denied your request. The Plan says the requested walker exceeds your needs in the home.
Maximus overturned the Plans denial for medical necessity. The Plan stated that the issue was not medical
necessity but that the brand specific walker with seat requested exceeds your needs in the home and is not
covered by Medicare.
The Plan is correct in this case. The Plan must follow Medicare rules. The rules state that for equipment to be
covered, it must be appropriate and needed for use inside the home. The brand specific walker with seat and
breaks and accessories requested is not required for use in the home. There are no medical records provided to
show this level of walker is required in the home. Although this item may be helpful, neither Medicare nor the
Plan covers this equipment for use in the home. Therefore, we decided that the Plan does not have to provide
coverage for a brand specific walker with seat, brakes, and accessories.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the tetanus, diphtheria toxoids and acellular pertussis vaccine 
(Tdap) (90715), and administration (90471) provided on June 16, 2022. 
 
You asked the Plan to pay for the immunization. You say that you do not have Medicare Part D. You say that 
you need this to be covered. You also say that it is preventive. The Plan denied your request. The Plan says the 
immunization in this case is not covered under Medicare Part B. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the immunization. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the immunization. 
Therefore, we decided that the Plan does not have to pay for the tetanus, diphtheria toxoids and acellular 
pertussis vaccine (Tdap) (90715), and administration (90471) provided on June 16, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance transport provided on March 2, 2022. 
 
You asked the Plan to pay for the ambulance transport. You say that the auto insurance should be the primary. 
You also are asking the Plan to reprocess the claim for repayment. The Plan denied your request. The Plan says 
the auto insurance carrier has paid more than the full amount so there is nothing left for the Plan to pay. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer.  However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate 
their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary 
insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the 
Plan can pay for the services and submit a bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has contacted the 
auto insurance carrier and confirmed they have already paid more than the Medicare-allowed amount, which is 
$411.79 of the claim. As the secondary insurer, the Plan cannot be held responsible for the ambulance transport 
until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not 
have to pay for ambulance transport provided on March 2, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SNF care provided from April 1, 2022, to April 26, 2022. 
 You asked the Plan to pay for SNF care. You say that you are appealing the denied claim out of medical 
necessity. The Plan denied your request. The Plan says the enrollee's condition did not require daily skilled 
services at a SNF level of care. 
 
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 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 that the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy 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 care have not been met. Therefore, we decided that the Plan does not have 
to pay for SNF care provided from April 1, 2022, to April 26, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided May 19, 2022, to June 17, 
2022. 
 You asked the Plan to pay for the home health services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the claim is not payable as submitted. 
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
Review of the file shows that the NOA was submitted with an admission date of January 19, 2022. Since the 
first date of service for the plan year 2022 was January 19, 2022, this is the correct admission date to be entered 
on all subsequent final claims. As the claim does not match the NOA submitted, no payment can be made on 
this claim. Therefore, we decided that the Plan does not have to pay for the home health services provided May 
19, 2022, to June 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scaling and root planing - four or more teeth 
per quadrant (D4341) 17-24, 25-32 and periodontal scaling and root planing - one - three teeth, per quadrant 
(D4342) 09-16, 01-08. 
 
You asked the Plan to pre-approve dental services. You say that it is in your benefit to have the requested 
services completed and hope the services will be covered. 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. Periodontal scaling and root 
planing - four or more teeth per quadrant (D4341) and periodontal scaling and root planing - one - three teeth, 
per quadrant (D4342) are not covered under the Plans dental benefits. 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested periodontal scaling and 
root planing - four or more teeth per quadrant (D4341) 17-24, 25-32 and periodontal scaling and root planing - 
one - three teeth, per quadrant (D4342) 09-16, 01-08 are not among those covered under this benefit. Therefore, 
we decided that the Plan does not have to pre-approve periodontal scaling and root planing - four or more teeth 
per quadrant (D4341) 17-24, 25-32 and periodontal scaling and root planing - one - three teeth, per quadrant 
(D4342) 09-16, 01-08.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an apicoectomy on tooth #24 (D3410), a bone graft on tooth 
#24 (D3428), and a retrograde filling on tooth #24 (D3430) provided on August 2, 2022. 
 
You asked the Plan to pay for the dental services. You say that these services should be covered. The Plan 
denied your request. The Plan says that endodontic services 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 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 an 
apicoectomy on tooth #24 (D3410), a bone graft on tooth #24 (D3428), and a retrograde filling on tooth #24 
(D3430) provided on August 2, 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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 do not 
require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, at an intensive rehabilitation therapy program. The enrollee continues to have a need for skilled 
therapy with ongoing safety concerns and a potential for functional improvement however, the documentation 
doesnt support that he would meet criteria for admission to an acute inpatient rehabilitation facility.  There is 
no indication that the enrollee would require skilled rehabilitation in an IRF, participating in rehab services 15 
hours a week, under the supervision of a physician with at least 3 visits weekly to regain or maintain his 
functional status. The enrollee can receive further services at a lower 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service March 28, 
2022. 
 You asked the Plan to pay for procedure code 99100. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says procedure code 99100 is considered bundled 
and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service March 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a rest home visit and nail trimming provided on September 
15, 2022, by an OON provider. 
 
You asked the Plan to pay for a rest home visit and nail trimming. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the enrollee must receive care from 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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a rest home visit and nail trimming provided on 
September 15, 2022, by an OON provider.