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

 
We decided that the Plan does not have to pay for a crown (D2740) and a core build-up (D2950), provided by a 
participating provier on March 1, 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 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 1, 2022, due to 
your annual maximum allowance amount being met. Therefore, we decided that the Plan does not have to pay 
for a crown (D2740) and a core build-up (D2950), provided by a participating provider on March 1, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from 
February 19, 2022, through March 20, 2022. 
 
You asked the Plan to pay for the SNF care. You say that it is felt that Medicare payment can be made for these 
services. The Plan denied your request. The Plan says there were no daily skilled needs during this period. 
Medicare payment was correctly denied.  
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 SNF care. Our reviewer says that the 
SNF services provided do not meet Medicare coverage criteria. Our physician reviewer found the enrollee is a 
62-year-old female with pneumoperitoneum and urinary tract infection. From a nursing perspective, the 
enrollee received oral medications and insulin. There were stable vital signs, and the enrollee was alert with 
confusion. She was treated for abdominal and back pain. Regarding rehabilitation services, the enrollee 
received physical, occupational, and speech therapy. The enrollee required a mechanical lift for transfers. She 
required varying assist with daily living activities. 
 
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 SNF care have not been met. Therefore, we decided that the Plan does not 
have to pay for the skilled nursing facility (SNF) care provided from February 19, 2022, through March 20, 
2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the HH PT visits (CPT code G0151 x16). 
 
You asked the Plan to pre-approve the home health physical therapy visits. You say that the services are 
necessary. The Plan denied your request. The Plan says the enrollee requires little to no help with moving in 
bed, standing up, and performing transfers. The Plan states the enrollee's records do not support the need for a 
skilled physical therapist to make more home visits at this time. 
 
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 the home health physical therapy visits. 
Our physician reviewer found the health plans denial should be upheld. The enrollee does not have 
documented, ongoing, HH PT needs. The enrollee appears to have reached a plateau in function. Skilled 
services are not required to establish a maintenance program or to prevent deterioration of the enrollees 
condition. The enrollees care needs can be provided at a lower level of care. As such, the requested, ongoing, 
HH PT services are not medically necessary or reasonable. 
 
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 home health physical therapy visits have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the HH PT visits (CPT code G0151 x16).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral imaging (D0210) and a comprehensive oral 
evaluation (D0150), provided by a participating provider on April 1, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for this. 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 October 4, 2021. 
Therefore, we decided that the Plan does not have to pay for intraoral imaging (D0210) and a comprehensive 
oral evaluation (D0150), provided by a participating provider on April 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction, erupted tooth or exposed root (elevation 
and/or forceps removal) (D7140) provided April 11, 2022.
 
You asked the Plan to pay for the tooth extraction. You say that you were not told your dental coverage had 
changed. The Plan denied your request. The Plan says this service is 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 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 
extraction, erupted tooth or exposed root (elevation and/or forceps removal) (D7140) provided April 11, 2022. 
 
Your complaint about potentially not being provided complete information by plan representatives 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve outpatient rehabilitation services to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve rehabilitation services. You say that you need to start therapy in 10 days. 
The Plan denied your request. The Plan says these services can be provided in-network. 
 
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 
outpatient rehabilitation services to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for the billed codes 87481, 87500, 87640, 87653, 87801, and 87798. We 
decided that the Plan does not have to pay for the billed codes 87150 and 87641.  
 
You asked the Plan to pay for this testing as billed. You say that this was medically necessary testing. The Plan 
says that codes 87150 and 87641 are bundled into payment for other services. It is felt the Plan is not obligated 
to make an appeal decision on the other codes. 
 
We decided that the Plan has to pay for the billed codes 87481, 87500, 87640, 87653, 87801, and 87798.  
 
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 claim for the codes at issue was denied due to requesting information not being received. That this 
information was subsequently received as an appeal request would not exempt these codes from an appeal 
decision on the Plan level. Since the Plan has forfeited the opportunity to provide a rationale for the denied 
codes, we find the denial is not supported. Therefore, we decided that the Plan has to pay for the billed codes 
87481, 87500, 87640, 87653, 87801, and 87798.  
 
We also decided that the Plan does not have to pay for the billed codes 87150 and 87641. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
Code 87150 is a Column 2 code in relation to 87500. Code 87641 is a Column 2 code in relation to 87150. 
These Column 2 codes were not billed with the required modifier to bypass the coding edit. Therefore, we 
decided that the Plan does not have to pay for the billed codes 87150 and 87641. 
 
 
 
 
 
 
 
 
 
 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 CDx liquid biopsy rendered on March 28, 
2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that next generation sequencing is 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 pay for these services. Our reviewer says that the 
services were not medically necessary. Our physician reviewer found the enrollee has a history of stage IIC 
adenocarcinoma of the colon. Pathology revealed poorly differentiated large cell neuroendocrine carcinoma. 
The Guardant Reveal Liquid Biopsy does not have a Food and Drug Administration (FDA)-approved or FDA-
cleared indication for use in this patient's cancer (adenocarcinoma of the colon). The testing was not reasonable 
or medically necessary for the enrollee's diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the Guardant360 CDx liquid biopsy rendered on March 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 15, 2021 billed with 
codes 81206 and 81292. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as billed. 
 The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
June 15, 2021 billed with codes 81206 and 81292.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the evaluation and management (EM) services provided on 
March 14, 2022. 
 
You asked the Plan to pay for the EM services. You say that this same code was billed and paid for another 
date of service. There is no reason this code should be denied. The Plan denied your request. The Plan says this 
was not billed with a valid place of service code. 
 
The Plan must follow Medicare rules. Medicare rules say that the EM services described by code 99335 is 
payable when billed with POS code 13, 14, 33, or 55.  
 
We looked at the file and Medicare rules. This claim was billed with POS code 11 which is not an appropriate 
POS for this service. Based on this information, we decided that Medicare rules for coverage of the EM 
services have not been met. Therefore, we decided that the Plan does not have to pay for the evaluation and 
management (EM) services provided on March 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral imaging (D0220) and a limited oral evaluation 
(D0140), provided by an out-of-network provider on April 12, 2021. 
 
You asked the Plan to pay for intraoral imaging and a limited oral evaluation. You say that you thought your 
initial exam would be completely covered. The Plan denied your request. The Plan says the rendered dental 
services are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 intraoral 
imaging (D0220) and a limited oral evaluation (D0140), provided by an out-of-network provider on April 12, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary due to the infection 
in your foot. The Plan denied your request. The Plan says the stay is not medically necessary based on SNF 
criteria. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our physician reviewer 
found you do not meet severity of illness or intensity of service criteria for 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 pre-approve SNF care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for incision and drainage of abscess (D7510) provided on April 
7, 2022. 
 
You asked the Plan to pay for incision and drainage of abscess (D7510). You say that you feel this should be 
covered because you did have the services done and the procedure itself was more dental. You say that you had 
no choice because it was infected. The Plan denied your request. The Plan says payment is subject to the plan 
benefits (e.g. calendar year maximum), limitations and exclusions at the time the claim is submitted. Coverage 
is limited to those services listed in the Plan's Evidence of Coverage. If a service is not listed, it is not covered. 
Services that are not covered include but are not limited to: services not listed as covered under this plan. 
 
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 incision 
and drainage of abscess (D7510) provided on April 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the pneumatic compressor and segmental pneumatic 
appliance to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the pneumatic compressor and segmental pneumatic appliance. You say that 
the enrollee needs to start compression therapy to reduce and maintain this life-long condition as well as 
reducing ulcerations and avoiding further injections. The Plan denied your request. The Plan says the provider 
is out-of-network. 
 
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 pneumatic compressor and segmental pneumatic appliance. We found no 
exception that would require the Plan to pre-approve the pneumatic compressor and segmental pneumatic 
appliance. Therefore, we decided that the Plan does not have to pre-approve the pneumatic compressor and 
segmental pneumatic appliance to be provided by an out-of-network (OON) provider.
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 clinical documentation provided supports the 
need for IRF care. The Plan denied your request. The Plan says the need for IRF care is not supported by the 
records received. 
 
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. The enrollee 
was admitted for lumbar spine surgery. The enrollee's medical problems are stable. There are no complex 
nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical 
record supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve BIO4 allograft for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that the clinical value and effectiveness of BIO4 allograft in the setting 
of spinal fusion surgery has not been demonstrated in the peer-reviewed literature. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. There is limited 
published, large-scale, long-term peer-reviewed literature that shows this request to be an effective and/or safe 
treatment for the enrollee's pathology. There is no compelling rationale presented or extenuating circumstances 
noted to support the medical necessity of this request as an exception. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve BIO4 allograft for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 3 office visits and treatment to include teeth extractions 
 
You asked the Plan to pre-approve the dental services. You say that you have huge dental needs and have 
excellent dental coverage. You are asking that the Plan be the secondary insurance. Your dental issues are 
related to a medical diagnosis and should be covered by your medical insurance. The Plan denied your request. 
The Plan says the requested services are not covered under the Plan benefits as dental care is only covered in 
certain specific instances. 
 
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 3 
office visits and treatment to include teeth extractions