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

 
We decided that the Plan does not have to pay for the irrigation of gingival pockets with medicinal agent 
(D4921) and drugs or medicaments dispensed in the office for home use (D9630) provided on March 9, 2022. 
 
You asked the Plan to pay for the irrigation of gingival pockets with medicinal agent and drugs or medicaments 
dispensed in the office for home use. You say that that the uncovered procedure is actually a preventative 
procedure as it is to prevent further bone loss. The Plan denied your request. The Plan says dental service codes 
D4921 (the irrigation of gingival pockets with medicinal agent) and D9630 (drugs or medicaments dispensed in 
the office for home use) are not covered under the member's contract under any normal circumstances.  
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
irrigation of gingival pockets with medicinal agent (D4921) and drugs or medicaments dispensed in the office 
for home use (D9630) provided on March 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral x-rays (D0210) and the comprehensive oral 
evaluation (D0150) provided by a network provider on January 1, 2022. 
 
You asked the Plan to pay for the dental services. You say that your previous dentist did not send your dental 
records to this provider. You say you do not know how much time passed since your last dental appointment. 
The Plan denied your request. The Plan says your benefit for the intraoral x-rays (D0210) and the 
comprehensive oral evaluation (D0150) 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 Plan's 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 benefits for the intraoral x-rays (D0210) and the comprehensive oral evaluation (D0150) were 
exhausted on date of service January 5, 2021.  Therefore, we decided that the Plan does not have to 
pay for the intraoral x-rays (D0210) and the comprehensive oral evaluation (D0150) provided by a 
network provider on January 1, 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 records provided support the need for IRF care. 
The Plan denied your request. The Plan says the guidelines for coverage have not been met. The Plan says that 
the enrollee's needs can be met at an alternate level of care. 
 
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 surgical repair of a hip fracture after a fall. 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrocardiogram (93005) and ambulance supplies 
(A0422) provided on October 13, 2021. 
 
You asked the Plan to pay for the electrocardiogram and ambulance supplies. You say that you would like 
these codes reprocessed based on the services rendered. The Plan denied your request. The Plan says these 
services have denied correctly per Medicare guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services which include but are not 
limited to oxygen, drugs, extra attendants, supplies, electrocardiogram (EKG), and night differential are no longer paid separately for ambulance services. Based on this information, we decided that Medicare does not 
provide separate payment for the electrocardiogram and ambulance supplies have not been met. Therefore, we 
decided that the Plan does not have to pay for the electrocardiogram (93005) and ambulance supplies (A0422) 
provided on October 13, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable loop recorder (ILR). 
 
You asked the Plan to pre-approve an ILR. You say that the records provided support the need for an ILR. The 
Plan denied your request. The Plan says a routine ILR is not medically necessary after atrial fibrillation 
ablation. 
 
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 an ILR. Our reviewer says that an ILR 
is not considered medically reasonable and necessary in this case. Our physician reviewer found, while the 
enrollee has a history of atrial fibrillation, there is no documentation provided to suggest a history of 
unexplained syncope, cryptogenic stroke or any other apparent indication for an ILR. There is insufficient 
documentation to support the medical necessity for insertion of an ILR in this enrollees clinical management. 
 
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 ILR have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an implantable loop recorder (ILR).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for endodontic therapy, anterior tooth (D3310) provided on 
September 29, 2021. 
 
You asked the Plan to pay for the dental services. You say that there are charges that you don't agree with. You 
also say that you have never received a bill for their services. 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 September 29, 2021. 
Therefore, we decided that the Plan does not have to pay for endodontic therapy, anterior tooth (D3310) 
provided on September 29, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection services coded 96376 provided on March 21, 
2022. 
 You asked the Plan to pay for the injection services. You say that you would like this claim reprocessed based 
on the records provided. The Plan denied your request. The Plan says based on Medicare billing regulations, no 
separate payment is made for this service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Medicare rules say services with status indicator 
N are paid under the OPPS, but their payment is packaged into payment for a separately paid service 
 
We looked at the file and Medicare rules. In this case, CPT code 96376 has a status indicator of N which 
indicates the payment is bundled for this service and not separately made. Based on this information, we 
decided that Medicare rules for coverage of the injection services have not been met. Therefore, we decided 
that the Plan does not have to pay for the injection services coded 96376 provided on March 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 24, 2021, billed with 
codes 81238, 81220, 81225, 81230, 81227, 81355, 81241, 81291 and 81240. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like this claim reprocessed 
based on the medical records. The Plan denied your request. The Plan says this claim has not been billed as 
required by Medicare billing regulations. 
 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 
May 24, 2021, billed with codes 81238, 81220, 81225, 81230, 81227, 81355, 81241, 81291 and 81240.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the face-down position table and associated costs provided 
on December 1, 2021. 
 You asked the Plan to pay for the face-down position table. You say that you would like this claim paid as you 
were told it was necessary. The Plan denied your request. The Plan says these devices are statutorily non-
covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose. The rules say face-down positioning tables are statutorily noncovered because they do not fall 
within a Medicare benefit category. Therefore, we decided that the Plan does not have to pay for the face-down 
position table and associated costs provided on December 1, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy services provided on February 1, 2022. 
 
You asked the Plan to pay for the physical therapy services. You say that you would like this claim reprocessed 
and approved for payment based on the medical records. The Plan denied your request. The Plan says the 
provider was not eligible to perform the services as billed on the date in question. 
 
The Plan must follow Medicare rules. Medicare rules say that outpatient rehabilitation therapy services must be 
provided by a qualified professional. A qualified professional means a physical therapist, occupational 
therapist, speech-language pathologist, physician, nurse practitioner, clinical nurse specialist, or physicians 
assistant, who is licensed or certified by the state to furnish therapy services, and who also may appropriately 
furnish therapy services under Medicare policies.   
 
We looked at the file and Medicare rules. In this case, the documentation supports that the providers license 
was suspended by the relevant State Board of Physical Therapy Examiners on January 26, 2022. Based on this information, we decided that Medicare rules for coverage of the physical therapy services have not been met. 
Therefore, we decided that the Plan does not have to pay for the physical therapy services provided on 
February 1, 2022.
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. The Plan denied 
your request. The Plan says the enrollee's records do not show that they require these skilled services on a daily 
basis, nor that daily skilled services can be provided only on an inpatient basis in a SNF. The Plan states the 
services they require can safely be received at a different setting, for example, home with home health, in 
residential care, or home with close follow-up with the enrollee's doctor. 
 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 the enrollee's physical function is at or near their baseline and they can receive services at a lower level 
of care. Although the enrollee has a wound to their skin wound there is no complex daily care required at this 
time. Admission to a SNF for inpatient skilled rehabilitation services 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiac genetic testing services performed on December 
10, 2021. 
 
You asked the Plan to pay for the cardiac genetic testing services. You say that you would like this claim 
reprocessed based on the medical records for medical necessity. The Plan denied your request. The Plan says 
this is a non-covered screening service and not eligible for payment. 
 
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 pay for the cardiac genetic testing services. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found he record indicates that the enrollee has coronary artery disease. The record 
provided does not indicate how the requested test will impact the management of the enrollee's condition. The record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, sof 
the requested service. The elements of the coverage criteria were not satisfied. 
 
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 cardiac genetic testing services have not been met. Therefore, we decided 
that the Plan does not have to pay for the cardiac genetic testing services performed on December 10, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the porcelain crown (D2740) for tooth # 29 provided on February 28, 2022. 
 
You asked the Plan to pay for the dental service. You say that you do not understand why this is not covered. 
You also say that 2 different dentists advised this service needs to be done due to fracture. The Plan denied 
your request. The Plan says that crowns are only covered for extensive decay or fracture. 
 
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. The Plan covers the dental 
service when the services are medically necessary and reasonable. 
 
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 dental service. Our reviewer says that the 
crown for tooth # 29 was medically necessary. Our physician reviewer found the documentation indicates that 
tooth # 29 has a large defective restoration and a fractured tooth. The reviewer found that a crown restoration is 
medically reasonable and necessary to provide adequate masticatory function and to protect the tooth from 
further fracture. 
 
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 the dental service have been met. Therefore, we decided that the Plan has to pay 
for the porcelain crown (D2740) for tooth # 29 provided on February 28, 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 a resin-based composite - two surfaces, anterior (D2331) 
provided on April 5, 2022. 
 
You asked the Plan to pay for the dental services. You say that you went to the dentist last year for an exam 
and teeth cleaning and the claim was approved and paid. You say that you were not notified of the special 
circumstances and if you used your same dentist, you would not be approved. 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 a resin-based composite - two surfaces, anterior (D2331) provided on April 5, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 2, 2021 billed with 
codes 81206, 81235, and 81321. 
 
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 
April 2, 2021 billed with codes 81206, 81235, and 81321.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete mandibular denture (D5731), the limited oral 
evaluation (D0140), and the complete maxillary denture adjustment (D5410) provided by a network provider 
on December 8, 2021, to February 10, 2022. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 50% 
coinsurance up to the maximum dental allowance. 
 
You have been asked to pay $86.50 which is 50% of the allowed amount for the complete mandibular denture 
(D5731). The allowed amount is $173. ($173 x 50% = $86.50). The complete mandibular denture (D5731) falls 
within the Dental services benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan.
 
You asked the Plan to pay for the complete mandibular denture (D5731) and the limited oral evaluation 
(D0140). You say that the dentist should never have re-lined the partial denture. The Plan denied your request. 
The Plan says you have been charged the correct cost-sharing amount for the reline complete maxillary 
dentures (D5731) and the limited oral evaluation (D0140) 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the limited oral evaluation (D0140) is 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
complete mandibular denture (D5731), the limited oral evaluation (D0140), and the complete maxillary denture 
adjustment (D5410) provided by a network provider on December 8, 2021, to February 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the knee scooter (CPT code E0118). 
 
You asked the Plan to pre-approve the knee scooter. You say that the knee scooter is necessary. The Plan 
denied your request. The Plan says the requested service is not covered by Medicare or the health plan. 
 
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 knee scooter. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no documentation that the knee scooter at issue in this case meets Medicare criteria for 
medically reasonable and necessary. The knee scooter has not been shown to be reasonable and necessary, safe 
and effective in the Medicare population. 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 knee scooter have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the knee scooter (CPT code E0118).