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

 
We decided that the Plan does not have to pay for the reline complete lower denture (D5751) provided by an 
out-of-network provider on May 17, 2022. 
 
You asked the Plan to pay for the dental service. You say that you were not told that the provider did not accept 
Medicaid or Medicare. 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 8, 2022. 
Therefore, we decided that the Plan does not have to pay for the reline complete lower denture (D5751) 
provided by an out-of-network provider on May 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on March 9, 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 are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Specifically, we find that the testing described by the billed code is considered specimen validity testing which is not separately payable. Therefore, we decided that the Plan 
does not have to pay for the laboratory services rendered on March 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided by a participating 
provider on May 31, 2022. 
 
You asked the Plan to pay for the dental services. You say that you believe the Plan should 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 January 7, 2022. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided by a 
participating provider on May 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the implant (D6065) and the abutment (D6058) provided by 
an out-of-network provider on June 4, 2022. 
 
You asked the Plan to pay for the implant (D6065) and the abutment (D6058). You say that you were told that 
you had coverage for crowns under your plan and there was no mention of an implant in regard to the 
procedure. The Plan denied your request. The Plan says the 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the implant (D6065) and the abutment 
(D6058) are not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pay for the implant (D6065) and the abutment (D6058) provided by an out-of-network provider on June 4, 
2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided on March 20, 
2022, and March 21, 2022. 
 
You asked the Plan to pay for the SNF care. You say that the services which the enrollee required and received 
are coverable under the Medicare Act. The Plan denied your request. The Plan says while on Hospice, SNF 
level services are not a covered benefit. The Plan also says the enrollee expired on March 21, 2022. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided on March 20, 
2022, and March 21, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care services provided from June 7, 2021, to 
July 5, 2021. 
 
You asked the Plan to pay for the home health care services. You say that you would like this claim to be 
processed for payment. The Plan denied your request. The Plan says the initial Request for Anticipated 
Payments (RAP) claim was not received within 5 calendar days from the start of care. 
 
The Plan must follow Medicare rules. Medicare rules say that all HHAs must submit a RAP within 5 calendar 
days after the start of care date for initial 30-day periods and within 5 calendar days after the from date for 
each subsequent 30-day period of care. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health care services have not been met. Specifically, the record indicates the RAP was 
not submitted within 5 days from the start of care date. Therefore, we decided that the Plan does not have to 
pay for the home health care services provided from June 7, 2021, to July 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services on May 6, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration for 
payment. 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 January 28, 2022. 
Therefore, we decided that the Plan does not have to pay for dental services on May 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an occlusal guard - hard appliance, full arch (D9944) 
provided on March 15, 2022. 
 
You asked the Plan to pay for an occlusal guard - hard appliance, full arch (D9944). You say that to please 
consider this appeal favorably and cover this durable medical equipment as you would any other. The Plan 
denied your request. The Plan says non-routine dental care is excluded by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an 
occlusal guard - hard appliance, full arch (D9944) provided on March 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for removal of impacted tooth (D7220 x2, D7230) provided on 
June 1, 2022. 
 
You asked the Plan to pay for removal of impacted tooth. You say that you were not aware the services would 
not be covered. The Plan denied your request. The Plan says the services at issue 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 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 removal 
of impacted tooth (D7220 x2, D7230) provided on June 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and 
first intraoral periapical x-ray (D0220) provided on January 24, 2022. 
 
You asked the Plan to pay for the problem focused limited oral evaluation and first intraoral periapical x-ray. 
You say that you believe your dental rider covers these procedures. The Plan denied your request. The Plan 
says these services are not covered benefits under your dental plan. The Plan also says that your enrollment in 
the Plan's supplemental dental rider did not become effective until February 1, 2022. 
 
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 
problem focused limited oral evaluation (D0140) and first intraoral periapical x-ray (D0220) provided on 
January 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on March 24, 2021. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration for 
payment. 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 March 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on August 13, 2020, to May 18, 
2021. 
 
You asked the Plan to pay for dental services. You say that you were not aware the provider did not submit the 
bills to your plan. The Plan denied your request. The Plan says this service exceeds timely filing limitations. 
 
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 dental services was not filed until July 15, 2022. 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 dental services provided on August 13, 2020, to May 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on May 25, 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 May 25, 2022. Therefore, 
we decided that the Plan does not have to pay for the dental services on May 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and prophylaxis 
(D1110) provided on June 21, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the dental services. You say that you have never been advised that you need to 
see an assigned dentist. You also say that the treating provider you saw is in your neighborhood, and within 
walking distance from your home. 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 periodic oral evaluation (D0120) and prophylaxis (D1110) provided on June 21, 2022, by an out-
of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and 
appliances (E0656, E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device and appliances. You say that the device 
and supplies are medically necessary. The Plan denied your request. The Plan says there is no documentation in 
the medical records provided that this enrollee has lymphedema extending into the chest, trunk, or abdomen. 
The enrollee had a single trial of E0651 on 7/5/2022 where it was documented that he could tolerate the 
treatment session. The E0652 pump was requested the same day. The Plan also says this does not meet the 
Medicare guidelines for a four-week trial of the basic pump. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652) and appliances (E0656, E0667).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on September 1, 2021, billed 
with codes 81408, 81407, 81302, 81223, 81345, and 81330. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like this claim reprocessed and 
approved for payment. 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 
September 1, 2021, billed with codes 81408, 81407, 81302, 81223, 81345, and 81330.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (20680-59) provided on March 16, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the use of modifier -59 
is not supported. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
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 the use 
of modifier -59 is not supported by the records provided. Our physician reviewer found that removal of implant 
prior to ankle arthrodesis would not be reported separately as the hardware removal is considered necessary to 
the arthrodesis. Therefore, modifier -59 cannot be verified. 
 
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 the services (20680-59) provided on March 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an annual wellness visit provided on March 10, 2022. 
 
You asked the Plan to pay for annual wellness visit. You say that you confirmed with a Plan representative that 
this service was never submitted or paid in 2022. The Plan denied your request. The Plan says the denial of 
payment for this service is correct, because an annual wellness visit was covered on date of service January 18, 
2022 so this benefit was 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 provided on March 10, 
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 you need this facility due to medical necessity of 
therapy, dialysis, and staff on hand to handle your complex medical needs in one location. The Plan denied 
your request. The Plan says it was not medically necessary, and a lower level of care might be appropriate. 
 
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 there is not a reasonable expectation that this patient 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 77063 billed for date of service April 28, 
2022. 
 
You asked the Plan to pay for procedure code 77063. The Plan denied your request. The Plan says payment for 
code 77063 is bundled into payment for code 77066.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 77063 
is a column II code to column I code 77066. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 77063 billed for date of service April 28, 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 does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for respiratory failure and congestive heart failure. 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 he 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.