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

 
We decided that the Plan does not have to pay for the PrismRA test provided on June 6, 2022. 
 
You asked the Plan to pay for the PrismRA test. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says additional information was needed for review. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers FDA-approved NGS 
testing, when the test is FDA approved. 
 
We looked at the file and Medicare rules. Research shows that the PrismRA test is not FDA approved. Based 
on this information, we decided that Medicare rules for coverage of the PrismRA test have not been met. 
Therefore, we decided that the Plan does not have to pay for the PrismRA test provided on June 6, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided on July 28, 2022. 
 
You asked the Plan to pay for self-administered drugs. You say that this should be covered. The Plan denied 
your request. The Plan says this type of benefit to be self-administered. Unfortunately, that means that it cannot 
be covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs provided 
on July 28, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a gastrointestinal tract capsule endoscopy (91110). 
 
You asked the Plan to pre-approve a gastrointestinal tract capsule endoscopy. The Plan denied your request. 
The Plan says there were no qualifying conditions for the procedure, and this request is not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that plans must pay for a medical service or item if 
regular Medicare would pay for it in this case. 
 
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 a gastrointestinal tract capsule 
endoscopy. Our reviewer says that the enrollee does not meet the criteria for coverage for a gastrointestinal 
tract capsule endoscopy. Our physician reviewer found the available records neither documents the finding of 
gastrointestinal blood loss nor of iron deficiency to warrant a wireless capsule endoscopy as medically 
appropriate and necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a gastrointestinal tract capsule endoscopy have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a gastrointestinal tract capsule endoscopy (91110).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 87150, 87798, 87481, 87801, 
and 87799 provided on August 30, 2022.  
You asked the Plan to pay for the laboratory services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services provided are not a covered benefit. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, the laboratory services, was requested solely for screening purposes. Medicare 
does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay 
for the laboratory services coded 87150, 87798, 87481, 87801, and 87799 provided on August 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete maxillary denture (D5110) and a complete 
mandibular denture (D5120) provided on September 20, 2022. 
 
You asked the Plan to pay for the dentures. You say that the new dentures were medically necessary. The Plan 
denied your request. The Plan says your benefit for the requested items or services 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 items or services was exhausted on date of service February 14, 2019. 
Therefore, we decided that the Plan does not have to pay for a complete maxillary denture (D5110) and a 
complete mandibular denture (D5120) provided on September 20, 2022.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
You asked the Plan to pre-approve periodontal scaling and root planing - four or more teeth per quadrant tooth 
#15 (D4341 x4). You say that you have an infection in your mouth, the tooth is broken and it needs to be 
removed.  The Plan says that the service is not medically necessary. 
 
 
 We decided that the Plan has to pre-approve the lower right and lower left periodontal scaling and root 
planning tooth #15.  
 
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 Plan covers the dental 
services 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 pre-approve the dental services. Our reviewer says 
that the service is partially reasonable and necessary. Our reviewer found the scaling and root planing under 
code D4341 is medically necessary for the lower right and lower left quadrants. The remainder of the treatment 
is not considered medically necessary. The x-rays provided show four or more areas of bone loss in each of the 
lower quadrants and is associated with abnormal pocket readings. The upper arch x-rays do not clearly show 
such multiple areas of bone loss and as such does not meet medical necessity at this time under code D4341 
which is reserved for four or more areas of bone loss in a quadrant. The remaining treatment aside from an 
approved surgical extraction of severely broken down tooth #15 is not within the purview of the current policy. 
 
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 services have been met. Therefore, we decided that the Plan has to 
pre-approve the lower right and lower left periodontal scaling and root planning tooth #15 
 
We decided that the Plan does not have to pre-approve the upper right and upper left periodontal 
scaling and root planning tooth #15.  
 
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. 
 
Therefore, we decided that the Plan does not have to pre-approve the upper right and upper left periodontal 
scaling and root planning tooth #15. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 31, 2022. 
 
You asked the Plan to pay for an office visit. You say that these services were medically necessary The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on January 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown on tooth #12 (D2740) provided on October 17, 
2022. 
 
You asked the Plan to pay for the crown. You say that both crowns were medically necessary. 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 17, 2022. 
Therefore, we decided that the Plan does not have to pay for a crown on tooth #12 (D2740) provided on 
October 17, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the services are medically 
necessary. The Plan denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
   
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case. Our physician reviewer found the enrollee was approved for a non-emergent thyroidectomy. Based on the 
records, it was not expected that the enrollee would require hospital services that would likely cross 2 
midnights following the procedure. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on 
October 6, 2022. 
 
You asked the Plan to pay for an evaluation. You say that you are appealing the denial of a comprehensive oral 
evaluation. 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 November 6, 2021. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) 
provided on October 6, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for full mouth debridement (D4355) provided on November 17, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says that your benefit for the requested item or service 
has already been exhausted. 
 
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.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The Plan has 
not made reasonable and diligent efforts to gather and forward to us information regarding their decision to 
deny your request. There is no evidence showing your benefit for the requested item or service was previously 
exhausted. Therefore, we decided that the Plan has to pay for full mouth debridement (D4355) provided on 
November 17, 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
  You asked the Plan to pre-approve SNF care. You say that continued care at a skilled nursing facility is 
medically necessary. The Plan denied your request. The Plan says skilled services can be provided on an 
intermittent outpatient basis, in a long-term care facility, or at the home with home health care services. 
 
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 reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (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 skilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from November 
18, 2022, through November 19, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the services should be covered. The 
Plan denied your request. The Plan says the services were not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
   
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the review has determined that the record did not show that at the time of inpatient 
admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including 
earlier emergency department and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided from November 18, 2022, through 
November 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a periodic oral evaluation (D0120) and prophylaxis 
(D1110) provided on August 30, 2022. 
 
You asked the Plan to pay more for the dental services. You say that the amount the Plan paid is incorrect. The 
Plan denied your request. The Plan says you are responsible for any charged amount above the Plans cost-
sharing amount when your services are received from an out-of-network provider. The Plan also says that the 
cost sharing amount applied is correct. 
 
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. 
 
You have been asked to pay a total of $30.50 for a periodic oral evaluation ($21.50 coinsurance + $9 difference 
between the charged and approved amounts). You have also been asked to pay a total of $67 for prophylaxis 
($38 coinsurance + $29 difference between the charged and approved amounts). This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to pay more for a periodic oral evaluation (D0120) and prophylaxis (D1110) provided on August 
30, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infrared therapy (97026) provided from May 19, 2022, to 
June 1, 2022. 
 
You asked the Plan to pay for the infrared therapy. You say that you would like the information you submitted 
to be reviewed at the earlier convenience. The Plan denied your request. The Plan says infrared therapy is 
considered not reasonable and necessary by Medicare and is excluded from coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that the use of infrared and/or near-infrared light 
and/or heat, including monochromatic infrared energy, is non-covered for the treatment, including the 
symptoms such as pain arising from these conditions, of diabetic and/or non-diabetic peripheral sensory 
neuropathy, wounds and/or ulcers of the skin and/or subcutaneous tissues. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the infrared therapy have not been met. Therefore, we decided that the Plan does not have to pay 
for the infrared therapy (97026) provided from May 19, 2022, to June 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a threshold ramp (E1399). 
 
You asked the Plan to pre-approve a threshold ramp. You say that the item is necessary. The Plan denied your 
request. The Plan says the requested item is not primarily medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a threshold ramp (E1399).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diabetic supplies provided on August 19, 2022. 
 
You asked the Plan to pay for diabetic supplies. You say that all criteria were met for payment. The Plan 
denied your request. The Plan says these supplies have been correctly denied. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order. The date of delivery of supplies happened prior to the date 
of service, August 19, 2022. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for diabetic supplies 
provided on August 19, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the covid-19 testing provided on July 19, 2022. 
 
You asked the Plan to pay for the covid-19 testing. You say that the services were medically necessary, and 
you are appealing with supporting records. The Plan denied your request. The Plan says Original Medicare is 
responsible for payment. 
 
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 covid-19 testing provided on July 19, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergency ambulance transport provided on May 
26, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that this service is not subject to consolidated 
billing on the date of a skilled nursing facility discharge. The Plan denied your request. The Plan says Original 
Medicare is responsible for payment.  
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 non-emergency ambulance transport provided on May 26, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on October 8, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services at issue have been billed correctly. The 
Plan denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on October 8, 2021.