Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home healthcare services provided from April 4, 2022, to 
April 28, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the home healthcare services. You say that you believe this claim was 
inappropriately denied, and you would like it to be reprocessed for payment. The Plan denied your request. The 
Plan says the treating provider is not a network provider with the Plan, and the services were not referred by a 
network provider. The Plan also says that these services are not urgent or emergent, nor were they approved in 
advance. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the home healthcare services provided from April 
4, 2022, to April 28, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the removal of impacted wisdom teeth #17 and #32 
(D7220). 
 
You asked the Plan to pre-approve wisdom tooth extractions. You say that you need the wisdom teeth extracted 
or it will become life threatening. The Plan denied your request. The Plan says any code not listed in the 
contract is not a covered procedure. Since the requested code does not appear on the list, the decision to deny 
pre-approval is correct. 
 
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 pre-approve the 
removal of impacted wisdom teeth #17 and #32 (D7220).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an apicoectomy - molar first root (D3425), and a retrograde 
filling - per root (D3430), provided on May 5, 2022. 
 
You asked the Plan to pay for an apicoectomy - molar first root (D3425) and a retrograde filling - per root 
(D3430). You say that you are requesting coverage for the extended root canal procedure. You say that you 
have additional dental coverage to help pay for dental work beyond the routine cleaning and exams each year. 
The Plan denied your request. The Plan says these services are not covered under your benefit package. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an 
apicoectomy - molar first root (D3425), and a retrograde filling - per root (D3430), provided on May 5, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to be more stable and improving and should only require short-
term additional acute care services that can safely be administered at the current facility until more stable and 
appropriate for a lower level of care. The enrollee does not require services at the LTACH that are not already 
available at the current facility. 
 
   
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and a panoramic x-
ray (D0330) provided on May 17, 2022. 
 
You asked the Plan to pay for the dental services. You say that if the dentist would have looked at your 
previous records, they would have seen your x-rays did not need to be repeated. 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 August 10, 2020. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and a 
panoramic x-ray (D0330) provided on May 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cone beam imaging (D0364) provided on February 17, 2022. 
 
You asked the Plan to pay for imaging. You say that you have been making payments towards your balance for 
the cone beam imaging. The Plan denied your request. The Plan says cone beam imaging (D0364) is not 
covered by your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for cone 
beam imaging (D0364) provided on February 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the glasses purchased on April 25, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the glasses. You say that you needed glasses because the ones you had were 
broken. The Plan denied your request. The Plan says you received this item from a non-contracted provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the glasses purchased on April 25, 2022, by an 
out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a consultation (D9310) provided on May 11, 2022. 
 
You asked the Plan to pay for a consultation. You say that you disagree with the denial of dental services. The 
Plan denied your request. The Plan says a consultation (D9310) is not covered by your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a 
consultation (D9310) provided on May 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the extractions (D7140 and D7210), a maxillary denture 
(D5130), and a mandibular denture (D5140) for tooth #2, #13, #20, #21, #22, #23, #24, #25, #26, #27, and #28. 
 
You asked the Plan to pre-approve the dental services. You say that you would like the procedures to 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 of February 24, 2022. 
Therefore, we decided that the Plan does not have to pre-approve the extractions (D7140 and D7210), a 
maxillary denture (D5130), and a mandibular denture (D5140) for tooth #2, #13, #20, #21, #22, #23, #24, #25, 
#26, #27, and #28.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implant/abutment supported removable maxillary 
denture (D6110) and an implant/abutment supported removable mandibular denture (D6111). 
 
You asked the Plan to pre-approve the dental services. You say that these implants are medically necessary. 
The Plan denied your request. The Plan says an implant/abutment supported removable maxillary denture 
(D6110) and an implant/abutment supported removable mandibular denture (D6111) are not covered by your 
routine dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an 
implant/abutment supported removable maxillary denture (D6110) and an implant/abutment supported 
removable mandibular denture (D6111).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee will receive the appropriate level of care 
in the acute rehabilitation setting. Completion of inpatient rehabilitation will help avert unplanned re-admission 
to the acute care hospital and ensure a safe discharge home where the enrollee can continue recovery with 
home health and transition to a neuro outpatient program. The Plan denied your request. The Plan says the 
service requested is not supported based on the records we 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 enrollee has a history including peripheral vascular disease, end-stage renal 
disease, diabetes mellitus and obesity who was admitted to the hospital due to right foot gangrene. The enrollee 
was treated surgically with a below-the-knee amputation and has stabilized medically but has had some 
delirium and anemia. The most recent therapy notes indicate that the enrollee requires extensive assistance for 
transfers, bed mobility and is unable to ambulate. The enrollee's level of confusion has limited ability to 
participate in skilled rehabilitation services. There are no complex nursing or rehabilitation needs. While the 
enrollee has a need for physical or occupational therapy, there is no documentation of a need for an intensive 
rehabilitation program. 
 
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 IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive periodontal evaluation - new or 
established patient (D0180) provided November 15, 2021. 
 
You asked the Plan to pay for the comprehensive periodontal exam. You say that you feel your standard exam 
and cleaning should be covered despite the periodontal services performed. 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 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 
comprehensive periodontal evaluation - new or established patient (D0180) provided November 15, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient surgery services provided on March 2, 2022 to 
March 3, 2022, by an OON provider. 
 
You asked the Plan to pay for outpatient surgery services. You say that the Plan processed the claim 
incorrectly. The Plan denied your request. The Plan says the out-of-network services were not authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for outpatient surgery services provided on March 2, 
2022 to March 3, 2022, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tetanus, diphtheria, pertussis (Tdap) vaccination (90715) 
and administration (90471) provided on March 30, 2022. 
 
You asked the Plan to pay for the immunization. You say that this was not explained to you that it would not be 
covered. You also say that this should be covered for the elderly. The Plan denied your request. The Plan says 
the claim processed correctly. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the immunization. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the immunization. 
Therefore, we decided that the Plan does not have to pay for the Tetanus, diphtheria, pertussis (Tdap) 
vaccination (90715) and administration (90471) provided on March 30, 2022.  
 
Benefits for the immunization may be available under Medicare Part D. Contact the Plan that administers Part 
D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tetanus, diphtheria, pertussis (Tdap) vaccination (90715) 
and administration (90471) provided on May 7, 2022. 
 
You asked the Plan to pay for the immunization. You say that your doctor gave you a prescription to get a Tdap 
vaccine. You also say that your insurance did not pay anything. The Plan denied your request. The Plan says 
the claim processed correctly. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the immunization. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the immunization. 
Therefore, we decided that the Plan does not have to pay for the Tetanus, diphtheria, pertussis (Tdap) 
vaccination (90715) and administration (90471) provided on May 7, 2022.  
 
Benefits for the immunization may be available under Medicare Part D. Contact the Plan that administers Part 
D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance (D4910) provided on May 19, 2022. 
 
You asked the Plan to pay for periodontal maintenance. You say that you did not know that the provider left the 
network in April 2022 at the time of your appointment. The Plan denied your request. The Plan says 
periodontal maintenance (D4910) is not covered by your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 
periodontal maintenance (D4910) provided on May 19, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 20936 and 22846 billed for date of service 
April 6, 2022. 
 
You asked the Plan to pay for procedure codes 20936 and 22846. You say that the operative report should be 
reviewed, and the claim reconsidered for additional reimbursement. The Plan denied your request. The Plan 
says procedure code 20936 and 22846 are considered bundled and not separately payable. 
  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 20936 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 20936 is not separately payable. We have also confirmed that code 22846 is a column II code 
to column I code 22853. Procedure code 22846 has not been billed with an appropriate modifier to bypass the 
edit. Based on this information, we decided that Medicare rules for coverage of procedure code 20936 and 
22846 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 20936 
and 22846 billed for date of service April 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), intraoral x-rays 
(D0210), prophylaxis (D1110), and fluoride treatment (D1206) provided on June 13, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
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 comprehensive oral evaluation (D0150), intraoral x-rays (D0210), prophylaxis (D1110), and 
fluoride treatment (D1206) provided on June 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve guided tissue regeneration of tooth #28 (D4266). 
 
You asked the Plan to pre-approve guided tissue regeneration. You say that the procedure is necessary due to 
your bone loss. The Plan denied your request. The Plan says the requested procedure is not a covered benefit 
according to your contract. 
 
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 pre-approve 
guided tissue regeneration of tooth #28 (D4266).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve the requested device. You say that you have been using the device to check 
your blood sugars. The Plan denied your request. The Plan says you are not doing multiple daily insulin 
injections. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 We looked at the file and Medicare rules. The documentation does not indicate that you use insulin with at least 
three daily injections or require frequent self-adjustment of insulin dosage based on the blood glucose testing 
results. Based on this information, we decided that Medicare rules for coverage of the requested device have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.