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

 
We decided that the Plan does not have to pay for lab services provided on September 30, 2021. 
 
You asked the Plan to pay for the lab services. You say that these lab services are covered by Medicare. 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 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 September 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the root canal (D3320) provided on October 4, 2021. 
 
You asked the Plan to reimburse you for the dental service. You say that you were never advised that you 
needed to see a provider that accepts Medicare. You also say that you would like to be reimbursed for this 
service. The Plan denied your request. The Plan says the provider in this case has opted out of Medicare. The 
Plan also says that payment cannot be made to providers that have opted out of Medicare. 
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, dental services performed by a 
provider that has opted out of Medicare are not among those covered under this benefit. Therefore, we decided 
that the Plan does not have to reimburse you for the root canal (D3320) provided on October 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve porcelain fused to noble metal crowns (D2752) and core 
buildups (D2950) for teeth #2, #10 and #14. 
 
You asked the Plan to pre-approve crowns and core buildups. You say that these teeth are in desperate need of 
restoration and these services are necessary to save these teeth. The Plan denied your request. The Plan says 
these services are not medically necessary as tooth #10 has less than 50% bone support which means a poor 
long-term prognosis despite the restorations, and teeth #10 and #14 have recurrent decay. The criteria for 
coverage of crowns are not met. 
 
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 crowns and 
core buildups 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 crowns and core buildups. Our reviewer 
says that the requested services are not medically necessary. Our physician reviewer found that tooth #2 has an 
existing two surface restoration with possibly a buccal restoration as well, #10 appears to have an existing 
composite veneer with decay on the mesial aspect (noted as distal in the clinical notes), and #14 appears to 
have distal decay with existing occlusal restorations. The bone support on #2 and #14 is more than 50%, the 
bone support on #10 is at about 30%. The severe periodontal compromise of tooth #10 makes it a poor 
candidate for a crown restoration as it would have a poor long-term prognosis with the loss of over 50% of the 
bone. Tooth #2 does not have a substantial loss of tooth structure such that it would require the strength of a 
crown to function properly in the occlusion. There are 2-3 involved surfaces and no cusps involved, indicating 
the tooth may be restored with a conventional restoration. Tooth #14 has existing occlusal amalgam 
restorations that were noted as leaking; the x-ray appears to show possible distal decay as well. Tooth #14 does 
not exhibit a substantial loss of tooth structure such that it would require the strength of a crown, and a 
conventional restoration would provide adequate repair to the tooth. Core buildups are only necessary where 
there is inadequate structure to support a crown restoration, if so approved. Therefore, the requested services 
for teeth #2, #10 and #14 are not medically necessary in this case. 
 
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 crowns and core buildups have not been met. Therefore, we decided that the 
Plan does not have to pre-approve porcelain fused to noble metal crowns (D2752) and core buildups (D2950) 
for teeth #2, #10 and #14.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve the SNF admission. You say that you are in need of physical and 
occupational therapy, and need to be transferred to a SNF to get this treatment. The Plan denied your request. 
The Plan says the criteria for admission to a SNF have not been met. 
 
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 the SNF admission. Our reviewer says 
that you do not meet the Medicare criteria for SNF care. Our physician reviewer found 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 SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Although you have skilled therapy needs, 
these needs are not on a daily basis. Based on this information, we decided that Medicare rules for coverage of 
the SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
skilled nursing facility (SNF) admission.
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 enrollee needs LTACH care. The 
Plan denied your request. The Plan says the enrollee is receiving appropriate in-patient acute care and does not 
require transfer to an LTACH. 
 
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 that the enrollee appears to be improving and should only require short-term 
additional acute care services that can be safely administered at the current facility for the time being until a 
lower level of care is appropriate. The enrollee does not require services at the LTACH that are not already 
available at the current facility. There are no services at the LTACH that the enrollee requires that are not 
already available and covered at the current facility.  
 Admission to LTACH is not medically necessary as it would not be clinically advantageous. Transfer to a 
lower level of care may be considered when treatment has completed. 
 
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 pre-approve a custom fabricated abutment (D6057) and implant 
supported crown (D6066). 
 
You asked the Plan to pre-approve the custom fabricated abutment and implant supported crown. You say that 
you were verbally told that these services were covered. The Plan denied your request. The Plan says these 
services are not covered benefits under your dental plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
custom fabricated abutment (D6057) and implant supported crown (D6066).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infectious agent detection by nucleic acid (DNA or RNA), 
not otherwise specified (87798) infectious agent detection by nucleic acid (DNA or RNA) (87482) provided 
April 14, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that procedures performed were deemed 
clinically necessary by performing provider as per the enrollee's medical needs. Please review attached medical 
records and reprocess accordingly. The Plan denied your request. The Plan says the PCR testing is considered 
unproven and not medically necessary. 
 
 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered. 
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay 
for infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified (87798) infectious agent 
detection by nucleic acid (DNA or RNA) (87482) provided April 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve reline complete maxillary denture (indirect) (D5750), 
mandibular partial denture - cast metal framework with resin denture bases (including retentive/clasping 
materials, rests and teeth) (D5214), and complete denture - maxillary (D5110) 
 
You asked the Plan to pre-approve the reline complete upper denture, lower partial denture and complete upper 
denture. You say that the dentures you have now are too bulky, you cannot chew, and food gets stuck in your 
teeth. The Plan denied your request. The Plan says dentures are 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 pre-approve reline complete maxillary denture (indirect) (D5750), mandibular partial denture - cast metal framework with 
resin denture bases (including retentive/clasping materials, rests and teeth) (D5214), and complete denture - 
maxillary (D5110)
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve four dental implants (D6010), four implant supported 
crowns (D6065) and four prefabricated abutments (D6056). 
 
You asked the Plan to pre-approve the dental services. You say that these services are necessary. The Plan 
denied your request. The Plan says these services are not covered by your dental benefit. 
 
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 four 
dental implants (D6010), four implant supported crowns (D6065) and four prefabricated abutments (D6056).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cone beam computed tomography (CT) image capture 
(D0383) and consultation (D9310) provided on November 19, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the cone beam CT image capture and consultation. You say that you do not feel 
it is fair or right to disallow payment to the provider. You also say that you do not feel it is fair that you have to 
pay for these services. The Plan denied your request. The Plan says these services were rendered by a non-
contracted provider. The Plan also says that your plan does not cover services from a provider who is not in-
network. 
 
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 
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the cone 
beam computed tomography (CT) image capture (D0383) and consultation (D9310) provided on November 19, 
2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the preventive procedure (D1999) provided on November 30, 2021. 
 
You asked the Plan to pay for the preventive procedure. You say that you would like to know why this service 
was denied. The Plan denied your request. The Plan says this service is not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
preventive procedure (D1999) provided on November 30, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an esophagogastroduodenoscopy procedure (43235) 
provided on October 11, 2021. 
 
You asked the Plan to pay for an esophagogastroduodenoscopy. You say that you have provided records to 
substantiate the service at issue. The Plan denied your request. The Plan says rules for payment have not been 
met because the service at issue is inclusive to another billed code. 
 
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, the CPT Code Manual definition of code 43235 is "Esophagogastroduodenoscopy, flexible, 
transoral; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate 
procedure)." 
We asked our coder 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 an esophagogastroduodenoscopy. Our reviewer says that the 
service at issue does not meet criteria for reimbursement. Our reviewer found that CPT code 43235 is not 
considered inclusive to CPT code 43775; however, the operative report does not document the endoscopy 
procedure is not related to the laparoscopic procedure performed. If the provider is performing an endoscopy 
procedure to verify any injury incurred by other procedures performed, then this procedure would not be 
reported separately. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an esophagogastroduodenoscopy have not been met. Therefore, we decided that 
the Plan does not have to pay for an esophagogastroduodenoscopy procedure (43235) provided on October 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a resin-based composite (D2331) provided by a participating 
provider on November 19, 2021. 
 
You asked the Plan to pay for a resin-based composite. You say that the first filling was done poorly. The Plan 
denied your request. The Plan says the benefit limit for D2331 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. The Plan covers a resin-based 
composite when the services every two years. 
 
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 a resin-based composite have not been met. Therefore, we decided that the Plan 
does not have to pay for a resin-based composite (D2331) provided by a participating provider on November 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve porcelain fused to high noble metal crowns (D2750) for 
teeth #11 and #12. 
 
You asked the Plan to pre-approve the crowns. You say that crowns are medically necessary for these teeth, 
and without the crowns there is a high chance of fracture, loss of tooth, and need for a partial denture in the 
future. The Plan denied your request. The Plan says these teeth both have poor periodontal health, and therefore 
the criteria for clinical coverage of crowns are not met in this case. 
 
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 crowns 
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 crowns. Our reviewer says that the 
requested crowns are not supported as medically necessary in this case. Our physician reviewer found the 
documentation provided indicates that teeth #11 and #12 contain gross caries and very poor periodontal support 
of less than 50%. The prognosis is poor for success of the indicated treatment, and therefore the requested 
crowns are not supported as medically reasonable and necessary. 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 crowns have not been met. Therefore, we decided that the Plan does not 
have to pre-approve porcelain fused to high noble metal crowns (D2750) for teeth #11 and #12.
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 disagree with the denial. The Plan denied your 
request. The Plan says the services are not medically necessary. 
 
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 medically necessary. Our physician reviewer found the enrollee was admitted to the 
hospital for infection of the right knee after recent knee replacement surgery, atrial fibrillation, and rheumatoid arthritis. He is now medically stable with no complex nursing or rehabilitation needs. She does not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While the enrollee has a need for physical and/or occupational therapy, there is 
no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that 
the 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance (D4910), oral exam (D0120), 
and filling (D2392) provided on October 14, 2021. 
 
You asked the Plan to pay for the dental services. You say that you were not aware of or informed that the 
$1,000 limit was exhausted. you say that you are on a limited income. You also say that you cannot afford to 
pay this bill. The Plan denied your request. The Plan says there is an annual maximum benefit of $1,000. The 
Plan also says that the annual maximum benefit has 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 and the services are listed as covered, 
the annual maximum benefit of $1,000 has been exhausted. The record shows that the Plan paid $318 for services you received June 10, 2021, and $682 for services you received on October 14, 2021. $318 + $682 = 
$1,000. The record shows that after the annual maximum is exhausted, any remaining charges are your 
responsibility. Therefore, we decided that the Plan does not have to pay for the periodontal maintenance 
(D4910), oral exam (D0120), and filling (D2392) provided on October 14, 2021.