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

 
We decided that the Plan does not have to pay for SNF care provided April 1, 2022 to April 3, 2022 and from 
April 20, 2022 to April 30, 2022. 
 
You asked the Plan to pay for SNF care. The Plan denied your request. The Plan says SNF care provided from 
April 1, 2022 to April 3, 2022 and from April 20, 2022 to April 30, 2022 does not meet the Medicare coverage 
criteria. 
 
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 pay for SNF care provided from April 1, 2022 to 
April 3, 2022 and from April 20, 2022 to April 30, 2022. Our reviewer says that the requested SNF care is not 
considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found 
that based on the documentation provided, the enrollee did not qualify for SNF coverage. The enrollee did not 
have documented skilled nursing needs. The enrollee did not have documented skilled therapy needs. Daily 
skilled services were not required to establish a maintenance program or to prevent deterioration of the 
enrollees condition. The enrollees care needs were custodial and could, as a practical matter, be provided at a 
lower level of care (ex. home, assisted living, long term care). 
 
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 provided from April 1, 2022 to April 3, 2022 and from April 20, 2022 
to April 30, 2022 have not been met. Therefore, we decided that the Plan does not have to pay for coverage of 
SNF care provided from April 1, 2022 to April 3, 2022 and from April 20, 2022 to April 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for limited oral evaluations (D0140 x2), intraoral periapical 
radiographic images (D0230 x2, D0220), and a core buildup (D2950) provided from May 13, 2022, through 
June 3, 2022. 
 
You asked the Plan to pay for the dental services. You say that you want the Plan to pay for the services. The 
Plan denied your request. The Plan says your benefit for the intraoral periapical radiographic image has already 
been exhausted. The limited oral evaluations and core buildup are not covered services. 
 
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 intraoral periapical radiographic image was exhausted on date of service May 13, 
2022. Additionally, the limited oral evaluations and core buildup are not covered benefits. Therefore, we 
decided that the Plan does not have to pay for limited oral evaluations (D0140 x2), intraoral periapical 
radiographic images (D0230 x2, D0220), and a core buildup (D2950) provided from May 13, 2022, through 
June 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140), and an intraoral periapical 
radiographic image (D0220) provided on July 8, 2022, by an out-of-network provider. 
 
You asked the Plan to pay for the dental services. You say that you were not aware that the provider was out-
of-network. 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 limited oral evaluation (D0140), and an intraoral periapical radiographic image (D0220) provided 
on July 8, 2022, by an out-of-network provider.
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure code 80307. We decided that the Plan does not have to pay 
for procedure code 83789.  
 
You asked the Plan to pay for drug testing services (80307 and 83789) billed for date of service May 10, 2022. 
You say that these services were necessary and are supported in the medical record. The Plan says that these 
services are not payable, as the payment for code 83789 is included in the payment for code G0481 and another 
presumptive drug testing code has already been paid for this enrollee for the date in question. 
 
We decided that the Plan has to pay for procedure code 80307.  
 
The Plan must follow Medicare rules. The rules say that only one code from the 80305-80307 range may be 
reported per date of service for the same enrollee. The rules also 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. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan did not provide any evidence to show that another 
presumptive drug testing code (80305-80307) was already reported and paid to any provider for this enrollee 
on the date in question. Therefore, we decided that the Plan has to pay for procedure code 80307.  
 
We also decided that the Plan does not have to pay for procedure code 83789. 
 
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 code 83789 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 procedure code 83789. 
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve four (4) additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve additional PT visits. You say that the enrollee still has pain with limited 
mobility and needs ongoing therapy. The Plan denied your request. The Plan says they have agreed to pre-
approve six additional visits; however, the remaining four visits requested are not medically necessary and reasonable in this case. The six additional visits would be sufficient to transfer the enrollee's therapy and care to 
a home exercise plan and caregiver. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 additional PT visits. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that additional requested therapy generally is not accepted as specific 
and effective therapy for the enrollees condition beyond what was approved by the health plan. The enrollee 
has had prior therapy and the documentation does not reveal that the patient's requires the unique skills of a 
professional therapist to safely and effectively provide treatment, that the services can be safely and effectively 
performed only by a therapist, or by or under the supervision of a therapist. The enrollee will have ample 
therapy to transition to an independent home exercise program. The requested services are not part of a 
maintenance program, and the specialized skill, knowledge and judgment of a qualified therapist is not required 
to establish, design and/or deliver a program to maintain the patient's current condition or to prevent or slow 
further deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional PT visits have not been met. Therefore, we decided that the Plan does 
not have to pre-approve four (4) additional physical therapy (PT) visits.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on January 17, 2022, billed with 
codes 81210, 81328, 81407, 81408 and 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that these services were necessary and are 
supported in the medical record. The Plan denied your request. The Plan says this claim was not billed in 
accordance with Medicare rules. 
 
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 
January 17, 2022, billed with codes 81210, 81328, 81407, 81408 and 81479.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the retreatment of a previous root canal therapy provided on 
March 23, 2022. 
 
You asked the Plan to pay for the retreatment of a previous root canal. You say that the services should be 
covered as you disagree with the denial. The Plan denied your request. The Plan says the services denied 
correctly as they do not fall within 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 the 
retreatment of a previous root canal therapy provided on March 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a porcelain/ceramic crown (D2740) for tooth numbers 
11, 10, 9, 8, 7, 6 and the adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities (D0431). 
 
You asked the Plan to pre-approve the dental services. You say that you need the crowns removed due to the 
pain and bleeding. The Plan denied your request. The Plan says your benefit for the requested item or service 
has already been exhausted for the porcelain/ceramic crown (D2740) for tooth numbers 11, 10, 9, 8, 7, 6. The 
Plan also says that the adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities (D0431) is 
not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 a porcelain/ceramic crown (D2740) for tooth numbers 11, 10, 9, 8, 7, 6 was exhausted 
on date of service April 9, 2021. The record also shows that the adjunctive pre-diagnostic test that aids in 
detection of mucosal abnormalities (D0431). Therefore, we decided that the Plan does not have to pre-approve 
a porcelain/ceramic crown (D2740) for tooth numbers 11, 10, 9, 8, 7, 6 and the adjunctive pre-diagnostic test 
that aids in detection of mucosal abnormalities (D0431).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional payment for the office or other outpatient visit for 
the evaluation and management of an established patient, which requires a medically appropriate history and/or 
examination and moderate level of medical decision making (99214) provided May 4, 2022. 
 
You asked the Plan to provide additional payment for the vision office visit. You say that this was a diabetic 
retinal exam. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $25 
copayment for office visits to specialists.  
 You have been asked to pay a $25 copayment for the vision office visit. This item/service falls within the office 
visits to specialists benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. 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 provide additional payment for the office or 
other outpatient visit for the evaluation and management of an established patient, which requires a medically 
appropriate history and/or examination and moderate level of medical decision making (99214) provided May 
4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for resin-based composite - three surfaces, posterior (D2393) 
and resin-based composite - four or more surfaces, posterior (D2394) provided on May 11, 2022. 
 
You asked the Plan to pay for dental services. You say that you thought your optional supplemental dental 
service would be back dated to cover these services. The Plan denied your request. The Plan says you were not 
enrolled in the supplemental dental coverage at the time the supplemental dental services were received. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for resin-based composite - three 
surfaces, posterior (D2393) and resin-based composite - four or more surfaces, posterior (D2394) provided on 
May 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on August 1, 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 the service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 dental 
services on August 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service May 17, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says procedure code 99100 is 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 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service May 17, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy provided by a participating provider. 
 
You asked the Plan to pre-approve physical therapy. You say that additional PT sessions are medically 
necessary. The Plan denied your request. The Plan says these services have been correctly denied. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 physical therapy. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the medical criteria for additional physical therapy have not been met. 
The enrollee has been approved sufficient therapy to ensure competence in a home exercise 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 physical therapy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve physical therapy provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a resin-based composite (D2393, D2392) provided on May 
24, 2022. 
 
You asked the Plan to pay for the resin-based composite. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they do 
not fall within 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 resin-
based composite (D2393, D2392) provided on May 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental crowns (D6740, D6245) provided on May 12, 2022. 
 
You asked the Plan to pay for the dental crowns. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within 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 dental 
crowns (D6740, D6245) provided on May 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment pay for the comprehensive oral examination, 
intraoral x-ray, and removal of plaque (D0150, D0210, D1110) provided on February 16, 2022. 
 
You asked the Plan to waive the copayment pay for the comprehensive oral examination, intraoral x-ray, and 
removal of plaque. You say that the services should be covered as you disagree with the charges. The Plan 
denied your request. The Plan says the cost-sharing applied correctly based on the services provided and cannot 
be waived as it is contractually obligated and were agreed upon when signing up with 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 waive the 
copayment pay for the comprehensive oral examination, intraoral x-ray, and removal of plaque (D0150, 
D0210, D1110) provided on February 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection represented by code E2311, an 
expandable controller represented by code E2377, an expandable controller harness represented by code 
E2313, and a power seat elevation feature represented by code E2300. 
 
You asked the Plan to pre-approve codes E2311, E2377, E2313, and E2300. You say that you are in need of 
the items in dispute, as you are unable to walk and need to get around your home. The Plan denied your 
request. The Plan says it is not medically necessary to control the three requested power options through the 
joystick. The Plan says that the power seat elevation feature is non-covered because it does not serve a medical 
purpose.  
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. Medicare rules say that a power seat elevation feature is non-covered because it is 
not primarily medical in nature.   
 
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 codes E2311, E2377, E2313, and 
E2300. Our reviewer says that the items which remain in dispute are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee is independent in dressing. She does not 
require a single point of control via a joystick to manage multiple power drives. She has adequate upper body 
motion and strength to use standard drive controls. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of codes E2311, E2377, E2313, and E2300 have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an electronic connection represented by code E2311, an 
expandable controller represented by code E2377, an expandable controller harness represented by code 
E2313, and a power seat elevation feature represented by code E2300.