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

 
We decided that the Plan does not have to pay for the At-Home COVID test (E1399) provided January 22, 
2022. 
 
You asked the Plan to pay for the At-Home COVID test. You say that you feel you should be reimbursed. The 
Plan denied your request. The Plan says this service was not covered under your Plan at the time of purchase. 
 
The Plan must follow Medicare rules. The Plan offers a supplemental benefit for at-home COVID tests that 
exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan contract 
says that at-home COVID tests will be covered starting February 1, 2022. 
 
We looked at the file and Medicare rules. The Plan contract offers a supplemental benefit to cover the at-home 
COVID test. The Plans benefit for this service began on February 1, 2022. The COVID test at issue was 
provided prior to the implementation of this benefit. Therefore, we decided that the Plan does not have to pay 
for the At-Home COVID test (E1399) provided January 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scaling and root planing in all four 
quadrants (D4341) and periodontal maintenance (D4910). 
 
You asked the Plan to pre-approve the dental services. You say that you have pocket depths of 5mm or greater. 
The Plan denied your request. The Plan says the documentation submitted does not show bone loss, discharge, 
redness and swelling of the gums and pockets depths of 5 mm or greater. The Plan also says there is no history 
of periodontal therapy. 
 
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 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 coverage criteria has not been met. Our physician reviewer found that the provided x-rays and periodontal 
charting do not show any periodontal issues except in the distal area of tooth #13 where there is a 
deposit of tartar at the cementum enamel junction along with pocket readings of 4 mm on the distal area of 
tooth #13 and the mesial area of tooth #14. As there were less than four teeth involved in any quadrant, it is not 
reasonable to apply code D4341 in any quadrant. Our physician reviewer also found that there is no 
documentation of periodontal bone loss, discharge, redness and swelling of the gums, and pockets depths of 5 
mm or greater to warrant periodontal maintenance (D4910). 
 
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 not been met. Therefore, we decided that the Plan does 
not have to pre-approve periodontal scaling and root planing in all four quadrants (D4341) and periodontal 
maintenance (D4910).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical status does not require intensive physician and nursing oversight in an IRF. While the enrollee may 
benefit from additional multiple therapies, including physical and occupational therapy, the documentation 
does not reveal that she requires this therapy on an intensive IRF level or can tolerate intensive therapy. The 
therapy notes indicate she is limited by shortness of breath, weakness, and anxiety. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a biopsy performed on March 19, 2021. 
 
You asked the Plan to pay for a biopsy performed on March 19, 2021. You say that you should not be 
responsible for this amount because this should be covered at 100% under the Preventative Care benefit. The 
Plan denied your request. The Plan says you are responsible for a $295 copayment for surgery provided at an 
ambulatory surgical center. 
 
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 $295 
copayment for Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and 
Ambulatory Surgical Centers.  
 
You have been asked to pay a $295 copayment for a biopsy. A biopsy falls within the Outpatient Surgery and 
Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 pay for a biopsy performed on March 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the periodic oral evaluation (D0120) and prophylaxis 
(D1110) provided on April 5, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay more for the periodic oral evaluation and prophylaxis. You say that you thought 
your cleaning and exam would be covered in full. The Plan denied your request. The Plan says you are 
responsible for the $10 copayment per covered service, plus any charged amount above the Plan's cost-sharing 
amount when your services are received from an OON provider. 
 
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. 
 
You have been asked to pay a $10 copayment per service, plus the difference between the OON provider's 
charges and the Plan's payment. 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 the periodic oral 
evaluation (D0120) and prophylaxis (D1110) provided on April 5, 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 bone replacement graft (D7953) provided on March 14, 2022. 
 
You asked the Plan to pay for the graft. You say that this service was medically necessary and should be 
covered. The Plan denied your request. The Plan says bone replacement graft (D7953) is 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 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 a bone 
replacement graft (D7953) provided on March 14, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home infusion therapy services coded S9328 provided 
from February 26, 2022, to March 25, 2022. 
 
You asked the Plan to pay for the home infusion therapy service. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable. 
 
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 S9328 is home infusion therapy, implanted pump pain 
management infusion; administrative services, professional pharmacy services, care coordination, and all 
necessary supplies and equipment (drugs and nursing visits coded separately), per diem. 
 
 We find that CPT code S9328 is not supported in the medical record. Specifically, this code has a status code 
of "I". A status code of I means that this code is not valid for Medicare purposes. Medicare uses another code 
for reporting of, and payment of these services. Based on this information, we decided that Medicare rules for 
coverage of the home infusion therapy service have not been met. Therefore, we decided that the Plan does not 
have to pay for the home infusion therapy services coded S9328 provided from February 26, 2022, to March 
25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the 2D oral/facial photographic image obtained intra-orally 
or extra-orally (D0350) provided March 10, 2022. 
 
You asked the Plan to pay for the 2D oral/facial photograph. You say that these photographs were necessary 
and should be covered. 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 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 2D 
oral/facial photographic image obtained intra-orally or extra-orally (D0350) provided March 10, 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 for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs this level of care. The 
Plan denied your request. The Plan says that records do not show that the enrollee needs care that can only be 
provided in an acute care hospital or that the enrollee will require an average 25-day length of stay in 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. The patient 
appears to be more stable and improving but requires additional short-term acute care services that can safely 
be completed at the current facility until more stable and appropriate for a lower level of care. The patient does 
not require services at the LTACH that are not already available at the current facility. Our physician reviewer 
found that the enrollee's condition does not meet Medicare criteria for LTACH services. 
 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 for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services provided on June 8, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that if one laboratory procedure evaluates multiple 
genes using a next generation sequencing procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, ultianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis CPT code.  
 We looked at the file and Medicare rules. In this case, the requested genetic testing was billed with multiple 
codes. Per Medicare rules, the testing should be reported with one unit of one CPT code. Based on this 
information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we 
decided that the Plan does not have to pay for the genetic testing services provided on June 8, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chest x-ray services provided on January 12, 2022. 
 
You asked the Plan to pay for the x-ray services. The Plan denied your request. The Plan says only one 
radiology report was submitted for review. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. 
 
We looked at the file and Medicare rules. We find that CPT code 71045 was billed and paid by the Plan on 
January 26, 2022. Comparison of the two claims shows these are exact duplicates. There is no evidence 
presented to support that the billed services were provided twice on the same date.  Based on this information, we decided that the Medicare rules have not been met. Therefore, we decided that 
the Plan does not have to pay for the chest x-ray services provided on January 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical placement of implant body: endosteal implant 
(D6010) provided on December 15, 2021. 
 
You asked the Plan to pay for the endosteal implant. You say that you believe you qualify for coverage for the 
implant under the medical policy. 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 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 
surgical placement of implant body: endosteal implant (D6010) provided on December 15, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a replacement continuous positive airway pressure (CPAP) 
machine. 
 
You asked the Plan to pre-approve a CPAP machine. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says that the requested item is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that CPAP is covered for certain indications. 
 
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 CPAP machine. Our reviewer says 
that the documentation supports that the requested replacement CPAP machine is medically reasonable and 
necessary. Our physician reviewer found you have been on CPAP for obstructive sleep apnea (OSA) since 
2017. Your statement shows that your CPAP was recalled by Respironics, the manufacturer. CPAP is 
considered medically necessary for you. Because your original device was more than five years old at the time 
of the recall, you are eligible for a replacement device. Therefore, you meet criteria for the requested device. 
 
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 CPAP machine have been met. Therefore, we decided that the Plan has to pre-
approve a replacement continuous positive airway pressure (CPAP) machine.  
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Regadenoson (J2785), cardiovascular stress test 
(93015), sestamibi (A9500), and myocardial perfusion imaging (78452). 
 
You asked the Plan to pre-approve Regadenoson, cardiovascular stress test, sestamibi, and myocardial 
perfusion imaging. The Plan denied your request. The Plan says the nuclear stress test is not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that typically, a patient will not require both a stress 
echocardiogram and a stress nuclear test for the same clinical problem. 
 
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 Regadenoson, cardiovascular stress test, 
sestamibi, and myocardial perfusion imaging. Our reviewer says that these services are not reasonable and 
necessary. Our physician reviewer found the patient has a history of elevated blood pressure. The patients pre-
test probability for an abnormal test is low and there is no documentation that his electrocardiographic 
monitoring (ECG) shows an uninterpretable pattern. Our reviewer found that there is no evidence provided that 
would support the need for radionuclide stress testing. Our physician reviewer also found that there is 
insufficient documentation to support the medical necessity for the requested cardiac stress testing in this 
patients clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Regadenoson, cardiovascular stress test, sestamibi, and myocardial perfusion 
imaging have not been met. Therefore, we decided that the Plan does not have to pre-approve Regadenoson 
(J2785), cardiovascular stress test (93015), sestamibi (A9500), and myocardial perfusion imaging (78452).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete denture - maxillary (D5110) and mandibular 
partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests 
and teeth) (D5214) provided June 22, 2021. 
 
You asked the Plan to pay for the dental services. You say that you cannot afford the cost of the services. 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 Plan's 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 28, 2019. 
Therefore, we decided that the Plan does not have to pay for the complete denture - maxillary (D5110) and 
mandibular partial denture - cast metal framework with resin denture bases (including retentive/clasping 
materials, rests and teeth) (D5214) provided June 22, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hot or cold packs therapy (97010) provided on January 13, 2022. 
 
You asked the Plan to pay for hot or cold packs therapy. You say that these services were pre-approved by the 
Plan and were billed appropriately. The Plan denied your request. The Plan says they have agreed to pay for the 
other therapy services; however, the payment for 97010 is always bundled into the payment for another item or 
service. This code is not eligible for separate payment. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 We find that CPT code 97010 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 97010 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of hot or cold packs therapy have not been met. Therefore, we decided that the Plan does not have to pay for 
hot or cold packs therapy (97010) provided on January 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bitewings - four radiographic images (D0274), periodic 
oral evaluation - established patient (D0120), and prophylaxis - adult (D1110) provided August 10, 2021. 
 
You asked the Plan to pay for the bitewing x-rays, periodic oral exam and dental cleaning. You say that this 
should have nothing to do with Medicare not being accepted by your dentist. The Plan denied your request. The 
Plan says these services are not covered because the provider has 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 Plans coverage rules apply in this case. The Plan covers the bitewing 
x-rays, periodic oral exam and dental cleaning when you see any licensed dental provider who accepts 
Medicare patients in the United States and has not opted out of Original Medicare. 
 
We looked at the file and Medicare rules. The services at issue in this appeal were provided in a non-urgent, 
non-emergent situation by the provider who has opted out of the Medicare program. Based on this information, 
we decided that the Plan's rules for coverage of the bitewing x-rays, periodic oral exam and dental cleaning 
have not been met. Therefore, we decided that the Plan does not have to pay for the bitewings - four 
radiographic images (D0274), periodic oral evaluation - established patient (D0120), and prophylaxis - adult 
(D1110) provided August 10, 2021.