Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic radiographic image (D0330), limited oral 
evaluation - problem focused (D0140), extractions, erupted tooth requiring removal of bone and/or sectioning 
of tooth, and including elevation of mucoperiosteal flap if indicated (D7210), and unspecified preventive 
procedure, by report (D1999) provided November 11, 2021, and December 6, 2021. 
 You asked the Plan to pay for the panoramic x-ray, limited oral exam, extractions and unspecified preventative 
procedures. You say that you were not aware the provider had opted out of Medicare. 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 panoramic 
x-ray, limited oral exam, extractions and unspecified preventative procedures 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. The file included a signed 
private contract showing indicating that claims from this provider could not be submitted to Medicare and no 
Medicare reimbursement would be provided to you for the services. Based on this information, we decided that 
the Plan's rules for coverage of the panoramic x-ray, limited oral exam, extractions and unspecified 
preventative procedures have not been met. Therefore, we decided that the Plan does not have to pay for the 
panoramic radiographic image (D0330), limited oral evaluation - problem focused (D0140), extractions, 
erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal 
flap if indicated (D7210), and unspecified preventive procedure, by report (D1999) provided November 11, 
2021, and December 6, 2021.
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 the SNF stay should be approved. The 
Plan denied your request. The Plan says you do not meet the CMS criteria for skilled nursing level of care. 
 
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 qualify for SNF services. Our physician reviewer found you do not have documented skilled 
nursing needs or skilled therapy needs. Your care needs can be provided at a lower level of 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for domiciliary services provided on December 17, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for domiciliary services. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 domiciliary services provided on December 17, 
2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 3, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider is out-of-network and it was determined 
these services can be received in-network. 
 
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 an office visit provided on January 3, 2022 by an 
out-of-network (OON) provider.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for surgical services provided to the enrollee on December 8, 2021. 
 
You asked the Plan to pay for this should be paid for.. You say that this should be paid for. The Plan denied 
your request. The Plan says that the denied codes are not supported in the medical records submitted. 
 
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 
the denied codes is: 
 
CPT 38720: 
 
Cervical lymphadenectomy (complete) 
 
CPT 42415: 
 
Excision of parotid tumor or parotid gland; lateral lobe, with dissection and preservation of facial nerve 
 
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 this should be paid for.. Our reviewer says that the services at 
issue in this case were supported by the medical records. Our reviewer found the record indicates that the 
enrollee underwent a procedure. The operative report and pathology report sufficiently describe the 
performance of the noted codes. The elements of the coverage criteria are satisfied.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this should be paid for. have been met. Therefore, we decided that the Plan has 
to pay for surgical services provided to the enrollee on December 8, 2021.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (86077) provided on January 11, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the MUE value was 
exceeded. 
 The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 86077 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. 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 services (86077) 
provided on January 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cold compression therapy device provided on November 
2, 2021. 
 
You asked the Plan to pay for the services provided. You say that using the device was better than taking 
narcotics. The Plan denied your request. The Plan says the device is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. A fluid circulating cold pad with pump is not considered medically 
necessary. Based on this information, we decided that Medicare rules for coverage of the services provided 
have not been met. Therefore, we decided that the Plan does not have to pay for the cold compression therapy 
device provided on November 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Telehealth visit provided on January 31, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for Telehealth visit. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider is out-of-network and it was determined 
these services were not urgent or emergent. 
 
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 Telehealth visit provided on January 31, 2022 by 
an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay for D0367, D0470, and D9944. We decided that the Plan does not have to 
pay for D0350.  
 You asked the Plan to pay for a cone beam imaging, diagnostic casts, TMD appliance, and an oral/facial 
photographic imaging. You say that you were told that since this was TMJ related this would be covered. The 
Plan says that the requested services are not medically necessary. 
 
We decided that the Plan has to pay for D0367, D0470, and D9944.  
 
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 D0367, D0470, D9944, and D0350. Our 
reviewer says that they partially agree some of these services are medically necessary. Our physician reviewer 
found that D0367, D0470, and D9944 are medically necessary. D0350 is not medically necessary. 
 
Therefore, we decided that the Plan has to pay for D0367, D0470, and D9944.  
 
We also decided that the Plan does not have to pay for D0350. 
 
Our physician reviewer found that D0350 is not medically necessary. Therefore, we decided that the Plan does 
not have to pay for D0350. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on January 18, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not 
supported. 
 
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 G0483 is "Drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or 
more drug class(es), including metabolite(s) if performed". 
 We find that CPT code G0483 is not supported in the medical record. Specifically, the records do not show that 
22 or more drug classes were tested on the date of service in question. 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 drug testing services provided on January 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 23, 2021. 
 
You asked the Plan to pay for the lab services. You say that you would like this claim reprocessed and 
approved for payment. 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 June 23, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tacrolimus. 
 
You asked the Plan to pre-approve Tacrolimus. You say that the services are necessary. The Plan denied your 
request. The Plan says your plan does not have a Medicare Part D benefit, or a separate pharmacy benefit 
managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Tacrolimus.  
 
Benefits for Tacrolimus 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics. 
 
You asked the Plan to pay for foot orthotics. You say that you used to have coverage for orthotics under your 
previous insurance and you assumed that they would continue to be covered. The Plan denied your request. The 
Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pay for foot orthotics.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a debridement of extensive eczematous or infected skin 
(11000) billed for date of service September 23, 2021. 
 
You asked the Plan to pay for a debridement of extensive eczematous or infected skin. You say that you have 
provided medical records to support the service billed. The Plan denied your request. The Plan says rules for 
payment have not been met because the available records do not support the service billed. 
 
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 11000 is "Debridement of extensive eczematous or 
infected skin; up to 10% of body surface." 
 
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 a debridement of extensive eczematous or infected skin. Our 
reviewer says that the code at issue does not meet criteria for payment. Our reviewer found that the documentation supports wound care for grafting. Medicare rules have indicated that the following procedures 
are considered part of active wound care management and are not considered as debridement: removal of 
devitalized tissue from wound(s), non-selective debridement without anesthesia (e.g., wet-to-moist dressings, 
enzymatic, abrasion), including topical application(s), wound assessment, and instruction(s) for ongoing care. 
In this case, 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 a debridement of extensive eczematous or infected skin have not been met. 
Therefore, we decided that the Plan does not have to pay for a debridement of extensive eczematous or infected 
skin (11000) billed for date of service September 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued use of a negative pressure wound therapy 
pump and supplies. 
 You asked the Plan to pre-approve negative pressure wound therapy pump. You say that removing the wound 
therapy could be harmful to your healing process. The Plan denied your request. The Plan says the denial of 
authorization for continued use of this device is correct, because you have exceeded the 4-month limit and 
there has been no wound size improvement since the previous month's evaluation. 
 
The plan follows Medicare rules. Medicare rules state that a negative pressure wound therapy (NPWT) pump is 
not covered if a measurable degree of wound healing has failed to occur over the prior month. 
 
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 negative pressure wound therapy pump. 
Our reviewer says that you do not meet the Medicare criteria for continued use of a negative pressure wound 
therapy pump. Our physician reviewer found the records document that 4 months have elapsed using the 
negative pressure wound therapy pump in the treatment of your most recent wound and a measurable degree of 
wound healing has failed to occur. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of negative pressure wound therapy pump have not been met. Therefore, we 
decided that the Plan does not have to pre-approve continued use of a negative pressure wound therapy pump 
and supplies.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2740) provided by a participating provider on 
March 8, 2022. 
 
You asked the Plan to pay for a crown. You say that you were unaware that there was a benefit limit. The Plan 
denied your request. The Plan says the benefit limit for a crown has already been met and 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. The Plan covers two crowns 
per calendar year. 
 
We looked at the file and Medicare rules. Evidence was provided to show that a crown was provided on 
January 18, 2022, and on February 8, 2022. Based on this information, we decided that the Plan's rules for 
coverage of a crown have not been met. Therefore, we decided that the Plan does not have to pay for a crown 
(D2740) provided by a participating provider on March 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prefabricated abutment (dental code D6056) for tooth #3, 
#7, #10, and #13 provided on February 10, 2021. 
 
You asked the Plan to pay for the prefabricated abutment. You say that you do not understand why the benefit 
is denied and would like to appeal for the denied service. The Plan denied your request. The Plan says that the 
service being appealed is not a covered benefit under the enrollee's dental benefit plan and the code is not on 
the covered list. 
 
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 prefabricated abutment (dental code D6056) 
for tooth #3, #7, #10, and #13 provided on February 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal scaling and root planing (D4342) provided by an 
out-of-network provider on January 27, 2022. 
 
You asked the Plan to pay for periodontal scaling and root planing. You say that you thought this would be 
covered at a 30% coinsurance. The Plan denied your request. The Plan says these services have been correctly 
denied. 
 
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 periodontal scaling and root 
planing (D4342) provided by an out-of-network provider on January 27, 2022.