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

 
We decided that the Plan does not have to pre-approve periodontal scaling and root planing - four or more teeth 
per quadrant (D4341). 
 
You asked the Plan to pre-approve periodontal scaling and root planing - four or more teeth per quadrant 
(D4341). The Plan denied your request. The Plan says this is not a covered benefit under your 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 pre-approve 
periodontal scaling and root planing - four or more teeth per quadrant (D4341).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal scaling and root planing (D4341) provided on 
February 9, 2022. 
 
You asked the Plan to pay for periodontal scaling. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says periodontal scaling and root planing (D4341) is not covered by 
your supplemental 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 
periodontal scaling and root planing (D4341) provided on February 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scaling and root planing of each quadrant 
(D4341). 
 
You asked the Plan to pre-approve the dental services. You say that you need this deep cleaning. The Plan 
denied your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service December 19, 2020. 
Therefore, we decided that the Plan does not have to pre-approve periodontal scaling and root planing of each 
quadrant (D4341).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapy services (97112 and 97530) provided April 28, 
2022, to May 11, 2022. 
 
You asked the Plan to pay for codes 97112 and 97530. You say that the medical records support the billing of 
codes 97112 and 97530. The Plan denied your request. The Plan says the medical records do not support the 
billing of codes 97112 and 97530. 
 
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 97112 is Therapeutic procedure, 1 or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or 
proprioception for sitting and/or standing activities. The definition of code 97530 is Therapeutic activities, 
direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 
minutes. 
 
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 codes 97112 and 97530. Our reviewer says that the medical 
records do not support the billing of codes 97112 and 97530. Our reviewer found the medical records do not 
fully support the billed procedure codes as the amount of time that was spent on each activity was not properly 
documented in accordance with CMS guidelines. Additional information needs to be properly documented for 
the codes to be acceptable when billed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of codes 97112 and 97530 have not been met. Therefore, we decided that the Plan 
does not have to pay for the therapy services (97112 and 97530) provided April 28, 2022, to May 11, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve five physical therapy visits. 
 
You asked the Plan to pre-approve therapy visits. You say that additional therapy visits are medically 
necessary. The Plan denied your request. The Plan says the remaining five visits are medically necessary. 
 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 therapy 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 you have been provided home exercise education and approved 
for additional therapy to ensure competence in this home 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 therapy visits have not been met. Therefore, we decided that the Plan does not 
have to pre-approve five physical therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lightweight wheelchair. 
 
You asked the Plan to pre-approve these services. 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. Medicare rules say that a lightweight wheelchair is covered when 
specific criteria are met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the records do not support that you 
cannot adequately self-propel a standard weight wheelchair. The criteria for coverage are not met and the 
lightweight wheelchair is not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a lightweight wheelchair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for interim partial dentures (D5821 and D5810) provided by a 
participating provider. 
 
You asked the Plan to pay for interim partial dentures. You say that you believe the Plan should pay for this. 
The Plan denied your request. The Plan says the requested services are not covered 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 interim 
partial dentures (D5821 and D5810) provided by a participating provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (83789-59) provided on March 1, 
2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says the documentation does not support 
separate payment for this service. 
 
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 the laboratory services 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 the laboratory services (83789-59) provided on March 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation - new or established patient 
(D0150) provided on May 20, 2022.  
 
You asked the Plan to pay for the dental services. You say that you were told the dentist was in-network and 
that the insurance would cover the entire procedure. The Plan denied your request. The Plan says your benefit 
for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
 
 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service June 09, 2021. Therefore, 
we decided that the Plan does not have to pay for a comprehensive oral evaluation - new or established patient 
(D0150) provided on May 20, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 70450 and 96374 billed for date of service 
March 10, 2022. 
 
You asked the Plan to pay for procedure codes 70450 and 96374. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says payment for code 70450 is 
bundled into payment for code 70496. Additionally, the enrollee received services (96374) while in an 
outpatient hospital setting. Per Medicare payment guidelines, code 96374 has a PC/TC indicator of 5 and 
payment may not be made for this code when provided to patients in an outpatient hospital setting. 
 
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, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Additionally, the enrollee received services (96374) while in an outpatient hospital setting. Per 
Medicare payment guidelines, code 96374 has a PC/TC indicator of 5 and payment may not be made for this 
code when provided to patients in an outpatient hospital setting. Based on the claim submitted, Medicare 
billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 
70450 and 96374 billed for date of service March 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periapical x-ray (D0220) provided on June 30, 2022. 
 
You asked the Plan to pay for the dental services. You say that the x-ray should be paid. The Plan denied your 
request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service May 24, 2022. Therefore, 
we decided that the Plan does not have to pay for a periapical x-ray (D0220) provided on June 30, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve five (5) additional home physical therapy visits for the 
enrollee. 
 You asked the Plan to pre-approve five (5) additional home physical therapy visits. You say that these services 
are medically necessary. The Plan denied your request. The Plan says that the approved visits should allow 
adequate time to address goals and develop a home exercise program. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 five (5) additional home physical 
therapy visits. Our reviewer says that five (5) additional home physical therapy visits are not medically 
reasonable and necessary. The enrollee does not have documented, ongoing, home health physical therapy 
needs. The enrollee is functioning at a level commiserate with a lower level of care. Our physician reviewer 
found that the enrollee's condition does not meet Medicare criteria for five (5) additional home physical therapy 
visits. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of five (5) additional home physical therapy visits have not been met. Therefore, 
we decided that the Plan does not have to pre-approve five (5) additional home physical therapy visits for the 
enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a maxillary partial denture (D5213) and an immediate 
mandibular partial denture (D5224) provided by a participating provider. 
 
You asked the Plan to pay for partial dentures. You say that you cannot afford to pay for this. The Plan denied 
your request. The Plan says partial dentures are not covered 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 
maxillary partial denture (D5213) and an immediate mandibular partial denture (D5224) provided by a 
participating provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prosthetic cream. 
 
You asked the Plan to pre-approve prosthetic cream. You say that the requested cream will help the enrollee 
protect skin integrity and allow her to walk longer distances without her prosthetic pinching and rubbing her skin. You say that the enrollee also has issues with water build-up under the linters and it is causing them to fall 
during ambulation. You say that this is extremely dangerous, as she is a bilateral amputee that does not use an 
assistive device. You say that the cream is requested as an alternative to providing her with a new socket. The 
Plan denied your request. The Plan says the item which remains in dispute is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The rules also say that OTC items are not covered. Therefore, we decided that the Plan 
does not have to pre-approve prosthetic cream.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance (D4910) provided on June 10, 
2022. 
 
You asked the Plan to pay for periodontal maintenance. You say that you do not understand your dental 
benefits. The Plan denied your request. The Plan says periodontal maintenance (D4910) is not covered by your 
supplemental 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 
periodontal maintenance (D4910) provided on June 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for endodontic therapy (D3330) provided on June 6, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service June 6, 2022. Therefore, 
we decided that the Plan does not have to pay for endodontic therapy (D3330) provided on June 6, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the COVID-19 home test kit provided on January 15, 2022.

You asked the Plan to pay for the COVID-19 home test kit. You say that you would like to be reimbursed for the COVID-19 test kit. The Plan denied your request. The Plan says this test kit was purchased before the Plan's reimbursement policy went into effect.

The Plan must follow Medicare rules. Medicare did not provide coverage for at-home COVID-19 home test kits on the date of purchase. While the Plan approved coverage for COVID-19 home test kits starting on February 1, 2022, this kit was purchased on January 15, 2022. Based on this information, we decided that Medicare rules and Plan's contractual rules for coverage of the COVID-19 home test kit have not been met. Therefore, we decided that the Plan does not have to pay for the COVID-19 home test kit provided on January 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on October 7, 2021.

You asked the Plan to pay for physician's services. The Plan denied your request. The Plan says the claim processed correctly, the enrollee's point of service benefit was exhausted, no prior authorization was requested, and services are not considered urgent/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 did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician's services provided on October 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for acupuncture provided on January 1, 2022, through your Wellness Allowance benefit.

You asked the Plan to reimburse you for the acupuncture. You say that you are unsure if it was denied because of it stating special transition instead of listing out each line of what it was. The Plan denied your request. The Plan says there was no itemized bill for your acupuncture services for reimbursement towards your wellness allowance for 2022.

We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the Wellness Allowance benefit have not been met. Specifically, no itemized bill for your acupuncture services for reimbursement towards your wellness allowance for 2022 was submitted. Therefore, we decided that the Plan does not have to reimburse you for acupuncture provided on January 1, 2022, through your Wellness Allowance benefit.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the COVID-19 home test kit purchased on January 18, 2022.

You asked the Plan to pay for the COVID-19 home test kit. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says the criteria for coverage have not been met.

The Plan must follow Medicare rules. Medicare rules say that as of April 4, 2022, enrollees can get up to eight free COVID-19 home test kits. The Plan's contract clarifies that coverage will be provided for COVID-19 home test kits purchased starting February 1, 2022. 

We looked at the file and Medicare rules. In this case, this test was purchased prior to Medicare and the Plan's starting coverage dates of COVID-19 home test kits. Based on this information, we decided that Medicare rules for coverage of the COVID-19 home test kit have not been met. Therefore, we decided that the Plan does not have to pay for the COVID-19 home test kit purchased on January 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist telehealth visit provided on November 22, 2021.

You asked the Plan to waive the copayment for the specialist telehealth visit. You say that there should be no copayment charged because it was a telehealth visit. The Plan denied your request. The Plan says this visit was not arranged through the  telehealth services supplemental benefit. Therefore, the proper copayment was applied.

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 $30 copayment for per visit to a specialist. The copayment amount charged was $20 which is less than the $30 copayment for the specialist telehealth visit.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the COVID-19 home test kit purchased on December 28, 2021.

You asked the Plan to pay for COVID-19 test kit. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says the Plan's COVID-19 at home test kit reimbursement policy had not yet gone into effect.

The Plan must follow Medicare rules. Medicare rules say that they will provide coverage for COVID-19 home test kits purchased after April 4, 2022. The Plan's contract indicates that they will start reimbursing COVID-19 home test kits purchased after February 1, 2022. We looked at the file and Medicare rules. In this case, the COVID-19 home test kit was purchased on December 28, 2021, prior to both Medicare and the Plan's COVID-19 home test kit reimbursement dates. Based on this information, we decided that Medicare rules for coverage of COVID-19 test kit have not been met. Therefore, we decided that the Plan does not have to pay for the COVID-19 home test kit purchased on December 28, 2021.