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

 
We decided that the Plan does not have to pay more for a periodic oral evaluation (D0120), prophylaxis 
(D1110), bitewings (D0274), and intraoral imaging (D0220), provided by an out-of-network provider on 
February 17, 2022. 
 
You asked the Plan to pay more for the dental services. You say that these services have always been paid 
before. The Plan denied your request. The Plan says you are responsible for any charged amount above the 
Plans cost-sharing amount when your services are received from an out-of-network provider. 
 
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. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
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 a periodic oral evaluation (D0120), 
prophylaxis (D1110), bitewings (D0274), and intraoral imaging (D0220), provided by an out-of-network 
provider on February 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral exam (D0120) and dental cleaning (D1110) 
provided by an out-of-network provider on April 6, 2022. 
 
You asked the Plan to pay for the dental services. You say that in past years, you have not had issues with 
seeing this particular dentist. You say you understand a preferred provider list has been implemented for 2022 
and asked the Plan to make an exception  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. The Plan says 
claims from 2022 must be processed according to your 2022 benefits, not the previous years benefits. The Plan 
also says you did not contact the Plan to confirm coverage prior to receiving 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. 
 
 
 
 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 periodic oral exam (D0120) and dental cleaning (D1110) provided on April 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the immediate denture - mandibular (D5140) provided 
January 4, 2022. 
 
You asked the Plan to pay for the immediate lower denture. You say that a sales representative advised that 
dentures would be covered under your benefits. The Plan denied your request. The Plan says this service is not 
covered under your benefits. The Plan also says no misinformation was provided by plan representatives. 
 
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 
immediate denture - mandibular (D5140) provided January 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete maxillary denture (D5110) provided by a 
participating provider on March 23, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for this. 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 June 18, 2020. Therefore, 
we decided that the Plan does not have to pay for a complete maxillary denture (D5110) provided by a 
participating provider on March 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481, 87640, 87653, and 87798 billed for 
date of service September 23, 2021. 
 
You asked the Plan to pay for procedure codes 87481, 87640, 87653, and 87798. You say that you disagree 
with the Plan's denial. The Plan denied your request. The Plan says payment for codes 87481, 87653, and 
87798 is bundled into payment for code 87801. 
 
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 87481, 
87653, and 87798 is a column II code to column I code 87801. This claim has not been billed with an 
appropriate modifier to bypass the edit. 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 87481, 87640, 87653, and 
87798 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 a power mobility device. 
 
You asked the Plan to pre-approve a power mobility device. You say that this is medically necessary for the 
enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
The file shows that the enrollees condition can be improved by a walker. This means that Medicare rules for 
coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
power mobility device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cone beam imaging (D0366) provided on May 12, 2022. 
 
You asked the Plan to pay for imaging. You say that you were unaware this service was not covered. The Plan 
denied your request. The Plan says cone beam imaging (D0366) 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 cone 
beam imaging (D0366) provided on May 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a specialist office visit to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve a specialist office visit. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says that it is not medically necessary to go out of network to 
receive treatment from the requested provider as they have a provider who is contracted with the Plan and can 
provide the same treatment. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a specialist office visit to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that the clinical value and effectiveness of bone marrow aspirate in the 
setting of spinal fusion surgery has not been demonstrated in the peer-reviewed literature. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. There is a lack of 
large volume, long-term peer-reviewed outcome studies to support the use of bone marrow aspirate for this 
enrollees medical condition. There is no compelling rationale presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve bone marrow aspirate for the enrollee.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services (81455) provided July 22, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that this is an FDA-approved test that is covered 
by Medicare The Plan denied your request. The Plan says that there is a Local Coverage Determination (LCD) 
that indicates that any panel that tests for the FANCC and BLM genes are noncovered. Since this panel 
includes these genes, the denial is correct 
 
The Plan must follow Medicare rules. The rules 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. The Plan references Local Coverage Articles (LCA) A55183 and A55113 in 
their determination, which are not binding for the services at issue and is superseded by National Coverage 
Determination (NCD) 90.2, which allows for coverage of this testing. Therefore, we decided that the Plan has 
to pay for the laboratory services (81455) provided July 22, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the filling (D2393) provided January 24, 2022. 
 
You asked the Plan to pay for the dental services. You say that the provider did not inform you that they were 
OON. 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 the filling (D2393) provided January 24, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically necessary. Our physician reviewer found that you presented to 
the emergency department on September 1, 2022 with a left groin wound. You were treated with wound 
packing and sent to the SNF on oral antibiotics. You were re-evaluated on September 2, 2022 by physical and 
occupational therapy and were walking five feet with a walker with moderate assistance. You needed 
maximum assistance for transfers and moderate assistance for activities of daily living. You have no skilled 
nursing needs. You have skilled therapy needs but do not require skilled therapy on a daily basis. As a practical 
matter, you do not require the necessary services on an inpatient basis at the SNF 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a comprehensive oral evaluation (D0150), 
bitewings (D0274), intraoral imaging (D0220), and prophylaxis (D1110), provided by an out-of-network 
provider on March 10, 2022. 
 
You asked the Plan to waive the coinsurance for a comprehensive oral evaluation, bitewings, intraoral imaging, 
and prophylaxis. You say that you do not agree with the amount you are being charged. The Plan denied your 
request. The Plan says the correct coinsurance has been 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% 
coinsurance for the covered dental services provided by an out-of-network provider.  
 
You have been asked to pay less than a 30% coinsurance of the allowed amount for a comprehensive oral 
evaluation, bitewings, intraoral imaging, and prophylaxis. The total allowed amount is $327. You are being 
asked to pay $72.10, which is less than the 30% coinsurance amount of $98.10 ($327 x 30% = $98.10). 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 waive the coinsurance for a comprehensive oral evaluation (D0150), bitewings 
(D0274), intraoral imaging (D0220), and prophylaxis (D1110), provided by an out-of-network provider on 
March 10, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 3D rendering with interpretation and reporting of 
computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image 
postprocessing under concurrent supervision; requiring image postprocessing on an independent workstation 
(CPT code 76377). 
 
You asked the Plan to pre-approve the service. You say that you are in pain. You state that you need surgery 
and have nerve damage. You state that this is medically necessary for you and your recovery. The Plan denied 
your request. The Plan says the MRI is not necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no rationale given by the referring clinician for the need for 3D imaging to be done on a 
separate workstation. Such rationale must be included for the 3D portion of any scan to be approved. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve 3D rendering with interpretation and reporting of computed tomography, magnetic 
resonance imaging, ultrasound, or other tomographic modality with image postprocessing under concurrent 
supervision; requiring image postprocessing on an independent workstation (CPT code 76377).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional transportation mileage. 
 
You asked the Plan to pre-approve the additional miles. You say that without the approved trips, you will not 
be able to get to the appointments. The Plan denied your request. The Plan says additional mileage is not 
covered. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation up to 50 miles one-way per trip. 
 We looked at your request, the records in the case file, and the rules. Mileage over 50 miles one-way is not 
covered by the plan. Based on this information, we decided that the Plans rules for coverage of routine 
transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve additional 
transportation mileage.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve four (4) home health skilled nursing visits (CPT code 
G0299 x4). 
 
You asked the Plan to pre-approve the home health skilled nursing visits. You say that the services are 
necessary. The Plan denied your request. The Plan says your records show that your medical conditions, medication management, pain management, diet, and household safety have been reviewed and education has 
been provided. The Plan states your records do not support the need for a skilled nurse to make more visits. 
 
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 the home health skilled nursing visits. 
Our physician reviewer found the services up to and including August 26, 2022, can be considered appropriate 
given the documentation. However, after this date they would not be considered appropriate given that you 
were noted to be stable. 
 
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 home health skilled nursing visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve four (4) home health skilled nursing visits (CPT code G0299 x4).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on October 11, 2021 billed with 
codes 81407, 81408, 81432, 81479, 81295, and 81298. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services rendered are not separately payable. 
 
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. 
 
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 looked at the file and Medicare rules.  
In this case, we have confirmed that codes 81295 and 81298 are column II codes to column I code 81432 with 
a modifier indicator of 0. The column II code is therefore not payable. Based on the claim submitted, Medicare 
billing criteria have not been met. In addition, codes 81407, 81408, 81432, and 81479 was an NGS panel that 
was not billed with a single panel code as required. This means codes 81407, 81408, 81432, and 81479 are not 
payable.  
 
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 October 
11, 2021 billed with codes 81407, 81408, 81432, 81479, 81295, and 81298.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infrared therapy (97026) provided from October 18, 
2021, to December 20, 2021. 
 
You asked the Plan to pay for the infrared therapy. You say that the services were medically necessary and 
appropriate for the enrollee. You also say that the services should be paid. The Plan denied your request. The 
Plan says infrared therapy is not considered medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that infrared therapy is not medically reasonable and 
necessary.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the infrared therapy have not been met. Therefore, we decided that the Plan does not have to pay 
for the infrared therapy (97026) provided from October 18, 2021, to December 20, 2021.