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

 
We decided that the Plan does not have to waive the copayment for prophylaxis (D1110) bitewing two x-rays 
(D0272) intraoral periapical first x-rays (D0220) intraoral periapical each additional x-ray (D0230) provided 
February 16, 2021 by an out of network provider. 
 
You asked the Plan to waive the copayment for the dental services. You say that the doctor knew that she was 
not in the Plan's network and should have informed you of this before proceeding with the services. You should 
not have to pay the additional $785 because they overcharged for the service. The Plan denied your request. 
The Plan says the claim was processed with the correct cost share applied per the Evidence of Coverage 
 
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 if you choose to see an out 
of network dentist, you might be billed for charges above what the Plan pays, even for services listed as $0 
copayment for Dental care.  
 
 You have been asked to pay $79 for the dental services. The provider charged $197 for the dental services. The 
Plan paid $118. The contract specifically states that if you choose to see an out of network dentist, you might 
be billed for charges above what the Plan pays, even for services listed as $0 copayment. The services fall 
within the Dental services 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 waive the copayment for prophylaxis 
(D1110) bitewing two x-rays (D0272) intraoral periapical first x-rays (D0220) intraoral periapical each 
additional x-ray (D0230) provided February 16, 2021 by an out of network provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from August 
19, 2021, to September 17, 2021. 
 
You asked the Plan to pay for the SNF care. You say that the services are coverable under the Medicare Act. 
The Plan denied your request. The Plan says the enrollee did not receive daily skilled services. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the SNF care. Our reviewer says that the 
enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not 
have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled 
professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, 
knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing 
and/or skilled therapy on an inpatient basis in a SNF setting. 
 
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 care have not been met. Therefore, we decided that the Plan does not 
have to pay for the skilled nursing facility (SNF) care provided from August 19, 2021, to September 17, 2021.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve continued skilled nursing facility (SNF) services from May 2, 
2022, forward. 
 
You asked the Plan to pre-approve continued SNF care. You say that it is critical to your health to remain in the 
hospital. The Plan denied your request. The Plan says that the record sent by your provider indicates that you 
have been receiving rehabilitation in a SNF and have reached a functional level where you no longer require 
daily skilled therapy 
 
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 continued SNF care. Our reviewer says 
that continued SNF care from May 2, 2022, forward is medically reasonable and necessary. Our physician 
reviewer found that you do not have documented skilled nursing needs. You do have documented skilled 
therapy needs. You appear to be functioning below your baseline, following a recent bout of COVID-19. The 
documentation does not yet establish that you have reached a new, lower, level of function. Daily skilled 
services are required to establish a maintenance program or to prevent deterioration of your condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued SNF care have been met. The Plan must continue coverage for the 
SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been 
issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve 
continued skilled nursing facility (SNF) services from May 2, 2022, forward.  
 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 Next Generation Sequencing (NGS) Lung Cancer panel 
provided on October 8, 2021. 
 
You asked the Plan to pay for the NGS Lung Cancer panel. You say that this testing is medically necessary to 
allow for customized treatment of the enrollee's condition. The Plan denied your request. The Plan says this is 
not a covered test. 
 
Medicare rules say that molecular diagnostic laboratory tests such as TEST NAME are subject to the MolDX 
application, assessment, and approval process. Once this is complete, the test is assigned a reimbursement rate 
and unique test identifier. 
 We looked at the file and Medicare rules. The Lung Cancer Panel offered by this lab was reviewed by the 
MolDX contractor and found to not meet Medicare coverage criteria. Based on this information, we decided 
that Medicare rules for coverage of the NGS Lung Cancer panel have not been met. Therefore, we decided that 
the Plan does not have to pay for the Next Generation Sequencing (NGS) Lung Cancer panel provided on 
October 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the specimen validity testing (83789) provided on November 
2, 2021. 
 
You asked the Plan to pay for the specimen validity testing. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says when specimen validity testing is 
conducted as part of drug testing, it cannot be billed separately. 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Medicare rules say that specimen validity testing is not covered separately. 
 
The services at issue in this case are for the purpose of specimen validity testing. Based on this information, we 
decided that Medicare rules for coverage of the specimen validity testing have not been met. Therefore, we 
decided that the Plan does not have to pay for the specimen validity testing (83789) provided on November 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay the in network rate for the oral exam (D0120) and prophylaxis 
(D1110) provided on January 11, 2022, by the out of network dentist. 
 
You asked the Plan to pay the in network rate for the dental services. You say that you were advised in 
November that your providers were in network. You also say that you should not be responsible for this bill. 
The Plan denied your request. The Plan says out of network providers may bill you for any amount greater than 
what the pan pays the 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, out of network providers may bill you for any amount greater than what the pan pays the provider. Therefore, we decided that the Plan does not have 
to pay the in network rate for the oral exam (D0120) and prophylaxis (D1110) provided on January 11, 2022, 
by the out of network dentist.
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 
November 23, 2021. 
 
You asked the Plan to pay for a crown. You say that you feel like this should be covered. The Plan denied your 
request. The Plan says the benefit limit for D2740 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. The Plan covers two crowns 
per year. 
 
We looked at the file and Medicare rules. D2740 was provided on teeth #4 and #11. Based on this information, 
we decided that the Plan's rules for coverage of a crown for tooth #6 have not been met. Therefore, we decided 
that the Plan does not have to pay for a crown (D2740) for tooth #6 provided by a participating provider on 
November 23, 2021.
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 these services are medically necessary. The Plan 
denied your request. The Plan says that information regarding your prior level was not submitted. 
 
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. The 
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. You were admitted for a stroke.  Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While you have a need for physical and/or occupational therapy, there is no 
documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that you 
will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an 
IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the sacral spine x-ray rendered on October 14, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that modifier -26 is required for separate payment of 
the PC services when furnished in a different payment locality than the TC. 
 
We looked at the file and Medicare rules. The file shows that the services were not billed with the required -26 
modifier to allow for separate PC payment. Therefore, we decided that the Plan does not have to pay for the 
sacral spine x-ray rendered on October 14, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Rosuvastatin. 
 
You asked the Plan to pre-approve Rosuvastatin. You say that this is medically necessary. The Plan denied 
your request. The Plan says coverage of this medication is the responsibility of the enrollee's prescription drug 
plan. 
 
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 Rosuvastatin.  
 
 Benefits for Rosuvastatin 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyeglasses (V2020, V2100) provided on November 9, 2021. 
 
You asked the Plan to pay for the eyeglasses. You say that you were instructed to provide this claim for 
reimbursement. The Plan denied your request. The Plan says you have been reimbursed the full $100 allowed 
by your benefit, and you are responsible for the remaining cost. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services up to $100 once per calendar year. 
 
We looked at the file and the Plan's rules. The documentation indicates that the total cost of the eyeglasses was 
$169. The Plan has provided reimbursement to you in the amount of $100, and you are responsible for the 
remaining cost. This means you have been reimbursed the correct amount based on your contract with the Plan. 
Therefore, we decided that the Plan does not have to pay for the eyeglasses (V2020, V2100) provided on 
November 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown - porcelain fused to noble metal (D2752) and 
prefabricated post and core in addition to crown (D2954) provided December 29, 2021. 
 
You asked the Plan to pay for the crown and prefabricated post and core. You say that you were told the crown 
would be covered. The Plan denied your request. The Plan says these services are 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 crown - porcelain fused to noble metal (D2752) and prefabricated post and core in addition to crown (D2954) provided December 29, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on October 7, 2021. 
 
You asked the Plan to pay for the lab services. You say that there is no agreement that the codes are included in 
the dialysis rate. The Plan denied your request. The Plan says the testing is not separately reimbursable. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the lab testing services provided on October 7, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services provided on October 11, 2021. 
 
You asked the Plan to pay for the genetic testing services. You say that this testing should be covered based on 
medical necessity. The Plan denied your request. The Plan says the criteria for coverage of genetic testing have 
not been met as the documentation does not show how gene testing services would benefit treatment of 
enrollee. 
 
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 pay for the genetic testing services. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the documentation does not support that alternative laboratory or clinical tests to 
definitively diagnose the enrollees disorder/identify the condition are unavailable or that the results are clearly 
equivocal. Additionally, the documentation is insufficient to support that the results of the testing would 
directly impact the treatment or management of the enrollee. 
 
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 genetic testing services have not been met. Therefore, we decided that the 
Plan does not have to pay for the genetic testing services provided on October 11, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services for the 
enrollee. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee no longer requires daily skilled services and the 
continuation of SNF is 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 services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not 
meet Medicare criteria for continued SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continued skilled nursing facility (SNF) services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral periapical x-ray (D0220) and panoramic x-ray 
(D0330) provided on January 3, 2022. 
 
You asked the Plan to pay for the dental x-rays. You say that your provider did not know which x-rays were 
covered by your plan, and you feel the Plan should make an exception in this case since you did not use your 
dental benefits last year. The Plan denied your request. The Plan says these types of x-rays are not covered by 
your dental benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
intraoral periapical x-ray (D0220) and panoramic x-ray (D0330) provided on January 3, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided from 
November 8, 2021, to December 7, 2021. 
 You asked the Plan to pay for the SNF services. You say that SNF care was medically necessary. The Plan 
denied your request. The Plan says after November 7, 2021, the patient's SNF admission was 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 pay for the SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found based on the medical records provided, 
there is no documentation that the patient required skilled nursing services from November 8, 2021, through 
December 7, 2021. Records did not document the need for intravenous medications, new tube feeding, or 
ostomy care or daily complex wound care. While the patient did have skilled therapy needs, it was not 
necessary for the patient to receive these services on an inpatient basis in a SNF. 
 
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 services have not been met. Therefore, we decided that the Plan does 
not have to pay for skilled nursing facility (SNF) services provided from November 8, 2021, to December 7, 
2021.