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

 
We decided that the Plan does not have to pay for SNF care provided from January 1, 2022, to January 30, 
2022. 
 
You asked the Plan to pay for SNF care. You say that you are appealing the denied payment for the SNF care. 
The Plan denied your request. The Plan says the enrollee did not receive skilled therapy services during the 
dates of service. 
 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
Regarding rehabilitation services, the enrollee did not receive nor require skilled therapy for the dates in 
question. 
 
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 pay for SNF care provided from January 1, 2022, to January 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a medical eye examination (92004) 
provided on September 16, 2022. 
 
You asked the Plan to waive the copayment for a medical eye examination. You say that you disagree with the 
copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 a diagnostic eye examination.  
 
You have been asked to pay a $30 copayment for a medical eye examination. This item/service falls within the 
diagnostic eye examination 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 a medical 
eye examination (92004) provided on September 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete denture - mandibular (D5120). 
 
You asked the Plan to pre-approve the dental services. You say that you are unable to eat and have lost 30 
pounds. You also say that you need a new bottom denture made due to it being loose. 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 April 1, 2021. Therefore, 
we decided that the Plan does not have to pre-approve a complete denture - mandibular (D5120).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy with biopsy 
provided on September 22, 2022. 
 
You asked the Plan to waive the copayment for the diagnostic colonoscopy with biopsy. You say that you 
never had a copay for this service. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
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 $350 
copayment per visit at a hospital outpatient facility for outpatient surgery services. 
 
 You have been asked to pay a $350 copayment for the diagnostic colonoscopy with biopsy. This item/service 
falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy 
with biopsy provided on September 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on July 11, 2022. 
 
You asked the Plan to pay for office visit. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for office visit provided on 
July 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an unknown procedure code (D00001), panoramic 
radiographic image (D0330), a complete upper denture (D5110), and an extraction (D7140) for tooth #29 
provided on April 6, 2021, April 27, 2021, and November 2, 2021. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to reimburse you for the 
dental services. The Plan denied your request. The Plan says the denial of payment for the denture is correct 
because it is not covered by the Plan. Also, the claims for April 6, 2021, and April 27, 2021, were received past 
the 12-month timeframe. 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 follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the complete upper denture is not 
among those covered under this benefit. The record shows that the claims for April 6, 2021, and April 27, 
2021, was not filed until September 30, 2022. This means that more than 1 calendar year from the dates of 
services had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for an 
unknown procedure code (D00001), panoramic radiographic image (D0330), a complete upper denture 
(D5110), and an extraction (D7140) for tooth #29 provided on April 6, 2021, April 27, 2021, and November 2, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete mandibular denture (D5120). 
 
You asked the Plan to pre-approve the complete mandibular denture. You say that your lower denture keeps 
moving, and you cannot chew your food properly. You also say that you need the dentures to be made together 
so they will fit right. 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 15, 2021. Therefore, 
we decided that the Plan does not have to pre-approve a complete mandibular denture (D5120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), complete series 
of x-rays (D0210) and 2D oral/facial photographic image (D0350) provided on September 12, 2022. 
 
You asked the Plan to pay for the dental services. You say that you have an annual $1000 benefit for 
comprehensive care. The Plan denied your request. The Plan says these services are either not covered under 
your dental plan or your benefit for the requested item or service has 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 benefits for D0150 and D0210 was exhausted on date of service January 21, 2021. Additionally, 
D0350 is not covered under any circumstance. Therefore, we decided that the Plan does not have to pay for the 
comprehensive oral evaluation (D0150), complete series of x-rays (D0210) and 2D oral/facial photographic 
image (D0350) provided on September 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the podiatry visit provided by an out-of-
network provider on September 9, 2022. 
 
You asked the Plan to waive the copayment for the out-of-network podiatry visit. You say that you were 
charged an additional fee. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 $75 
copayment for out-of-network Medicare-covered podiatry visits in an office or home setting. 
 
You have been asked to pay a $75 copayment for the out-of-network podiatry visit. This item/service falls 
within the podiatry 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 the podiatry 
visit provided by an out-of-network provider on September 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gingival irrigationper quadrant (D4921 x 4). 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says these services are not a covered 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 services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve gingival 
irrigationper quadrant (D4921 x 4).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removal of lateral exostosis tooth #'s 1 and 16 (maxilla 
or mandible) (D7471). 
 
You asked the Plan to pre-approve the removal of lateral exostosis tooth #'s 1 and 16 (maxilla or mandible). 
The Plan denied your request. The Plan says this service is not covered under the benefit package. 
 
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 
removal of lateral exostosis tooth #'s 1 and 16 (maxilla or mandible) (D7471).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 18, 2022, to 
February 16, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the NOA for this claim was 
submitted timely. The Plan denied your request. The Plan says the claim has not been billed with the correct 
admission date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from January 18, 2022, to 
February 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a core buildup, including any pins when required 
(D2950) for tooth #14. 
 
You asked the Plan to pre-approve the core buildup. You say that you only had one billable root canal and 
crown done the entire calendar year, and you believe a mistake has been made with the denial. The Plan denied 
your request. The Plan says your benefit for the requested 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 service was exhausted on date of service June 7, 2022. Therefore, we 
decided that the Plan does not have to pre-approve a core buildup, including any pins when required (D2950) 
for tooth #14.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the therapeutic continuous glucose monitor (CGM). You say that you are 
requesting a reconsideration with additional medical records submitted for review. The Plan denied your 
request. The Plan says the enrollee does not require insulin three or more times daily. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
the therapeutic continuous glucose monitor (CGM) have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a therapeutic continuous glucose monitor (CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the 16 additional routine transportation trips. 
 
You asked the Plan to pre-approve the 16 additional routine transportation trips. You say that you are appealing 
the denial. The Plan denied your request. The Plan says the benefit limit is exceeded. 
 
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 a maximum of 60 trips per year.  
 
 
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve the 16 additional routine transportation trips.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ambulance ride provided on August 02, 2022. 
 
You asked the Plan to pay for an ambulance ride. You say that if you had known how much the copay was, you 
would not have taken the ride. The Plan denied your request. The Plan says that unauthorized, out-of-network 
care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an ambulance ride 
provided on August 02, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care, and wound care provided on September 
6, 2022. 
 
You asked the Plan to pay for nursing facility care and wound care. You say that this was medically necessary. 
The Plan denied your request. The Plan says the enrollee must receive care from a network provider. 
 
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 nursing facility care, and wound care provided on 
September 6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
August 19, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
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 code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service August 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacroiliac joint injection (27096). 
 
You asked the Plan to pre-approve a sacroiliac joint injection. You say that the requested service is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the request is not medically 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 a sacroiliac joint injection. Our 
reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that sacroiliac joint injections are recommended as an option if the patient has failed 
at least 4 to 6 weeks of aggressive conservative therapy, including physical therapy, home exercise and 
medication management. There should be evidence of a clinical picture that is suggestive of sacroiliac injury 
and/or disease. At least 3 positive exam findings of sacroiliac joint dysfunction should be present on physical 
exam such as: Patrick's test, thigh thrust, SI compression test, Yeoman's test, or Gaenslan's test. In this case, 
there is no documentation on physical examination of 3 or more positive tests results. The clinical value and 
effectiveness of a sacroiliac joint injection in the absence of tenderness and negative provocative testing results 
have not been demonstrated in the peer-reviewed literature.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a sacroiliac joint injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a sacroiliac joint injection (27096).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gingival irrigation  per quadrant (D4921). 
 
You asked the Plan to pre-approve the gingival irrigation  per quadrant (D4921). The Plan denied your 
request. The Plan says this service is not covered under the benefit package. 
 
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 
gingival irrigation  per quadrant (D4921).