Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve eight (8) home health skilled nursing visits. 
 
You asked the Plan to pre-approve the home health skilled nursing visits. You say that you are appealing the 
medical necessity denial for home health skilled nursing visits, due to encounter for adjustment and 
management of vascular access device. The Plan denied your request. The Plan says the currently approved 
visits appear sufficient to meet the skilled service needs of the member, with further visits not meeting medical 
necessity. 
 
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 there is inadequate documentation that additional skilled nursing services are 
required to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, or 
to establish/perform a maintenance program to maintain the patient's condition and/or prevent deterioration. 
Provided records do not document any laboratory evidence or other objective evidence of dehydration 
requiring intravenous fluids. Records do not report an inability to take in oral hydration or excessive fluid loss 
from diarrhea. The latest medical note from July 5, 2022, reports six days of constipation and "Crohn's 
ileocolitis in remission on Entyvio." 
 
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 eight (8) home health skilled nursing visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve graft procedures (dental code D4273) for tooth #23, 
#24, #25, and #26. 
 
You asked the Plan to pre-approve the graft procedures. You say that you need this service done because it will 
affect your implants. The Plan denied your request. The Plan says The Plan says these services are not covered 
by the Plan's 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 pre-approve graft 
procedures (dental code D4273) for tooth #23, #24, #25, and #26.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) and 
cone beam computed tomography (CT) capture and interpretation with field of view of both jaws; with or 
without cranium (D0367) provided January 19, 2022. 
 
You asked the Plan to pay for the limited oral exam and cone beam CT scan. You say that these services are 
necessary after cancer treatments. 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 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 limited oral evaluation - problem focused (D0140) and cone beam computed tomography (CT) capture and 
interpretation with field of view of both jaws; with or without cranium (D0367) provided January 19, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve periodontal scaling and root planing in the upper left quadrant 
(D4342). 
 
You asked the Plan to pre-approve periodontal scaling. You say that multiple claims have been submitted and 
denied. The Plan denied your request. The Plan says that a minimum of four affected teeth needs to be present 
in the quadrant to qualify for coverage. 
 
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. The Plan covers periodontal 
scaling when the services are medically necessary and reasonable. 
 
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 periodontal scaling. Our reviewer says 
that the criteria for coverage has been met. Our physician reviewer found the x-rays shown slight bone loss on 
tooth #13 and possibly tooth #9, which corresponds to the periodontal charting that was supplied. Our 
physician reviewer also says that there were at least 4-5 mm pockets on two of the teeth in the quadrant and 
there was slight bone loss noted on the provided x-rays. Code D4342 does provide for situations where there 
are one to three teeth in a quadrant that are periodontally involved. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of periodontal scaling have been met. Therefore, we decided that the Plan has to 
pre-approve periodontal scaling and root planing in the upper left quadrant (D4342).  
 
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 angiography services coded 75726 and 75774 provided 
on October 29, 2021. 
 You asked the Plan to pay for the angiography services. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the services billed are not separately payable. 
 
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 75726 
is a column II code to column I code 37244. We have confirmed that code 75774 is a column II code to column 
I code 37244.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 the angiography services coded 75726 and 75774 provided on October 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2750) provided by a participating provider on 
February 21, 2022. 
 
You asked the Plan to pay for a crown. You say that you believe the Plan should pay for this. The Plan denied 
your request. The Plan says the annual maximum benefit allowance has already been met and exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers a crown when 
the services are medically necessary and reasonable.  
 
We looked at the file and Medicare rules. Evidence was provided to show that the maximum benefit allowance 
amount of $1,500 was exhausted on February 11, 2022. Based on this information, we decided that the Plan's 
rules for coverage of a crown have not been met. Therefore, we decided that the Plan does not have to pay for a 
crown (D2750) provided by a participating provider on February 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on January 27, 2021, billed with 
codes 81206, 81292, and 81301. 
 
You asked the Plan to pay for the genetic testing. You say that this testing is medically necessary. The Plan 
denied your request. The Plan says this must be billed with a single panel code. This is why only 6 of the 9 
billed line item was approved for payment. 
 
The Plan must follow Medicare rules. Medicare 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. 
 
We looked at the file and Medicare rules. This testing is an NGS panel that was not billed with a single panel 
code as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
January 27, 2021, billed with codes 81206, 81292, and 81301.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional payment for the crown - porcelain/ceramic 
(D2740) and core buildup, including any pins when required (D2950) provided February 3, 2022. 
 
You asked the Plan to provide additional payment for the crown and core buildup. You say that your cost share 
should be $425. The Plan denied your request. The Plan says the cost sharing has been applied correctly to 
these services. 
 
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. The Plan covers the crown 
with a $425 copayment, core buildup with a $50 copayment and up to $325 additional for material upgrades.  
 
We looked at the file and Medicare rules. You have been asked to pay a $425 copayment for the crown, 
a $50 copayment for the core buildup and $325 for the brand name material upgrade. This means you have been 
asked to pay the correct amount based on your contract with the Plan. Therefore, we decided that the Plan does 
not have to provide additional payment for the crown - porcelain/ceramic (D2740) and core buildup, including 
any pins when required (D2950) provided February 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prophylaxis (D1110), periodic oral evaluation (D0120), 
and resin-based composites (D2330 and D2331) provided on March 16, 2022, by an out-of-network (OON) 
provider. 
 
You asked the Plan to pay for the prophylaxis, oral evaluation, and composites. You say that this out-of-
network dentist is familiar with the enrollees needs and is convenient. The Plan denied your request. The Plan 
says the services have been provided out-of-network and were not approved in advance. 
 Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the 
prophylaxis, oral evaluation, and composites when provided in-network and the services are medically 
necessary and reasonable.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of the prophylaxis, oral evaluation, and composites have not been met because they were provided 
out-of-network. Therefore, we decided that the Plan does not have to pay for the prophylaxis (D1110), periodic 
oral evaluation (D0120), and resin-based composites (D2330 and D2331) provided on March 16, 2022, by an 
out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device 
(HFCWOD). 
 
You asked the Plan to pre-approve a HFCWOD. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested device is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are 
medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases.  
 
 
 
 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 HFCWOD. Our reviewer says that the 
documentation does not support that the requested device is medically reasonable or necessary. Our physician 
reviewer found the enrollee has a diagnosis of chronic obstructive pulmonary disease (COPD). There is no 
documentation of bronchiectasis in the medical records, and the patient does not have cystic fibrosis or 
neuromuscular disease.  There is no convincing evidence that this treatment is beneficial for patients with 
COPD. 
 
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 HFCWOD have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a high frequency chest wall oscillation device (HFCWOD).
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve a crown on tooth #14 (D2750).

You asked the Plan to pre-approve a crown. You say that the tooth is difficult to clean each time you eat. The Plan denied your request. The Plan says that it is not medically necessary to replace the cap on the tooth because the x-rays do not show that there is a cavity under the old cap.

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 did not provide the medical records they used in their review. The Plan has not supported their decision to deny your request. Therefore, we decided that the Plan has to pre-approve a crown on tooth #14 (D2750). 

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 a panoramic x-ray (D0330) provided on January 11, 2022. 
 
You asked the Plan to pay for an x-ray. You say that the insurance company has never accepted or paid for this 
treatment. The Plan denied your request. The Plan says this service is covered by the Plan's routine dental 
benefits; your benefits for one panoramic x-ray every three plan years 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. The Plan covers one 
panoramic x-ray every three plan years. 
 
We looked at this case file, the Plans rules, and Medicare rules. The record shows the Plan paid for a 
panoramic x-ray provided on January 7, 2020; therefore, the benefit for a panoramic x-ray has been exhausted. 
Therefore, we decided that the Plan does not have to pay for a panoramic x-ray (D0330) provided on January 
11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endoskeletal ankle foot system, microprocessor 
controlled feature, dorsiflexion and/or plantar flexion control, includes power source (CPT code L5973). 
 
You asked the Plan to pre-approve the item. You say that the item is necessary. The Plan denied your request. 
The Plan says the Medicare rules have not been met. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the item have not been met. Review of the file shows the current 
foot from March 25, 2022, is a Blatchford Echelon foot. This is a K3 foot. This has a three (3) year warranty. A 
new K3 foot is requested. The current foot was supplied less than four (4) months ago. Your current foot is still 
under warranty. A replacement foot cannot be covered for you. Information from the manufacturer shows that 
this foot is still under warranty. Medicare cannot cover a replacement foot when the current foot is still under 
warranty. Your current foot is not documented as damaged and or needing repair. Therefore, we decided that 
the Plan does not have to pre-approve endoskeletal ankle foot system, microprocessor controlled feature, 
dorsiflexion and/or plantar flexion control, includes power source (CPT code L5973).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the drug testing provided on August 3, 2017. 
 
You asked the Plan to pay for the drug testing. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says that the documentation submitted does not 
support the service billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of 
code G0482 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs 
and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to 
gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, 
eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other 
universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and 
variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control 
material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all 
sources, includes specimen validity testing, per day; 15-21 drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0482 is supported in the medical record. Specifically, the lab report clearly shows that 
15-21 drug classes were tested in this case. Please note, we counted the classes based on the separately billable 
tests from the CPT Handbook. Also, the record indicates that this provider was directed by the Plan to not 
obtain records. With this direction, it is inappropriate for the Plan to deny these services based on the physician 
signature. Based on this information, we decided that Medicare rules for coverage of the drug testing have been 
met. Therefore, we decided that the Plan has to pay for the drug testing provided on August 3, 2017.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a low dose computed tomography (CT) scan for lung 
cancer screening for the enrollee. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says a study similar to this one has already been performed. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
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 scan. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found that the enrollee 
has bilateral pulmonary nodules, and is considered high risk due to smoking history. A diagnostic computed 
tomography (CT) scan is required, but the requested code - 71271 - does not apply, as the enrollee has no 
symptoms to suggest lung cancer. 
 
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 scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a low dose computed tomography (CT) scan for lung cancer screening for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on March 
11, 2022. 
 
You asked the Plan to pay for an evaluation. You say that you are on a fixed income and wants the insurance 
company to pay their portion. The Plan denied your request. The Plan says this service is covered by the Plan's 
routine dental benefits; however, your benefit for one comprehensive oral evaluation 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. The Plan covers one 
comprehensive oral evaluation (D0150) every three plan years. 
 
We looked at this case file, the Plans rules, and Medicare rules. The record shows the Plan paid for a 
comprehensive oral evaluation provided on March 5, 2021; therefore, the benefit for a comprehensive oral 
evaluation has been exhausted. Therefore, we decided that the Plan does not have to pay for a comprehensive 
oral evaluation (D0150) provided on March 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an out-of-network provider on 
November 30, 2021. 
 
You asked the Plan to pay for dental services. You say that you have been using this dentist for 10 years. The 
Plan denied your request. The Plan says services must be provided by a participating provider. 
 
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. The Plan covers covered 
dental services when the services are provided by a participating provider. 
 
We looked at the file and Medicare rules. The rendering dentist is out-of-network. Based on this information, 
we decided that the Plan's rules for coverage of dental services have not been met. Therefore, we decided that 
the Plan does not have to pay for dental services provided by an out-of-network provider on November 30, 2021.