Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the trimming of dystrophic nails provided on August 17, 
2022. 
 
You asked the Plan to pay for the routine foot care. You say that you have issues with your low back that 
prevent you from being able to bend over to trim or cut your own toenails. You also say that you did not know 
this would not be covered. The Plan denied your request. The Plan says routine foot care is not covered by 
Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that routine foot care is not covered. The only exception is 
for those who have a condition that results in severe loss of circulation or areas of poor sensation in the legs or 
feet or have fungal nails.  
 Records do not show that any of these conditions are present. The services you are asking the Plan to pay for 
are routine foot care services. Based on this information, we decided that Medicare rules for coverage of the 
routine foot care have not been met. Therefore, we decided that the Plan does not have to pay for the trimming 
of dystrophic nails provided on August 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the seat elevator (E2300). 
 
You asked the Plan to pre-approve the seat elevator. You say that the member needs this item. The Plan denied 
your request. The Plan says this item does not serve a medical purpose. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve the seat elevator (E2300).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 13, 2022, billed with 
codes 81292 and 81301. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says panel testing should be billed using one 
CPT code on the claim. 
 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. 
 
We looked at the file and Medicare rules. This was 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 billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
June 13, 2022, billed with codes 81292 and 81301.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care (99309) provided on 
March 14, 2022. 
 
You asked the Plan to pay for the nursing facility care. You say that the medically necessary service was 
rendered to the enrollee in good faith. The Plan denied your request. The Plan says this claim is a duplicate of a 
previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on April 21, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed service was provided twice on the same date. Based on 
this information, we decided that the Medicare rules for the nursing facility care have not been met. Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care (99309) provided on 
March 14, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you need more care and cannot go home. 
The Plan denied your request. The Plan says the LTACH is not medically necessary, and your needs can be met 
at a lower level of care such as an acute rehabilitation facility, skilled nursing facility, nursing facility, 
outpatient setting, or home care. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found you were admitted to the acute inpatient setting on December 20, 2023, for treatment 
of acute respiratory failure secondary to bilateral pneumonia and sepsis secondary to a chronic stage IV sacral 
decubitus ulcer. The medical record shows you did not require prolonged mechanical ventilation and has been 
successfully weaned to hi-flow supplemental oxygen. You do not require extensive or complex wound care 
management by skilled nursing of at least six and a half hours per day. There is no documentation provided 
indicating medical necessity for admission to a LTACH. You are receiving appropriate care at the present acute care hospital. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete denture - maxillary (D5110), and complete 
denture - mandibular (D5120). 
 
You asked the Plan to pre-approve the dental services. You say that you would like to have a new complete 
denture, as the dentures you have do not fit in your mouth. 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 January 10, 2020. 
Therefore, we decided that the Plan does not have to pre-approve a complete denture - maxillary (D5110), and 
complete denture - mandibular (D5120).
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 are in this hospital, very weak, and needs SNF 
care to get stronger. The Plan denied your request. The Plan says the enrollee exceeds mobility criteria for SNF 
admission. 
 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 reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found You do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (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 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient visits provided on January 25, 2021 to August 12, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for outpatient visits. You say that the records attached support the services provided. 
The Plan denied your request. The Plan says services can be obtained from an in-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 outpatient visits provided on January 25, 2021 to 
August 12, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown - porcelain/ceramic (D2740 x4) provided on July 13, 
2022. 
 
You asked the Plan to pay for the dental services. You say that you were told the dental work would be $2,600 
at time of service. You also say that you cannot afford this bill. The Plan denied your request. The Plan says 
your benefit for the requested item or service $1,000 dollar limit was met. 
 
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 July 13, 2022. Therefore, 
we decided that the Plan does not have to pay for a crown - porcelain/ceramic (D2740 x4) provided on July 13, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 88341, 88342, and 88360 billed for date of 
service February 1, 2022. 
 
You asked the Plan to pay for the billed services. You say that the denial is incorrect. The Plan denied your 
request. The Plan says the claim was billed without the correct modifier. 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 find that CPT code 88341, 88342, and 88360 are diagnostic tests that were not billed with a modifier to 
indicate whether the technical component or professional component is being billed. Based on this information, 
we decided that Medicare rules for coverage of the billed services have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 88341, 88342, and 88360 billed for date of service 
February 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prophylaxis - adult (D1110) and periodic oral evaluation - 
established patient (D0120) provided on March 8, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are appealing the claim payment denial. 
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 prophylaxis - adult (D1110) and periodic oral evaluation - established patient (D0120) provided on 
March 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown (D2740) for tooth #30 and core buildup, including 
any pins when required (D2950) for tooth #30 provided on September 21, 2022. 
 
You asked the Plan to pay for the crown and core buildup. You say that you would like the normal portion paid 
for the crown on tooth #30. 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 27, 2018. Therefore, 
we decided that the Plan does not have to pay for the crown (D2740) for tooth #30 and core buildup, including 
any pins when required (D2950) for tooth #30 provided on September 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown - porcelain/ceramic (D2740), and re-cement or re-
bond crown (D2920) provided on August 4, 2022, and August 22, 2022. 
 
You asked the Plan to pay for the crown - porcelain/ceramic (D2740), and re-cement or re-bond crown 
(D2920). You say that the crown needed to be replaced as there was decay under the original one. You also say 
that if it is not possible to cover the full cost of the crown, you respectfully ask for a portion to be paid for the 
services. The Plan denied your request. The Plan says these services are 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 pay for a crown - 
porcelain/ceramic (D2740), and re-cement or re-bond crown (D2920) provided on August 4, 2022, and August 
22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a localized deliveries of antimicrobial agents (D4381), 
gingival irrigations (D4921) for all four quadrants, and periodontal scalings and root planings (D4341) for the 
upper right and lower right quadrants. 
 
  You asked the Plan to pre-approve the localized deliveries of antimicrobial agents, gingival irrigations, and 
scalings and planings. The Plan denied your request. The Plan says localized delivery of antimicrobial agents 
and gingival irrigation are not covered under the enrollee's benefit plan. The Plan also says the enrollee has 
already received scalings and planings of the upper right and lower right quadrants within the past three years. 
 
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 localized delivery of antimicrobial 
agents (D4381) and gingival irrigation (D4921) are not among those covered under this benefit. The contract 
also says that periodontal scaling and root planing (codes D4341 and D4342) share a frequency limitation of 1 
per 3 calendar years per quadrant. The record shows that the enrollee received periodontal scalings and root 
planings (D4341) on the upper right and lower right quadrants on April 12, 2021, and their periodontal scalings 
and root planings (D4341) benefit for the upper right and lower right quadrants have been exhausted. 
Therefore, we decided that the Plan does not have to pre-approve a localized deliveries of antimicrobial agents 
(D4381), gingival irrigations (D4921) for all four quadrants, and periodontal scalings and root planings 
(D4341) for the upper right and lower right quadrants.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services (A0427, A0425) provided March 26, 
2022. 
 
You asked the Plan to pay for the ambulance services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as 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. 
 
We find that CPT code A0427, &  A0425 is not supported in the medical record. Specifically, the claim was 
not submitted with a valid frequency code. Based on this information, we decided that Medicare rules for 
coverage of the ambulance services have not been met. 
 
 
 
 
 
  
Therefore, we decided that the Plan does not have to pay for ambulance services (A0427, A0425) provided 
March 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Mobilux LED Hand-held Magnifier - 4x and Mobase 
Stand provided by an out-of-network provider on April 19, 2022. 
 You asked the Plan to pay for the magnifier. You say that you were told the prescription magnifying glass 
would be covered. You say you have severe vision issues, and this was recommended by your doctor. The Plan 
denied your request. The Plan says the service is not a covered service. 
 
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 does not cover this service. 
 
We looked at the file and the Plan's rules. Specifically, the item is not a covered benefit. Based on this 
information, we decided that the Plan's rules for coverage of the magnifier have not been met. Therefore, we 
decided that the Plan does not have to pay for the Mobilux LED Hand-held Magnifier - 4x and Mobase Stand 
provided by an out-of-network provider on April 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation - new or established patient 
(D0150), and intraoral - complete series of radiographic images (D0210) provided on September 13, 2022. 
 
You asked the Plan to pay for the dental services. You say that you had to change dentists for the second 
cleaning of the year. 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 October 5, 2021.  Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation - new or 
established patient (D0150), and intraoral - complete series of radiographic images (D0210) provided on 
September 13, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for pulmonary rehabilitation services 
provided June 7, 2022, to June 28, 2022. 
 
You asked the Plan to waive the copayments for pulmonary rehabilitation services. You say that you were not 
informed that you would have any copayments. 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 $20 
copayment per visit for pulmonary rehabilitation services.  
 
You have been asked to pay $120 for pulmonary rehabilitation services ($20/visit x 6 visits = $120). This 
item/service falls within the pulmonary rehabilitation 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 copayments for pulmonary rehabilitation services provided June 7, 2022, to June 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bone graft for repair of peri-implant defect (D6103), the 
debridement of a peri-implant defect (D6101), and the collection and application of autologous blood 
concentrate product (D7921) provided on May 9, 2022. 
 
You asked the Plan to pay for the bone graft for repair of peri-implant defect (D6103), the debridement of a 
peri-implant defect (D6101), and the collection and application of autologous blood concentrate product 
(D7921). You say that you had an existing implant that was infected. You say the services were medically 
necessary to keep the infection from spreading and causing more health issues. The Plan denied your request. 
The Plan says the services are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.  
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the bone 
graft for repair of peri-implant defect (D6103), the debridement of a peri-implant defect (D6101), and the 
collection and application of autologous blood concentrate product (D7921) provided on May 9, 2022.