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

 
We decided that the Plan does not have to pay for the gingivectomy or gingivoplasty (D4212) provided on 
February 24, 2022. 
 
You asked the Plan to pay for the gingivectomy or gingivoplasty. You say that you are confused as to why the 
Plan would pay for a filling that cannot be completed without removal of some gum tissue to allow access. The 
Plan denied your request. The Plan says this service is not a covered benefit under your dental plan. 
 
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 
gingivectomy or gingivoplasty (D4212) provided on February 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial maxillary denture (D5213) provided by a 
participating provider. 
 
You asked the Plan to pre-approve a partial maxillary denture. You say that you would like the Plan to approve 
D5213. The Plan denied your request. The Plan says the benefit limit for D5213 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 partial 
maxillary denture once every five plan years.  
 
We looked at the file and Medicare rules. D5213 was previously provided on January 11, 2022. Based on this 
information, we decided that the Plan's rules for coverage of a partial maxillary denture have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a partial maxillary denture (D5213) provided 
by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral - periapical first radiographic image (D0220) 
and limited oral evaluation - problem focused (D0140) provided February 17, 2021. 
 
You asked the Plan to pay for the periapical x-ray and limited oral exam. You say that you were unaware of the 
deadline, and the provider should have filed the claim. The Plan denied your request. The Plan says this claim 
was filed untimely. 
 
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. 
 
The record shows that a claim for the periapical x-ray and limited oral exam was not filed until March 29, 
2022. This means that more than one calendar year from the date of service had passed before a claim was 
filed. Therefore, we decided that the Plan does not have to pay for the intraoral - periapical first radiographic 
image (D0220) and limited oral evaluation - problem focused (D0140) provided February 17, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing (81400, 81241, 81240). 
 
You asked the Plan to pre-approve the genetic testing. You say that the genetic testing is medically necessary. 
The Plan denied your request. The Plan says this service is non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a non-coverage policy for genetic testing 
for thrombophilia testing for the Factor V Leiden (FVL) variant in the F5 gene, the G20210GA (G20210A) 
variant in the F2 gene, and the MTHFR gene which encodes the 5,10- methylenetetrahydrofolate reductase 
enzyme. 
 
We looked at the file and Medicare rules. This service is only covered for pregnant patients. The record does 
not show that the enrollee is pregnant. 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 pre-approve 
genetic testing (81400, 81241, 81240).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on November 29, 2021. 
 
You asked the Plan to pay for the lab services. You say that you would like this claim reprocessed per the 
medical records. The Plan denied your request. The Plan says you billed with an incorrect place of service on 
the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on November 29, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthetic agent injection (64445) provided on April 15, 
2021.  You asked the Plan to pay for the anesthetic agent injection (64445). The Plan denied your request. The Plan 
says CPT code 64445 is included in CPT code 01250 and cannot be separately reimbursed. 
 
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 64445 is a column II code to column I code 01250; however, 64445 
was billed with a modifier.  
 
We asked our coder 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 anesthetic agent injection (64445). Our reviewer says that 
the documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer found the 
anesthesia report documents an anesthetic agent injection was given. However, the documentation does not 
support anesthetic agent was performed for reasons other than introperative pain management. Therefore, this 
procedure would be included in the anesthesia service. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the anesthetic agent injection (64445) have not been met. Therefore, we decided 
that the Plan does not have to pay for the anesthetic agent injection (64445) provided on April 15, 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 the services were medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
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. Our 
physician reviewer found there is no documented need for intensive inpatient rehabilitation services. Medically necessary care can be provided at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from 
December 1, 2021, through December 31, 2021. 
 
You asked the Plan to pay for the SNF care as billed. You say that you would like this claim reprocessed. The 
Plan denied your request. The Plan says the claim has not been billed as required by Medicare coding 
regulations. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) care 
provided from December 1, 2021, through December 31, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve routine transportation trips (A0120). 
 
You asked the Plan to pre-approve routine transportation trips. You say that you are unable to get around on 
your own and you need transportation. The Plan denied your request. The Plan says routine transportation is 
not covered by your benefit plan. 
 
The Plan must follow Medicare rules. Medicare does not cover transport in a vehicle that is not an ambulance. 
The Plan follows the same rule.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Medicare rules for coverage of routine transportation trips have not been met. Specifically, the 
requested service is not covered by your plan. Therefore, we decided that the Plan does not have to pre-approve 
routine transportation trips (A0120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral exam (D0120) and prophylaxis (D1110) provided on 
May 5, 2022, by the out of network dentist. 
 
You asked the Plan to pay for the dental services. You say that you have used this provider exclusively over the 
last 30 years. You say that you would like to continue doing so. You also say that you were not aware that you 
had been assigned to another dentist. The Plan denied your request. The Plan says dental services received from 
an out of network dentist are not covered. 
 
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 dental services are not among those 
covered under this benefit when received by an out of network dentist. Therefore, we decided that the Plan 
does not have to pay for the oral exam (D0120) and prophylaxis (D1110) provided on May 5, 2022, by the out 
of network dentist.
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 the services are medically necessary. The 
Plan denied your request. The Plan says coverage criteria has not been met. 
 
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 there are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. The health plan has approved ongoing care 
in the current acute care 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 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: SNF
Decision: Favorable

 
We decided that the Plan has to reduce the copayment for the inpatient skilled nursing facility (SNF) care 
provided from August 6, 2021, through August 30, 2021. 
 
You asked the Plan to reduce the copayment. You say that the copayment has been incorrectly applied to the 
services provided. The Plan denied your request. The Plan says that the copayment has been applied correctly 
to the services provided in this case. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that you must pay a $0 copayment per day, for days 1-20 and a $184 copayment per 
day, for days 21-100 for skilled nursing facility care.  
 
The Plan says you must pay $1,300 for the skilled nursing facility care provided. Based on the Plan contract, 
however, you cannot be asked to pay more than $736 ($184 copayment x 4 days) for the SNF care provided. 
You received 24 days of skilled nursing facility care. The Plan contract states that you must pay a $0 
copayment per day, for days 1-20 and a $184 copayment per day, for days 21-100 for skilled nursing facility 
care. Therefore, we decided that the Plan has to reduce the copayment for the inpatient skilled nursing facility 
(SNF) care provided from August 6, 2021, through August 30, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) 
provided March 18, 2022. 
 
You asked the Plan to pay for the limited oral exam. You say that you do not understand why this isn't covered 
since exams are covered under your benefits. The Plan denied your request. The Plan says this service is 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) provided March 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Barostim Neo device. 
 
You asked the Plan to pre-approve a Barostim Neo device. You say that the requested device is medically 
necessary. The Plan denied your request. The Plan says the requested device is considered unproven and 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 Barostim Neo device. Our reviewer 
says that the Barostim Neo system would not be considered medically reasonable and necessary in this 
patients clinical management. Our physician reviewer found there remains an absence of randomized, blinded 
clinical studies examining long-term clinical outcomes establishing the value of Barostim Neo in patient 
management. 
 
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 Barostim Neo device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Barostim Neo device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custom abutments on tooth #12, 13, and 14 (D6057) and 
abutment supported crowns on tooth #12, 13, and 14 (D6058). 
 
You asked the Plan to pre-approve abutments and supported crowns. You say that you disagree with the denial 
of dental services. The Plan denied your request. The Plan says custom abutments (D6057) and abutment 
supported crowns (D6058) are not covered by your dental 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 pre-approve 
custom abutments on tooth #12, 13, and 14 (D6057) and abutment supported crowns on tooth #12, 13, and 14 
(D6058).
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 the services are medically necessary. The Plan 
denied your request. The Plan says rules for coverage have not been met. 
 
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. Our 
physician reviewer found there are no complex nursing or rehabilitation needs. The enrollee's needs can be met 
at a lower level of care. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: 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 the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 e requested LTACH care is not considered medically reasonable and necessary in this case. Our physician 
reviewer found there are no services available at the LTACH that the enrollee requires that are not available at 
the health care setting being offered by the health plan. The health plan has approved ongoing care in the 
current acute care setting. The requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only 
on an inpatient basis. 
 
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: 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 the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.While the medical record supports a need for physical and/or occupational therapy, there is no documented need for 
intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is 
not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 
 
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.