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

 
We decided that the Plan does not have to pay for the lower denture (D5140) provided on October 19, 2021. 
 
You asked the Plan to pay for the dental item. You say that had you known the denture would not be covered, 
you would not have gotten it. You say that you cannot afford to pay this bill. The Plan denied your request. The 
Plan says $949 has been applied to the cost of the lower denture. The Plan also says that the $2,000 annual 
dental allowance has been 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 and dentures are covered once every 5 
years, the $2,000 annual dental allowance has been exhausted. The record shows that after the $949 payment 
was applied to the lower denture, the annual dental allowance has been exhausted. Therefore, we decided that 
the Plan does not have to pay for the lower denture (D5140) provided on October 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gingival irrigation (D4921) and localized delivery of 
antimicrobial agents (D4381) provided on December 1, 2021. 
 
You asked the Plan to pay for the gingival irrigation and localized delivery of antimicrobial agents. You say 
that the provider did not explain what was actually being done. You also say that you were told it was a deep 
cleaning which is covered. The Plan denied your request. The Plan says these services are not covered by your 
health plan or Medicare. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
gingival irrigation (D4921) and localized delivery of antimicrobial agents (D4381) provided on December 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the topical application of fluoride varnish (D1206) and 
additional intraoral periapical x-ray (D0230) provided on January 20, 2022. 
 
You asked the Plan to pay for the topical application of fluoride varnish and additional intraoral periapical x-
ray. You say that you would like to appeal these services. The Plan denied your request. The Plan says the 
topical application of fluoride varnish is not a covered benefit. The Plan also says that your benefits for the 
additional intraoral periapical x-ray have been satisfied and the frequency limitation has been exceeded. 
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, topical application of fluoride varnish 
(D1206) is not among those covered under this benefit. The contract says that intraoral x-rays are limited to 1 
procedure code per calendar year. The record shows that you received a first intraoral periapical x-ray (D0220) 
on January 20, 2022 which was covered by the Plan, and your intraoral x-rays benefit has been exhausted. 
Therefore, we decided that the Plan does not have to pay for the topical application of fluoride varnish (D1206) 
and additional intraoral periapical x-ray (D0230) provided on January 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an occlusal guard (D9944) to be provided by a 
contracted provider. 
 
You asked the Plan to pre-approve an occlusal guard. You say that you would like the Plan to pay for this. 
The Plan denied your request. The Plan says D9944 is not a covered dental benefit. 
 
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 an 
occlusal guard (D9944) to be provided by a contracted provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF). 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says an intensive rehabilitation program is not medically necessary. 
 
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 you have debility and do not meet the coverage criteria for this admission. On a 
review of the available records, you are medically stable, and do not need physician close supervision three 
times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. There are no rehab nursing needs identified or documented in the record. At the current 
functional level, you do not need 3 hours a day five days a week of IRF therapies with interdisciplinary 
management and the rehab needs can be met in an alternate and lower setting such as in an assisted living 
facility with therapies as needed. IRF admission is not medically necessary based on medical stability, lack of 
medical complexity, and lack of rehab nursing needs and current functional level. The services can be safely 
received at a lower intensity and alternate setting, such as in a assisted living facility with services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve admission to an inpatient rehabilitation facility (IRF).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on January 11, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not billed correctly. 
 
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 these 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 the laboratory services rendered on January 11, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prochlorper. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says self-administered drugs are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Prochlorper.  
 
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for destruction of benign lesions (17110) provided on November 
1, 2021. 
 
You asked the Plan to pay for destruction of benign lesions. You say that diagnosis code B07.9 is appropriate 
in this case and is supported as a supported diagnosis for this code per LCA A56346. The Plan denied your 
request. The Plan says the diagnosis code billed in this case does not support the medical necessity for this 
service per the applicable LCA. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules also say that there are specific diagnosis codes which support the medical necessity of CPT code 17110. 
Any diagnosis codes that are not listed in the LCA are not supported as medically necessary. 
 
 We find that CPT code 17110 is not supported in the medical record. Specifically, the diagnosis codes billed on 
this claim are not included on the list of appropriate diagnosis codes to support the medical necessity of CPT 
code 17110. Please also note that the LCA cited in your argument (A56346) does not apply to the state where 
these services were provided. Based on this information, we decided that Medicare rules for coverage of 
destruction of benign lesions have not been met. Therefore, we decided that the Plan does not have to pay for 
destruction of benign lesions (17110) provided on November 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pharmacogenetic testing panel provided on September 
30, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says one code 
must be submitted for the panel. 
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 looked at the file and the rules. The claim shows that the testing panel was billed with multiple codes. If a 
single procedure is performed, only one code with one unit of service may be reported for the procedure. Based 
on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that 
the Plan does not have to pay for the pharmacogenetic testing panel provided on September 30, 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 this is medically necessary. The Plan denied your 
request. The Plan says this is not medically necessary. 
 
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 enrollee has debility and does not meet the coverage criteria for this admission. 
On a review of the available records, the enrollee is medically stable, and does not need physician close 
supervision three times per week (at a minimum) for the ongoing management of any active or acute 
exacerbations of chronic medical conditions. There are no rehab nursing needs identified or documented in the 
record. At the current functional level, the enrollee does not need 3 hours a day five days a week of IRF 
therapies with interdisciplinary management and the rehab needs can be met in an alternate and lower setting 
such as in an assisted living facility with therapies as needed. IRF admission is not medically necessary based 
on medical stability, lack of medical complexity, and lack of rehab nursing needs and current functional level. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87481) provided October 15, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed service. 
 
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 87481 is not supported in the medical record. Specifically, lab results for Candida 
species were not included in the record. Based on this information, we decided that Medicare rules for coverage 
of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services 
(87481) provided October 15, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for office visits provided by an out-of-network (OON) provider on 
November 12, 2021 and December 1, 2021. 
 
You asked the Plan to pay for office visits. You say that you went where your doctor told you to go and were 
not told that this provider was out-of-network. The Plan denied your request. The Plan says that the denial of 
payment for these services is correct, because this provider is out-of-network with the Plan and authorization 
was not obtained. 
 
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. Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a 
contract provider are considered approved by the plan unless notice is provided that the services will not be 
covered. 
 
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 specify whether the referring physician was in-network or out-
of-network with the Plan. The record does not include prior notice from the Plan that these visits would not be 
covered. Without this information, we cannot determine whether the referral made constituted plan-directed 
care. Therefore, the Plan has not shown that its decision to deny payment for these visits is correct or justified 
according to Medicare rules. Therefore, we decided that the Plan has to pay for office visits provided by an out-
of-network (OON) provider on November 12, 2021 and December 1, 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: 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 this is medically necessary. The Plan denied your 
request. The Plan says the services can be safely received in other settings, for example, a skilled nursing 
facility, home with home health services or home with outpatient therapy. 
 
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 you have debility, and do not meet the coverage criteria for this admission.  On a review of the available records, you are medically stable, and do not need physician close supervision 
three times per week (at a minimum) for the ongoing management of any active or acute exacerbations of 
chronic medical conditions. There are no rehab nursing needs identified or documented in the record. At the 
current functional level, you do not need 3 hours a day five days a week of IRF therapies with interdisciplinary 
management and the rehab needs can be met in an alternate and lower setting such as in an assisted living 
facility with therapies as needed. IRF admission is not medically necessary based on medical stability, lack of 
medical complexity, and lack of rehab nursing needs and current functional level. The services can be safely 
provided at a lower intensity and alternate setting, such as a skilled nursing facility, or in-home with services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from 
January 29, 2021, to February 23, 2021. 
 
You asked the Plan to pay for home health services. You say that this should be covered. The Plan denied your 
request. The Plan says this was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. The location where services were provided must 
always be reported along with the first visit reported on the claim.  
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, the first visit 
was not reported with a code indicating the location where the services were provided. Therefore, we decided 
that the Plan does not have to pay for the home health services provided to the enrollee from January 29, 2021, 
to February 23, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Oxycodone for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that the enrollee has been stable on this medication. The 
Plan denied your request. The Plan says that this is not covered under Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Oxycodone for the enrollee.  
 
Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic mammogram provided on 
February 1, 2022. 
 
You asked the Plan to waive the copayment for the mammogram. You say that the test was a follow-up from a 
previous test that showed abnormal results. You say that this test came back normal. The Plan denied your 
request. The Plan says you have been charged the correct cost sharing amount. 
 
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 $40 
copayment for X-rays and ultrasounds.  
 
You have been asked to pay a $40 copayment for the mammogram. Please note that any test resulting from 
abnormal results from a previous test is considered diagnostic. The mammogram falls within the Outpatient 
Diagnostic Tests and Therapeutic Services and Supplies 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 diagnostic mammogram provided on February 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an IRF admission provided from November 23, 2021, 
through December 2, 2021. 
 
You asked the Plan to pay for the IRF admission. The Plan denied your request. The Plan says based on 
Medicare guidelines, your request for approval of an Inpatient Rehabilitation Facility admission does not meet 
the requirements for approval. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of an IRF admission provided from November 23, 2021, through December 2, 2021 have been met. Specifically, medical records have not been 
provided despite multiple attempts by the Plan to obtain the required medical records. Therefore, we decided 
that the Plan does not have to pay for an IRF admission provided from November 23, 2021, through  
December 2, 2021.