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

 
We decided that the Plan does not have to pre-approve an implant supported lower denture (D6111) and an 
implant supported upper denture (D6110). 
 
You asked the Plan to pre-approve the dental services. You say that you have a broken tooth that needs to be 
extracted and replaced with a denture. The Plan denied your request. The Plan says implant supported dentures 
are not listed as covered services. 
 
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 implant supported 
dentures are not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pre-approve an implant supported lower denture (D6111) and an implant supported upper denture (D6110).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the case presentation, detailed and extensive treatment 
planning (D9450) and occlusion analysis (D9950) provided on January 19, 2022. 
 
You asked the Plan to pay for the case presentation and occlusion analysis. You say that you would like to be 
refunded for these services. The Plan denied your request. The Plan says these services are not covered 
expenses 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 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 case 
presentation, detailed and extensive treatment planning (D9450) and occlusion analysis (D9950) provided on 
January 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the preventive procedure (D1999) provided on October 20, 2021. 
 
You asked the Plan to pay for the preventive procedure. You say that on your paperwork it has the provider you 
were treated by as an in-network provider. 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 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 
preventive procedure (D1999) provided on October 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial periapical x-ray (D0220), and additional periapical 
x-ray (D0230) provided on November 3, 2021. 
 
You asked the Plan to pay for the periapical x-rays. You say that you do not know why you were charged for 2 
little x-rays. You say that you wanted a second opinion. You say that you never went. You also say that you feel like this was an overcharge. The Plan denied your request. The Plan says periapical x-ray is covered once 
per calendar year. The Plan also says that the frequency limit 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage and periapical x-ray is listed as 
covered, the frequency limit of once per calendar year has been exceeded. The record shows that the Plan paid 
for a periapical x-ray that you received on November 5, 2021. Therefore, we decided that the Plan does not 
have to pay for the initial periapical x-ray (D0220), and additional periapical x-ray (D0230) provided on 
November 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and periapical x-
rays (D0230 x 2) provided on August 19, 2021. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered. The Plan denied 
your request. The Plan says comprehensive oral evaluation is covered once every 3 years. The Plan says that 
periapical x-ray is covered once per calendar year. The Plan also says that the frequency limit 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage and the services are listed as covered, 
the frequency limits have been exceeded. The record shows that the Plan paid for a comprehensive oral 
evaluation and initial periapical x-ray received on September 13, 2021, thus exceeding the frequency limits. 
Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and 
periapical x-rays (D0230 x 2) provided on August 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740) and core buildup, including any pins 
when required (D2950). 
 
You asked the Plan to pre-approve a crown and core buildup. You say that these services are medically 
necessary because your crown has suffered damage and you need a new one. The Plan denied your request. 
The Plan says these services are not covered under your plan. The Plan also says that these services are covered 
under the Platinum dental rider, and you do not have a dental rider. 
 
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 a 
crown (D2740) and core buildup, including any pins when required (D2950).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for tooth root removal (D7250), and intraoral imaging (D0210) 
provided by a participating provider on December 2, 2021. 
 
You asked the Plan to pay for tooth root removal and intraoral imaging. You say that you believe the Plan 
should pay for this. The Plan denied your request. The Plan says D7250 is not a covered benefit. The Plan says 
that the benefit limit for D0210 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, D7250 is not among those covered 
under this benefit. Evidence was provided to show that D0210 was provided on April 29, 2021.  Therefore, we decided that the Plan does not have to pay for tooth root removal (D7250), and intraoral imaging (D0210) provided by a participating provider on December 2, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the positron emission tomography (PET). 
 
You asked the Plan to pre-approve PET. You say that you would like reconsideration because the PET is 
medically necessary. The Plan denied your request. The Plan says there are no medical records submitted 
documenting that the enrollee meets diagnostic criteria for both frontotemporal dementia (FTD) and 
Alzheimers dementia. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met.  
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 the positron emission tomography 
(PET). have been met. Specifically, the documentation submitted does not include sufficient clinical 
information to determine if the enrollee has a clinical indication for the requested PET or if the requested PET 
would be medically reasonable and necessary.. Therefore, we decided that the Plan does not have to pre-
approve the positron emission tomography (PET).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service December 
31, 2021. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
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 70450 
is a column II code to column I code 70496. 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 procedure code 70450 billed for date of service December 31, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing (G0483, 80307) provided on April 1, 2021. 
 
You asked the Plan to pay for drug testing. You say that this is supported in the records. The Plan denied your 
request. The Plan says this was 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 drug testing 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 drug testing (G0483, 80307) provided on April 1, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional routine transportation trips. 
 
You asked the Plan to provide additional transportation. You say that this transportation is necessary for you to 
get to your appointments, as you have no other way to get there. The Plan denied your request. The Plan says 
your supplemental benefit covers a maximum of 60 trips per year. Additional trips are not a covered benefit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 60 trips per year.  
 
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that your request exceeds the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to provide additional routine transportation trips.
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 inpatient rehabilitation is medically necessary for 
this enrollee. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The 
enrollee's ongoing skilled therapy and nursing needs can be provided in a lower level of care. 
 
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 that the complexity of the enrollees nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
documentation does support a need for physical and/or occupational therapy, there is no documented need for 
an intensive, multi-disciplinary rehabilitation program. 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.
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 did not provide a specific argument with your 
appeal request. The Plan denied your request. The Plan says the patient is getting appropriate care in their 
current acute care facility and transfer to an LTACH is not needed. 
 
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 the short-term acute care hospital can provide for all of the patients present inpatient 
care needs and the patient is receiving an appropriate level of care in the present setting. Continued care in the 
short-term acute care hospital is appropriate (and endorsed by the health plan) until the patient is stable to 
transfer to a lower level of care such as an inpatient rehabilitation facility, a sub-acute rehabilitation facility or a 
skilled nursing facility. 
 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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH services are medically 
necessary. The Plan denied your request. The Plan says the patient is getting appropriate care at their current 
acute care facility and transfer to LTACH is not medically necessary. 
 
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 the short-term acute care hospital can provide for all of the patients present inpatient 
care needs and the health plan has stated that continued care in the short-term acute care hospital will be 
covered. 
 
 
 
 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: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care beyond 
March 30, 2022. 
 
You asked the Plan to pre-approve continued SNF care. You say that continued SNF care is medically 
necessary. The Plan denied your request. The Plan says you do not meet criteria for continued SNF care 
beyond March 30, 2022. 
 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 continued SNF care. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found based on the medical records 
provided there is no documentation that you require skilled nursing services. Records do not document the need 
for intravenous medications, new tube feeding or ostomy care or daily complex wound care. While the records 
do show that you required skilled therapy services, there is no documentation that daily skilled services are 
required. You are walking household distances with no assistive device with stand-by assistance/supervision 
and is stand-by assist/supervision for transfers. Provided records do not document a significant decline in your 
functional status to necessitate further daily inpatient skilled therapy services. There is no documentation 
showing that you require services on an inpatient SNF 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 continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) care beyond March 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation services (99152) provided on August 
17, 2021. 
 
You asked the Plan to pay for the moderate sedation services (99152). You say that you are resubmitting the 
claim with attached medical records to be reviewed for payment. The Plan denied your request. The Plan says 
you are resubmitting the claim with attached medical records to be reviewed for payment. 
 
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 99152 is moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older. 
 
We find that CPT code 99152 is not supported in the medical record. Specifically, the records do not support 
the presence of an independent trained observer as required. Based on this information, we decided that 
Medicare rules for coverage of the moderate sedation services (99152) have not been met. Therefore, we 
decided that the Plan does not have to pay for the moderate sedation services (99152) provided on August 17, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for urology specialist office visits and lab 
services provided from October 7, 2021, to December 14, 2021. We also decided that the Plan does not have to 
waive the copayment for lab services provided on November 18, 2021. 
 
You asked the Plan to waive the copayments for specialist office visits and lab services. You say that the 
urology office visits, and lab tests were part of prostate screening process. You also say per the summary of benefits prostate screening is covered 100%.  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 $10 
copayment per facility for diagnostic lab services. The Plan contract also says that enrollees must pay a $40 
copayment for a specialist office visit. The contract also says there is no charge for a PSA test.  
 
The record shows that you had a prostate specific antigen (PSA) test on September 29,2021, and you were not 
charged. The PSA screening does not include follow up visits or other testing. You have been asked to pay a 
$40 copayment for each specialist office visit on October 7, 2021, November 8, 2021, November 18, 2021, and 
December 14, 2021. A specialist office visit falls within the Physician/Practitioner Services, Including Doctor's 
Office Visits benefit category.  
 
You have also been asked to pay the allowed amount of $3.48, which is less than the $10 copayment for a 
urinalysis/lab service on November 18, 2021, and December 14, 2021. You have also been asked to pay a $10 
copayment for lab services on November 18, 2021, which took place at a different facility. Lab services fall 
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 copayments for urology specialist office visits and lab services provided from 
October 7, 2021, to December 14, 2021. We also decided that the Plan does not have to waive the copayment 
for lab services provided on November 18, 2021.