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

 
We decided that the Plan does not have to pay for the dental services (D9952, D4263, and D4260) provided on 
November 23, 2021. 
 
You asked the Plan to pay for dental codes D9952, D4263, and D4260. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services 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, dental codes D9952, D4263, and 
D4260 are not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pay for the dental services (D9952, D4263, and D4260) provided on November 23, 2021.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Udenyca. 
 
You asked the Plan to pre-approve Udenyca. You say that the services are necessary. The Plan denied your 
request. The Plan says that based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Udenyca. Our reviewer says that the 
services are medically necessary. Our physician reviewer found the enrollee has had thrush and gingivitis 
related to neutropenia. The use of growth factors such as with Udenyca is reasonable and medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Udenyca have been met. Therefore, we decided that the Plan has to pre-approve 
Udenyca.  
 
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 pre-approve a dental graft. 
 
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 the services 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 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 
dental graft.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral complete series x-ray provided on December 27, 2021. 
 
You asked the Plan to pay for the intraoral complete series x-ray. You say that the dentist office took x-rays 
instead of a cleaning without your knowledge that these were duplicate x-rays. You say that you would not 
have gotten these done. The Plan denied your request. The Plan says the maximum allowed for this procedure 
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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, you also have a maximum benefit of 
one complete series of radiographic images every 36 months. The Plan paid for the intraoral complete series x-
ray provided on June 11, 2021, which exhausted your benefit. Therefore, we decided that the Plan does not 
have to pay for the intraoral complete series x-ray provided on December 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the apicoectomy - anterior (D3410) and retrograde filling - 
per root (D3430) provided August 24, 2021. 
 
You asked the Plan to pay for the apicoectomy and retrograde filling. You say that this should be covered as a 
surgery. The Plan denied your request. The Plan says these services are not covered under these 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 
apicoectomy - anterior (D3410) and retrograde filling - per root (D3430) provided August 24, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 28 pulmonary rehab (PR) visits (94625). 
 
You asked the Plan to pre-approve pulmonary rehab visits. You say that your doctor prescribed these services 
for you, and they are medically necessary. The Plan denied your request. The Plan says they have agreed to 
cover two visits a week for four weeks for a total of eight (8) visits. However, the remaining 28 visits requested 
are not medically necessary. 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary PR programs 
for those with moderate to very severe COPD. There must be a referral from the doctor treating the disease. 
The services must be provided in a doctor's office or an outpatient hospital setting. The PR program must 
include specific components. Benefits are limited to a maximum of 36 visits, with an additional 36 visits if 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve pulmonary rehab visits. Our reviewer 
says that the request for continued pulmonary rehabilitation beyond the 8 visits (twice weekly for 4 weeks) 
already approved is not medically necessary. Our physician reviewer found you had COVID-19 in November 
2021 and have had dyspnea and an oxygen requirement since. During recent pulmonary consultation, you 
reported dyspnea prior to COVID-19, and previous treatment with inhalers. There is a significant past smoking 
history, so there is a suspicion of COPD. However, you have not had Pulmonary Function Tests (PFTs), which 
are required to determine if you qualify for pulmonary rehab by Medicare criteria. The plan has approved 8 
sessions of pulmonary rehab. You do not meet Medicare criteria for additional sessions, because PFTs have not 
been done. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of pulmonary rehab visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 28 pulmonary rehab (PR) visits (94625).
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pre-approve 15 additional skilled nursing home health visits. 
 
You asked the Plan to pre-approve home health services. You say that additional home health skilled nursing 
visits are medically necessary. The Plan denied your request. The Plan says that the rules for additional home 
health skilled nursing services have not been met. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve home health services. Our reviewer 
says that home health skilled nursing visits are medically reasonable and necessary. Our physician reviewer 
found you are a 70-year-old female with past medical history of renal disease, heart failure and venous stasis 
ulcers currently receiving home health nursing and occupational therapy. Based on clinical documentation, 
skilled nursing services continue to be required as your wounds require the monitoring of a skilled professional 
nurse. The requested 15 additional home health skilled nursing visits are medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have been met. Therefore, we decided that the Plan has to 
pre-approve 15 additional skilled nursing home health visits.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (CPT code (s): 80053, 80061, 81000, 
83735, 84443, and 85025) provided on July 10, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the laboratory services have not been met. CPT code(s): 80053, 
80061, 81000, 83735, 84443, and 85025, remain not supported. The place of service on the CMS-1500 form 
line 24B must reflect the location of the patient when the specimen was obtained. The submitted claim form 
indicates the laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical 
documentation and/or claim history indicates that the specimen was obtained in an office setting POS 11.; 
therefore, the billed code cannot be verified. It is noted multiple attempts were made to obtain additional 
information from the provider. Therefore, we decided that the Plan does not have to pay for the laboratory 
services (CPT code (s): 80053, 80061, 81000, 83735, 84443, and 85025) provided on July 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services provided on January 12, 2022. 
 
You asked the Plan to pay for the dental services. You say that your agent referred you to this provider which 
she said was in-network. You say that you had no problems with claims for 2021 being paid. The Plan denied 
your request. The Plan says these services are not covered when performed by a non-network provider. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, out-of-network dental services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental 
services provided on January 12, 2022.
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 IRF admission is not medically necessary based on lack of, medical complexity, 
acute rehabilitation nursing needs and current functional status. Documentation does not support the necessity 
for admission to an IRF. The enrollee's rehabilitation needs can be met safely and provided at a lower intensity 
and alternate setting such as in an SNF.  
 
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 the Tempus gene panel provided on June 15, 2021, billed 
with codes 81206 and 81292. 
 
You asked the Plan to pay for the gene testing as billed. You say that this is medically necessary and should be 
paid. The Plan denied your request. The Plan says this panel was not ordered by a doctor and is not billed 
correctly. As such, only 11 of the 13 codes are approved for payment. 
The Plan must follow Medicare rules. Medicare rules say that if one laboratory procedure evaluates multiple 
genes using a next generation sequencing 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 is an NGS assay of multiple genes and was not billed with a 
single code as required. Based on this information, we decided that Medicare rules for coverage of the gene 
testing as billed have not been met. Therefore, we decided that the Plan does not have to pay for the Tempus 
gene panel provided on June 15, 2021, billed with codes 81206 and 81292.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
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 does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the enrollee 
has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive 
rehabilitation program.  
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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies. 
 
You asked the Plan to pre-approve a CGM and supplies. You say that you cannot control your glucose like you 
would like. The Plan denied your request. The Plan says that you are not injecting insulin three or more times a 
day. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a CGM and 
supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor (CGM) and supplies.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit provided on February 4, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for a home visit. You say that you should be covered under any authorization for the 
nursing home. The Plan denied your request. The Plan says the services were billed/rendered by non-
participating providers, and they have also determined that these services are not urgent or emergent, nor were 
they approved in advance. 
 
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 a home visit provided on February 4, 2022, by an 
out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gingivectomy, retainer crowns, core buildup, and 
porcelain/ceramic pontics. 
 
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 the services 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 Plan's coverage rules apply in this case. The Plan covers periodontal 
and prosthodontic services under the Medicaid portion of your Plan. 
 
We looked at the file and the Plan's rules. The file shows that the requested services are periodontal and 
prosthodontic services. These services are not covered by the Medicare portion of your Plan. Based on this 
information, we decided that the Plan's rules for coverage of these services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve gingivectomy, retainer crowns, core buildup, and 
porcelain/ceramic pontics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the charges for the extractions of teeth #'s 19 and 30 provided 
on January 24, 2022. 
 
You asked the Plan to waive the charges for the dental extractions. You say that this was denied in error 
because the contract clearly shows these are covered. The Plan denied your request. The Plan says the services 
rendered are indeed covered and were paid. You are only responsible for the $25 copayment for each 
extraction. 
 
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 $25 
copayment for each dental extraction.  
 
You have been asked to pay a $25 copayment for each of the two dental extractions. 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 charges for the extractions of teeth #'s 19 and 30 provided on January 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an L300 Go Lower System functional electrical 
stimulator (FES) for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that this is necessary to treat the enrollee's foot drop. 
The Plan denied your request. The Plan says that the clinical value and effectiveness of the L300 Go Lower 
System in the setting of hemiplegia following a stroke has not been demonstrated in the peer-reviewed 
literature. 
 
The Plan must follow Medicare rules. Medicare rules say that a functional electrical stimulator is covered if 
Medicare criteria have been met. 
 
We looked at the file and Medicare rules. The file does not indicate the enrollee is using this to treat muscle 
atrophy where nerve supply to the muscle is intact or being used to help walking because of a spinal cord 
injury. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve an L300 Go Lower System functional 
electrical stimulator (FES) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an office visit provided on January 28, 
2022. 
 
You asked the Plan to waive the deductible for the office visit. You say that the services should be covered as 
you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied correctly 
based on the services provided. 
 
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 there is a $1,000 deductible which applies to Physician/Practitioner services, 
including doctor's office visits.  
 
 
  The item or service you asked the Plan to waive the deductible for falls within the benefit category 
Physician/Practitioner services, including doctor's office visits. The Plan has followed Medicare rules by 
clearly disclosing in the contract that there is a $1,000 deductible which applies to Physician/Practitioner 
services, including doctor's office visits. This cost sharing is a contractual obligation that had not been met at 
the time the office visit was received on January 28, 2022. Therefore, we decided that the Plan does not have to 
waive the deductible for an office visit provided on January 28, 2022.