Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics/inserts (L3020).

You asked the Plan to pre-approve foot orthotics. You say that the requested inserts are medically necessary for the enrollee. The Plan denied your request. The Plan says this item is not a covered benefit.

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.  

Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics/inserts (L3020).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prosthesis with an advanced knee and foot (CPT 
code(s): L5828, L5845, L5981, L5850, L5925). 
 
You asked the Plan to pre-approve the items. You say that the items are necessary. The Plan denied your 
request. The Plan says the records we have do not show why the requested advanced knee and foot are needed. 
The Plan states a request for a prosthetic knee and foot that meets your needs and Medicare guidelines can be 
reviewed if submitted. 
 
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 items. Our physician reviewer 
found there is no documentation that support that the advanced knee and foot at issue in this case meet all of 
Medicare's LCD: Lower Limb Prostheses (L33787) criteria for medically reasonable and necessary for the 
enrollee. Provided records do not document any clinical records from the enrollee's medical practitioner to 
support the need for the advanced knee and foot. 
 
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 items have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a prosthesis with an advanced knee and foot (CPT code(s): L5828, L5845, L5981, L5850, 
L5925).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the wound care services provided on April 27, 2022, by an out-of-network (OON) provider.

You asked the Plan to pay for the services provided. You say that wound care supplies are a separately billable expense. The Plan denied your request. The Plan says there is no prior authorization for the services.

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 did not pre-approve the services 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 the wound care services provided on April 27, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation - new or established patient 
(D0150) provided on May 24, 2022. 
 
You asked the Plan to pay for the dental services. You say that you received a letter stating the Plan approved 
the request. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service January 17, 2020. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation - new or 
established patient (D0150) provided on May 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an orthotic or prosthetic accessory (L9900) billed for date of service October 15, 2021.

You asked the Plan to pay for an orthotic or prosthetic accessory. You say that the item at issue was billed correctly. The Plan denied your request. The Plan says rules for payment have not been met.

The Plan must follow Medicare rules. Medicare rules say that claims lines billed with codes without a KX, GA or GZ modifier will be rejected as missing information.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an orthotic or prosthetic accessory have not been met. Specifically, the claim at issue was billed without the required modifier(s). Therefore, we decided that the Plan does not have to pay for an orthotic or prosthetic accessory (L9900) billed for date of service October 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a refabricated stainless steel crown - primary tooth (D2930) 
provided on June 20, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were told by the Plan the dentist was out-
of-network and they would still cover the service and sent you a reimbursement form. You say that you used a 
reimbursement form the dentist's office supplied. The Plan denied your request. The Plan says the dental 
services were received from an out-of-network provider and are not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a refabricated stainless steel crown - primary tooth (D2930) provided on June 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal scaling and root planing and tooth extraction 
services (D7140, D4341) provided on June 13, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the dental services were received from an out-of-
network provider and are not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for periodontal scaling and root planing and tooth extraction services (D7140, D4341) provided on June 
13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical removal of residual tooth roots for tooth #18 
performed on July 14, 2022. 
 
You asked the Plan to pay for the dental extraction. You say that the extraction was for a tooth that was 
damaged as a result of a broken bridge which should have lasted longer. The Plan denied your request. The 
Plan says the claim was processed correctly. You received an extraction, but the record shows you were not 
obtaining dentures. Therefore, the extraction is 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 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 
surgical removal of residual tooth roots for tooth #18 performed on July 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gum surgery (D4261) to be provided by an out-of-
network provider. 
 
You asked the Plan to pre-approve the dental surgery. You say that you feel the service should be covered 
because you have an autoimmune disease. You say that the service is medically necessary, and you need help 
covering the cost. The Plan denied your request. The Plan says the claim was processed correctly. Dental 
services such as cleanings, routine dental exams, and dental x-rays are not covered without the supplemental 
dental option. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
 
 
 The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement 
of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or 
paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve gum surgery (D4261) 
to be provided by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D6740) provided on May 6, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your dental benefit maximum of $1,000 for the 
requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service May 6, 2022. Therefore, 
we decided that the Plan does not have to pay for a crown (D6740) provided on May 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intra-oral x-ray and comprehensive oral evaluation 
(D0150, D0210,) provided on June 21, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service July 6, 2021. Therefore, 
we decided that the Plan does not have to pay for an intra-oral x-ray and comprehensive oral evaluation 
(D0150, D0210,) provided on June 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for resin-based composites (D2330 and D2331) provided by a 
participating provider on July 25, 2022. 
 
You asked the Plan to pay for the dental services. You say that these services should be covered. The Plan 
denied your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service July 25, 2022. Two resin-
based composites have been approved and paid. Four resin-based composites have been denied due the benefit 
limit being exhausted. Therefore, we decided that the Plan does not have to pay for resin-based composites 
(D2330 and D2331) provided by a participating provider on July 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2740) provided on August 4, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial and the crown was medically necessary. The Plan denied your request. The Plan says the 
services denied correctly as they do not fall within 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 Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a crown 
(D2740) provided on August 4, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that the enrollee should be transferred to an LTACH for continuation of care for complex medical needs that require ongoing acute care. The Plan denied your request. The Plan says the enrollee is receiving appropriate in-patient acute care services in the acute care hospital and does not require transfer to LTACH.

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 that the enrollee appears to be more stable and improving and should only require short-term additional acute care services that can be safely provided at the current facility until more stable and appropriate for a lower level of care. The enrollee does not require services at the LTACH that are not already available at the current facility. Transfer to the LTACH is not medically necessary as the patient is not yet stable and as it would not be clinically advantageous at this time. Completion of treatment at the current facility is recommended.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral exam (D0120) and dental cleaning (D1110) 
provided by an out-of-network provider on June 21, 2022. 
 
You asked the Plan to pay for the dental services. You say that you think the claim that was submitted by the 
provider should be paid. The Plan denied your request. The Plan says the claim was processed correctly. The 
Plan says an Annual Notice of Change was issued to you in 2021 explaining that dental services would now be 
under a reimbursement program. The Plan also says that payments can no longer be issued unless the necessary 
reimbursement forms have been submitted directly by you. 
 
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 services are only 
reimbursable when submitted by you. Claims submitted by providers are no longer able to be processed. Based 
on this information, we decided that the Plan's rules for coverage of the dental services have not been met. 
Therefore, we decided that the Plan does not have to pay for a periodic oral exam (D0120) and dental cleaning 
(D1110) provided by an out-of-network provider on June 21, 2022.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the portable x-ray services provided to the enrollee on November 9, 2021.
You asked the Plan to pay for the portable x-ray services. You say that that this should be paid for. The Plan denied your request. The Plan says this service has been billed with an inappropriate Place of Service.
The plan follows Medicare rules. Medicare rules say that when services are provided by a mobile unit, the mobile unit should bill the POS as the entity that is being served.
Under Medicare rules, you should have billed POS 31- Skilled Nursing Facility. Instead, you billed POS 11-Office. This is not appropriate. Therefore, we decided that the plan does not have to pay for the portable x-ray services provided to the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable


We decided that the Plan does not have to pre-approve the semi-precision attachments (D6192x4).

You asked the Plan to pre-approve the semi-precision attachments (D6192x4). You say that you were told that this plan would cover your new dentures. The Plan denied your request. The Plan says the services are not covered benefits.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the 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 the semi-precision attachments (D6192x4).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that the requested continuation of SNF care is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for continued SNF care.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found clinical documentation shows that all appropriate therapy goals have been met. The enrollee is receiving routine skilled nursing assessments thus from a practical standpoint the enrollee does not require daily skilled services in a 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on February 8, 2022. 
 
You asked the Plan to pay for the services provided. You say that you were told you would not have to pay 
anything. The Plan denied your request. The Plan says the claim processed correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 
copay per day per provider. The deductible does apply for outpatient diagnostic tests.  You have been asked to pay a deductible and $10 copay for the lab services provided. The services fall within 
the outpatient diagnostic tests 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 pay for the laboratory services 
provided on February 8, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97010 billed for date of service May 9, 2022, 
to May 23, 2022. 
 
You asked the Plan to pay for procedure code 97010. The Plan denied your request. The Plan says procedure 
code 97010 is considered bundled and not separately payable. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 97010 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 97010 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 97010 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 97010 billed for date of service May 9, 2022, to May 23, 2022.