Persius/hicric huggingface dataset:
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 LTACH admission will provide the 
enrollee the appropriate acute care environment for ongoing medical management, while safely implementing 
patient tolerance based rehabilitative therapies in hopes of continued stroke and pulmonary recovery. The Plan 
denied your request. The Plan says based on Medicare guidelines, the requested LTACH services do not meet 
the requirements for approval. 
 
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 improving and should only require short-term 
additional acute care services that can be safely administered at the current facility for the time being until a 
lower level of care is appropriate. The enrollee does not require services at the LTACH that are not already 
available at the current facility. There are no services at the LTACH that the enrollee requires that are not 
already available and covered at the current facility. Admission to an LTACH is not medically necessary as it would not be clinically advantageous. Transfer to a lower level of care may be considered when treatment has 
completed. 
 
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 the custom fluoride carriers for topical fluoride applications 
you provided on November 29, 2021. 
 
You asked the Plan to pay for the custom fluoride carriers. You say that these carriers were necessary to reduce 
radiation-induced dental caries secondary to xerostomia. The Plan denied your request. The Plan says after 
internal medical review it was determined that based on Medicare guidelines, the custom fluoride carriers 
fortopical fluoride applications do not meet the requirements for approval.
 
Medicare generally does not cover dental services, even if the reason for the dental services is due to a medical 
condition. 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's limited dental coverage only covers exams, x-rays, cleanings, fillings, and anesthesia.  Neither Medicare nor the Plan offers coverage of custom fluoride carriers to protect 
the teeth from future problems as a result of radiation. 
 
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 
custom fluoride carriers for topical fluoride applications you provided on November 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services provided on September 16, 2021, and 
November 16, 2021. 
 
You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says payment cannot 
be issued for services performed by an opt out 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, dental services provided by a dentist 
that has opted out of Medicare 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 September 16, 2021, and November 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal scaling and root planing (code D4341) you 
received on May 28, 2021. 
 
You asked the Plan to pay for dental code D4341. You say that you received these services from a network 
provider, so you believe these services should be covered. The Plan denied your request. The Plan says this 
particular service is not covered under 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. This benefit includes coverage 
only for those dental services listed in the Dental Benefit service listing. Dental code D4341 is not listed as a 
covered dental service, regardless of whether or not you receive this service from an in-network provider. 
 
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 
periodontal scaling and root planing (code D4341) you received on May 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair (K0814). 
 
You asked the Plan to pre-approve a power wheelchair. You say that the requested power wheelchair is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the 
requested power wheelchair. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a power wheelchair. Our reviewer says 
that the enrollee does not meet criteria for the requested power wheelchair. Our physician reviewer found based 
on the medical records provided there is no documentation that the enrollee meets the above Local Coverage 
Determination (LCD): Power Mobility Devices (L33789) criteria for the requested power wheelchair. The 
power wheelchair is being requested to go outside the home, to doctor's appointments and to church services 
and is not being requested to allow participation in mobility related activities of daily living such as toileting, 
feeding, grooming and bathing in customary locations within the home. There is no documentation that the 
enrollee's mobility deficit cannot be helped by the use of a manual wheelchair. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a power wheelchair have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power wheelchair (K0814).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (76857) provided on March 8, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 
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. In this case, we have confirmed that code 76857 is a column II code to column I code 76775. 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 the services (76857) 
provided on March 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cone beam computed tomography (CT) capture and 
interpretation (D0364) provided on November 5, 2021. 
 
You asked the Plan to pay for the cone beam CT capture and interpretation. You say that you would like to be 
reimbursed for this service. The Plan denied your request. The Plan says this service is not a covered benefit. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for 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 pay for the cone beam computed 
tomography (CT) capture and interpretation (D0364) provided on November 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composite - three surfaces, posterior (D2393) 
provided November 4, 2021. 
 
You asked the Plan to pay for the filling. You say that you would like this service covered. The Plan denied 
your request. The Plan says you have exceeded the frequency limit for this service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers two fillings 
per calendar year. 
 
We looked at the file and Medicare rules. In this case the Plan has already covered two fillings in 2021. Based 
on this information, we decided that the Plan's frequency limit for coverage of the filling has been exceeded. 
Therefore, we decided that the Plan does not have to pay for the resin-based composite - three surfaces, 
posterior (D2393) provided November 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for monoclonal antibody COVID-19 infusion treatment provided 
on October 7, 2021. 
 
You asked the Plan to pay for monoclonal antibody infusion. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the denial of payment for this service is correct, because 
this claim for monoclonal antibody COVID-19 infusion administration should be billed to Original Medicare 
instead of the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that health care providers should bill monoclonal 
antibody COVID-19 treatment to Original Medicare for all patients enrolled in a Medicare Advantage plan in 
2020 and 2021.  
 
We looked at the file and Medicare rules. This service should be billed to Original Medicare instead of the 
Plan. Based on this information, we decided that Medicare rules for coverage of monoclonal antibody infusion 
have not been met. Therefore, we decided that the Plan does not have to pay for monoclonal antibody COVID-
19 infusion treatment provided on October 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the apicoectomy of the first root (D3425), apicoectomy of 
each additional root (D3426), and two retrograde fillings (D3430 x2) provided on November 4, 2021. 
 
You asked the Plan to pay for the apicoectomies and retrograde filling. You say that you believe this was an 
emergency situation. You also say that you relied on your dentist office to arrange treatment for you which 
would be covered by your insurance. The Plan denied your request. The Plan says these services are not 
covered benefits 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 
apicoectomy of the first root (D3425), apicoectomy of each additional root (D3426), and two retrograde fillings 
(D3430 x2) provided on November 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the preventive procedure (D1999), bone replacement graft 
for ridge preservation (D7953), deep sedation/general anesthesia (D9222 and D9223), and therapeutic 
parenteral drug (D9610) provided on November 15, 2021. 
 
You asked the Plan to pay for the preventive procedure, bone replacement graft, deep sedation/general 
anesthesia, and therapeutic parenteral drug. You say that you had to be on antibiotics until the surgery was 
performed, and you thought tooth extractions were covered under your plan. The Plan denied your request. The 
Plan says these services are not covered benefits under your dental plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.  
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
preventive procedure (D1999), bone replacement graft for ridge preservation (D7953), deep sedation/general 
anesthesia (D9222 and D9223), and therapeutic parenteral drug (D9610) provided on November 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the topical application of fluoride varnish and periodontal 
maintenance provided on January 10, 2022. 
 
You asked the Plan to pay for the topical application of fluoride varnish and periodontal maintenance. You say 
that they did not inform you of the cost for a teeth cleaning and putting on fluoride. You say that the procedures 
should be covered, and you are being overcharged. 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 pay for the 
topical application of fluoride varnish and periodontal maintenance provided on January 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction, erupted tooth requiring removal of bone 
and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210) provided 
November 3, 2021. 
 
You asked the Plan to pay for the tooth extraction. You say that the claim should be paid as in-network. The 
Plan denied your request. The Plan says this service is not covered because the provider was OON at the time 
the services were performed. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the tooth 
extraction when provided in-network.  
 
We looked at the file and Medicare rules. At the time the services were rendered, this provider was not part of the Plans network. Based on this information, we decided that the Plan's rules for coverage of the tooth 
extraction have not been met. Therefore, we decided that the Plan does not have to pay for the extraction, 
erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal 
flap if indicated (D7210) provided November 3, 2021.  
 
Non-contract provider appeals require a Waiver of Liability form indicating that the enrollee is not being held 
responsible for the items or services at issue. In this case, you signed and completed a Waiver of Liability form, 
indicating that you are a non-contract provider. 
 
You claim that you are a contract provider with the Plan. Contract providers do not have appeal rights through 
the Independent Review Entity (IRE) process. If you are indeed a contract provider with the Plan, you will 
need to contact the Plan directly regarding any appeal processes that they have for contract providers.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for molecular cancer genomics (CGx) testing (CPT code(s):  
81295-90-XS, 81298-90-XS, 81317-90-XS, 81403-90-XS, 81405-90-XS, 81406-90-XS, 81479-90-GY) 
provided on March 9, 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. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
The member had molecular cancer genomics (CGx) testing on March 9, 2021. The denial remains upheld as 
non-covered as Medicare denies coverage when a laboratory assays two or more genes in a patient in parallel. 
Those two or more genes will be considered part of the same panel. A panel constitutes a single procedural 
service, so one CPT code must be submitted for the panel. Based on this information, we decided that Medicare 
rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not 
have to pay for molecular cancer genomics (CGx) testing (CPT code(s):  81295-90-XS, 81298-90-XS, 81317-
90-XS, 81403-90-XS, 81405-90-XS, 81406-90-XS, 81479-90-GY) provided on March 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a therapeutic CGM. You say that this equipment is medically necessary for 
the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage have not been 
met. 
 
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 the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for 
coverage of a therapeutic CGM have not been met. Therefore, we decided that the Plan does not have to pre-
approve a therapeutic continuous glucose monitor (CGM).
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 you need rehab services to recover completely before 
returning home. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. 
Your ongoing skilled care needs can be provided in an alternate setting. 
 
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 your 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 you 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost sharing for doppler flow ultrasounds provided on 
October 8, 2021, and October 25, 2021. 
 
You asked the Plan to reduce the cost sharing for the ultrasounds. You say that the services were provided by 
an in-network provider but was billed by the facility which is out of network. You also say that you attained your out-of-pocket maximum in July of 2021. The Plan denied your request. The Plan says you have been 
charged the correct cost amount. The Plan also says that the facility on the claim is listed as the billing and 
servicing facility, and the facility is not in contract. 
 
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 30% 
coinsurance for out of network advanced imaging services, including ultrasounds, at a specialist's office. The 
Plan contract also says that enrollees have a combined maximum out of pocket amount of $10,000, which is the 
most you pay during the calendar year for covered services received from both in-network and out of network 
providers. 
 
The record shows you saw an out-of-network provider. The record also shows that, although you met your in-
network MOOP, you had not met your combined MOOP at the time services occurred. Therefore, cost sharing 
still applies to an out-of-network provider. You have been asked to pay $35.98, which is 30% of the allowed 
amount for each doppler flow ultrasound ($119.95 allowed amount x 30% coinsurance = $35.98). A doppler 
flow ultrasound 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 reduce the cost sharing for doppler flow ultrasounds provided on 
October 8, 2021, and October 25, 2021.