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

 
We decided that the Plan does not have to pay for the Inogen portable oxygen concentrator purchased on 
November 11, 2021. 
 
You asked the Plan to pay for the portable oxygen concentrator. You say that you would like this claim 
reprocessed by the Plan for medical necessity. The Plan denied your request. The Plan says payment cannot be 
made for this service. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. The appeal letter specifically indicates that it will 
be used when outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers 
equipment for use outside the home. Therefore, we decided that the Plan does not have to pay for the Inogen 
portable oxygen concentrator purchased on November 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4341) provided 
by a participating provider. 
 
You asked the Plan to pre-approve the dental services. You say that you never had these services done in 2020. 
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 November 12, 2020. 
Therefore, we decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4341) 
provided by a participating provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88341-26 billed for date of service 
November 24, 2021. 
 
You asked the Plan to pay for procedure code 88341-26. You say that you would like this claim reprocessed 
based on the medical records. The Plan denied your request. The Plan says payment for code 88341-26 is 
bundled into payment for code 88360. 
 
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 
88341-26 is a column II code to column I code 88360. 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 88341-26 billed for date of service 
November 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit and advanced care planning provided on 
February 23, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the home visit and advanced care planning. You say that you would like this 
claim reprocessed and approved for payment. The Plan denied your request. The Plan says prior authorization 
was not obtained for these services rendered by an OON provider. 
 
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 the home visit and advanced care planning 
provided on February 23, 2022, by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve continued SNF care. You say that the requested for continued 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 continued SNF care. Our reviewer says 
that the enrollee does not meet criteria for continued SNF care. Our physician reviewer found as of July 25, 
2022, the member did not require any skilled nursing or rehab services on a daily basis.  He was not expected 
to make measurable gains within a reasonable and predictable period of time or require skilled therapy to 
prevent deterioration with mobility or activities of daily living. The member did not require skilled therapy to 
establish a safe and effective maintenance program.  As a practical matter, the member did not require any 
skilled services on an inpatient basis, at a SNF level of care as of July 25, 2022. The member did not have any 
parental medications, daily complex wound care or nutrition given via a feeding tube.  The member received 
skilled care and improved; however, his functional improvement had plateaued by July 25, 2022, and he did 
not require any further inpatient skilled rehab services. The members function was at or near his new baseline 
level of function and he could be discharged to a lower level of care for further services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pontic on tooth #6 (D6245) and a crown on tooth #5 
and 7 (D6740). 
 
You asked the Plan to pre-approve a pontic and crown. You say that the enrollee does not believe that she will 
be able to adapt to a removable appliance. The Plan denied your request. The Plan says the information 
provided does not show why a denture cannot be used to replace the missing teeth. 
 
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 a pontic and 
crown when the services are medically necessary and reasonable.  
 
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 pontic and crown. Our reviewer says 
that the coverage criteria for these services have not been met. Our physician reviewer found that there is 
nothing in the supplied documentation that indicates there was any physical or psychological reason for not 
being able to wear a removable partial denture. Our physician reviewer also found that the letter of necessity noted only that the bridge was preferred over a removable appliance. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of a pontic and crown have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a pontic on tooth #6 (D6245) and a crown on tooth #5 and 7 (D6740).
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 enrollee will receive sub-acute level of care that 
he will receive. The Plan denied your request. The Plan says authorization denied because the IRF care is not 
medically necessary, and the enrollee's needs can be met at a lower level of care such as a skilled nursing 
facility (SNF). 
 
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's medical problems are stable, and there are no complex nursing or 
rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record 
supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
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: Favorable

 
We decided that the Plan has to pre-approve inpatient level of care. 
 
You asked the Plan to pre-approve inpatient level of care. You say that the requested inpatient level of care is 
medically necessary. The Plan denied your request. The Plan says that the requested inpatient level of care is 
not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 inpatient level of care. Our reviewer 
says that the requested inpatient level of care is medically necessary. Our physician reviewer found guidelines, 
as well as the current standard of care, are consistent with the requirement that in-patient electrocardiogram 
(ECG) monitoring be carried out when initiating this anti-arrhythmic drug because of its potential pro-
arrhythmic effect with risk of unheralded ventricular tachycardia, and potential need for defibrillation.  In 
summary, the evidence would suggest that it is reasonable and appropriate to authorize in-patient admission for 
initiation of dofetilide in the clinical management of this enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient level of care have been met. Therefore, we decided that the Plan has to 
pre-approve inpatient level of care.  
 
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 coded 81220, 81225, 81227, 81230, 
81240, 81241, 81291, 81335, 81355, and 81479 provided on May 11, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services are not payable 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. 
 We find that CPT codes 81220, 81225, 81227, 81230, 81240, 81241, 81291, 81335, 81355, and 81479 are not 
supported in the medical record. Specifically, if a laboratory assays two or more genes in an enrollee in 
parallel, those two or more genes will be considered part of the same panel. A panel constitutes a single 
procedural code, so one code must be submitted for the panel. Review of the file does not support that only one 
code was billed for the panel provided. 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 the 
laboratory services coded 81220, 81225, 81227, 81230, 81240, 81241, 81291, 81335, 81355, and 81479 
provided on May 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extractions, erupted tooth requiring removal of bone 
and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210), unspecified 
adjunctive procedure, by report (D9999), and therapeutic parenteral drugs, two or more administrations, 
different medications (D9612) provided September 30, 2021. 
 
You asked the Plan to pay for the extractions, unspecified adjunctive procedure and therapeutic parenteral 
drugs. You say that you have a history of anxiety disorder. The Plan denied your request. The Plan says these 
services are 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 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 
extractions, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of 
mucoperiosteal flap if indicated (D7210), unspecified adjunctive procedure, by report (D9999), and therapeutic 
parenteral drugs, two or more administrations, different medications (D9612) provided September 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional payment for the removable prosthodontic 
procedure, by report (D5899) and mandibular partial denture - cast metal framework with resin denture bases 
(including retentive/clasping materials, rests and teeth) (D5214) provided December 15, 2021. 
 
You asked the Plan to provide additional payment for the removable prosthodontic procedure and lower partial 
denture. You say that you were told you had full coverage. The Plan denied your request. The Plan says you 
have exhausted your dental benefit. Additionally, the Plan says that the removable prosthodontic procedure 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. The Plan covers the lower 
partial denture up to the annual maximum of $2,500.  We looked at the file and Medicare rules. The Plan provided documentation showing that your remaining dental maximum was applied to the lower partial denture. You have been asked to pay the amount above the maximum. Though the Plan offers dental benefits in excess of Medicare coverage, the removable prosthodontic procedure is not among those covered services. Therefore, we decided that the Plan does not have to provide 
additional payment for the removable prosthodontic procedure, by report (D5899) and mandibular partial 
denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) 
(D5214) provided December 15, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on December 14, 2021. 
 
You asked the Plan to pay for an office visit. You say that none of the diagnosis codes are related to the 
enrollee's hospice care. The Plan denied your request. The Plan says original Medicare is responsible for 
payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the office visit provided on December 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prefabricated abutments (D6056 x 8) and implant 
supported crowns (D6065 x 8). 
 
You asked the Plan to pre-approve the dental services. You say that you disagree with the denial of dental 
services. The Plan denied your request. The Plan says prefabricated abutments (D6056) and implant supported 
crowns (D6065) are not covered by 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 pre-approve 
prefabricated abutments (D6056 x 8) and implant supported crowns (D6065 x 8).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Neulasta. 
 
You asked the Plan to pre-approve Neulasta. You say that the requested Neulasta is medically necessary. The 
Plan denied your request. The Plan says the enrollee must try and fail Fulfila, Nyvepria, Udency, or Ziextenzo 
first. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Neulasta. Our reviewer says that the 
Plan's step therapy criteria have not been met. Our physician reviewer found the Plan requires a trial of Fulfila, 
Nyvepria, Udencya, or Ziextenzo first before they will approve the requested drug. In this case, the enrollee has 
not tried and failed the required drug(s). There is no documentation provided indicating that the plans required 
drug(s) would likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Neulasta have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Neulasta.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custom abutment on tooth #4 (D6057) and abutment 
supported crown on tooth #4 (D6062). 
 
You asked the Plan to pre-approve the dental services. You say that you disagree with the denial of dental 
services. The Plan denied your request. The Plan says custom abutment (D6057) and abutment supported 
crown (D6062) are not covered by 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 pre-approve 
custom abutment on tooth #4 (D6057) and abutment supported crown on tooth #4 (D6062).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the outpatient office visit (99203). 
 
You asked the Plan to pre-approve the office visit. You say that you developed root rot and is slowly and 
painfully losing your teeth. Your dentist told you to get your teeth pulled and get implants. Your doctor and 
dentist feel it would be best to have all your teeth removed at one visit which requires surgery under anesthesia. 
The Plan denied your request. The Plan says this service 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. The Plan covers extraction of 
teeth to prepare the jaw for radiation treatments of neoplastic cancer disease. For the purpose of teeth 
extraction, there is no history or plan for Radiation Treatment or notes indicating that you have cancer 
 
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 
outpatient office visit (99203).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the alveoloplasty in conjunction with extractions - one to 
three teeth or tooth spaces, per quadrant (D7311) provided January 27, 2022. 
 
You asked the Plan to pay for the alveoloplasty. You say that you thought this service would be covered by 
your insurance. 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 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 
alveoloplasty in conjunction with extractions - one to three teeth or tooth spaces, per quadrant (D7311) 
provided January 27, 2022.