Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mass spectrometry testing provided on March 3, 2021. 
 
You asked the Plan to pay for mass spectrometry test. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says the denial of payment for this test is correct, because this not 
otherwise specified code did not include a description and separate payment of this code with a -59 modifier is 
not justified. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
The medical records provided do not show that the service billed with the -59 modifier is a distinct procedural 
service. Specifically, the record does not show that this validity testing was a separate and distinct procedure 
from the covered drug testing billed on this claim.  
 Based on this information, we decided that Medicare rules for coverage of services billed with a -59 modifier 
have not been met. Therefore, we decided that the Plan does not have to pay for mass spectrometry testing 
provided on March 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on December 6, 2021. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you 
believe this claim should be covered because it was covered last time. The Plan denied your request. The Plan 
says if no transport occurs, this not considered to be a Medicare covered service. The Plan also says that the run 
sheet from the ambulance provider confirms that you refused transport and were not taken to the nearest 
facility. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
 
  The ambulance company did not provide transport services on December 6, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport (A0998) provided on December 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a seat lift chair and mechanism. 
 
You asked the Plan to pre-approve a seat lift chair and mechanism. You say that a seat lift chair is medically 
necessary. The Plan denied your request. The Plan says the medical records provided do not show that you 
meet all the required coverage criteria for this item.  
 
The Plan must follow Medicare rules. Medicare has specific coverage for a seat lift mechanism. Medicare does 
not cover the seat lift chair often sold with the seat lift mechanism. The medical records provided show you can 
transfer independently. The records show you can stand and sit without assistance. Medicare coverage criteria 
are not met. Therefore, we decided that the Plan does not have to pre-approve a seat lift chair and mechanism.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided to the enrollee on September 10, 
2021. 
 
You asked the Plan to pay for this service. You say that this claim should be  paid. The Plan denied your 
request. The Plan says this claim must be reviewed by Original Medicare first. 
 
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 medical services provided to the enrollee on September 10, 
2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve a SNF admission. You say that you cannot be safely discharged home. You 
also say that your home is not fit for safety, and you live alone so it would be a hazard to your health. The Plan 
denied your request. The Plan says the SNF services you are requesting do not meet the requirements for 
approval. 
 
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 a SNF admission. Our reviewer says 
that you do not meet the Medicare criteria for SNF care. Our physician reviewer found you do not have daily 
skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional 
nurse. You do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment 
of a skilled professional therapist. Our reviewer also found that you do not require daily skilled nursing and/or 
skilled therapy on an inpatient basis in a SNF setting. 
 
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 SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extractions (D7140) provided on December 6, 2021, and 
the immediate dentures (D5130, D5140) provided on December 13, 2021. 
 
You asked the Plan to pay for the dental services. You say that these services were necessary, and you do not 
understand why they are being denied. The Plan denied your request. The Plan says these services are not 
covered by your dental benefit. 
 
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 
extractions (D7140) provided on December 6, 2021, and the immediate dentures (D5130, D5140) provided on 
December 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a resin-based composite (D2393) for teeth #21 and #4 
provided by an in-network provider on January 21, 2022. 
 
You asked the Plan to pay for a resin-based composite. You say that you would like the Plan to pay for all of 
the dental work you had done. The Plan denied your request. The Plan says the benefit limit for D2393 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. The Plan covers two resin-
based composite per year.  
 
We looked at the file and Medicare rules. Evidence was provided to show that D2393 has already been 
provided for teeth #26 and #10. Based on this information, we decided that the Plan's rules for coverage of a resin-based composite have already been met. Therefore, we decided that the Plan does not have to pay for a 
resin-based composite (D2393) for teeth #21 and #4 provided by an in-network provider on January 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prefabricated abutments (D6056) and implant supported 
porcelain/ceramic crowns (D6065). 
 
You asked the Plan to pre-approve prefabricated abutments and implant supported porcelain/ceramic crowns. 
You say that you really need these services because you have implants and do not have all of your teeth. The 
Plan denied your request. The Plan says these services are not covered under your benefit 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 pre-approve 
prefabricated abutments (D6056) and implant supported porcelain/ceramic crowns (D6065).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical extraction (D7210) provided on December 28, 2021. 
 
You asked the Plan to pay for the surgical extraction. You say that you saw a different dental provider for this 
service and were led to believe that extractions were covered by your plan. The Plan denied your request. The 
Plan says surgical extractions are not covered by your dental benefit. 
 
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 
surgical extraction (D7210) provided on December 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuous glucose monitor (CGM) (K0554) and 
supplies (K0553). 
 
You asked the Plan to pre-approve the CGM and supplies. You say that the items are medically necessary. The 
Plan denied your request. The Plan says the clinical provided does not indicate that the beneficiary is insulin-
treated with multiple (three or more) daily administrations of insulin or a continuous subcutaneous insulin 
infusion (CSII) pump . 
 
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 the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
the CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve the 
continuous glucose monitor (CGM) (K0554) and supplies (K0553).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (82310, 82728, 83540, 83550, 84100) 
provided on September 3, 2021. 
 
You asked the Plan to pay for laboratory services. You say that here is no contractual agreement to include 
these services in dialysis. The Plan denied your request. The Plan says these services are not separately 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that all laboratory services furnished to individuals 
for the treatment of end-stage renal disease (ESRD) are included in the ESRD Prospective Payment System 
(PPS) as Part B services and are not paid separately. 
 
We looked at the file and Medicare rules. The laboratory services at issue were provided for the treatment of 
ESRD. Based on this information, we decided that Medicare rules for coverage of laboratory services have not 
been met. Therefore, we decided that the Plan does not have to pay for laboratory services (82310, 82728, 
83540, 83550, 84100) provided on September 3, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Urinary Tract Infection (UTI) panel provided on June 24, 
2021. 
 
You asked the Plan to pay for the UTI panel. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says this claim was not submitted with the correct POS 
code. 
 The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the UTI panel have not been met. Specifically, this claim was billed with the laboratory POS code. 
The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the 
Plan does not have to pay for the Urinary Tract Infection (UTI) panel provided on June 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy-duty power wheelchair (PWC) (K0801). 
 
You asked the Plan to pre-approve a heavy duty PWC. You say that the item is medically necessary. The Plan 
denied your request. The Plan says you do not meet the weight requirement for this wheelchair. 
 
The Plan must follow Medicare rules. Medicare rules say that a heavy duty PWC is covered if the patients 
weight is between 301 to 450 pounds. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a heavy duty PWC have not been met. Therefore, we decided that the Plan does not have to pre-
approve a heavy-duty power wheelchair (PWC) (K0801).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positioning cushion. 
 
You asked the Plan to pre-approve a positioning cushion. You say that a positioning cushion is medically 
necessary. The Plan denied your request. The Plan says a positioning cushion is a self-help device and is not 
covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. 
This item is available to the public and would be helpful even to those who are not sick or injured. Therefore, 
we decided that the Plan does not have to pre-approve a positioning cushion.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve guided tissue regeneration (D4267), bone replacement 
graft (D7953), and interim partial denture (D5821). 
 
You asked the Plan to pre-approve the dental services. You say that you really need dentures. You also say that 
you cannot chew on the side that needs dentures. The Plan denied your request. The Plan says guided tissue 
regeneration, bone replacement graft, and interim partial denture are not listed as covered services. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested guided tissue 
regeneration, bone replacement graft, and interim partial denture are not among those covered under this 
benefit. Therefore, we decided that the Plan does not have to pre-approve guided tissue regeneration (D4267), 
bone replacement graft (D7953), and interim partial denture (D5821).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (81286, 81410, 81411, 81413, 81414) 
provided on July 23, 2021. 
 
You asked the Plan to pay for laboratory services. You say that this is supported in the records. The Plan 
denied your request. The Plan says this was not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of laboratory services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for laboratory services (81286, 81410, 81411, 81413, 81414) provided on July 
23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mandibular immediate denture (D5140) or pay more for 
the three simple extractions (D7140 x3) provided on December 21, 2021 by an out-of-network (OON) 
provider. 
 
You asked the Plan to pay for the mandibular immediate denture and to pay more for the simple extractions. 
You say that you were not aware that the treating provider was OON. You also say that at the time your teeth 
were badly infected, and you needed a dentist. The Plan denied your request. The Plan says the mandibular 
immediate denture is not a covered benefit under your dental plan. The Plan also says that the total $618 
amount applied correctly as your liability for the extractions. 
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, mandibular immediate denture 
(D5140) is not among those covered under this benefit. The Plan contract also says that you are responsible for 
the difference between the billed amount and allowed amount for covered dental services that are received 
OON. Therefore, we decided that the Plan does not have to pay for the mandibular immediate denture (D5140) 
or pay more for the three simple extractions (D7140 x3) provided on December 21, 2021 by an out-of-network 
(OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a removal of torus mandibularis (D7473). 
 
You asked the Plan to pre-approve the removal of torus mandibularis. You say that you need this service 
provided so the lower plate will fit well. The Plan denied your request. The Plan says this service is not covered 
under your benefit package. 
 
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 a 
removal of torus mandibularis (D7473).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve braces to be provided by a participating provider. 
 
You asked the Plan to pre-approve braces. You say that you need your teeth corrected because they are not 
aligned correctly, and it is causing pain. The Plan denied your request. The Plan says braces are not a covered 
benefit. 
 
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 
braces to be provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyeglasses (V2750, V2761, V2762, V2784, V2020, 
V2781) purchased on September 3, 2021. 
 
You asked the Plan to pay for the eyeglasses. You say that you had purchased two pairs of eyewear on the date 
in question, and only one was covered by your Plan. You later had to return this pair and would like your 
benefit to be applied to the other pair you purchased. The Plan denied your request. The Plan says your routine 
eyewear benefit was exhausted prior to the date in question. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers up to $200 for routine eyewear once per calendar year. 
 
We looked at the file and the Plan's rules. The documentation shows that you previously used your eyewear 
benefits on August 27, 2021, from an in-network provider. The record shows that the Plan was billed $793.99 
for the eyewear provided on this date, and you have been asked to pay $475.19 after your benefits applied. 
Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have not been met. 
Therefore, we decided that the Plan does not have to pay for the eyeglasses (V2750, V2761, V2762, V2784, 
V2020, V2781) purchased on September 3, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a resin-based composite (D2330) for teeth #9 and #10 to be 
provided by a participating provider. 
 
You asked the Plan to pre-approve a resin-based composite. You say that you would like the Plan to approve 
and pay for this. The Plan denied your request. The Plan says that the benefit limit for D2330 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. The Plan covers a resin-based 
composite 6 times per calendar year. 
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of a resin-based composite have been met. The previous 6 resin-based composites were provided in 
2021. Therefore, we decided that the Plan has to pre-approve a resin-based composite (D2330) for teeth #9 and 
#10 to be provided by a participating provider. 
 
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.