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

We decided that the Plan does not have to pre-approve guided tissue regeneration, nonresorbable barrier, per 
tooth, including membrane removal (D4267x32). 
 
You asked the Plan to pre-approve guided tissue regeneration. You say that your mouth is destroyed, and you 
need the services to restore the function of your teeth. You also say that you want to have a healthy mouth and 
avoid infections. The Plan denied your request. The Plan says the requested 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 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 
guided tissue regeneration, nonresorbable barrier, per tooth, including membrane removal (D4267x32).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 20, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services are covered by Medicare. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
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 lab 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 lab services provided on May 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 14, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services are payable by Medicare. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
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 lab 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 lab services provided on May 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional supplies and materials rendered on September 
17, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that payment for codes with a status indicator of B is 
always bundled into payment for other services not specified. 
 
We looked at the file and Medicare rules. Billed procedure code 99072 (additional supplies, materials, and 
clinical staff time over and above those usually included in an office visit or other non-facility service(s), when 
performed during a Public Health Emergency, as defined by law, due to respiratory-transmitted infectious 
disease) has a status indicator of B and no separate Medicare payment. Therefore, we decided that the Plan 
does not have to pay for the additional supplies and materials rendered on September 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a complete lower 
denture (D5120). 
 
You asked the Plan to pre-approve a complete upper denture and a complete lower denture. You say that you 
have no dentures. You say you misplaced the dentures that you received in 2018 and now you need new ones. 
You also say you were advised that you cannot get new ones until June 8, 2023. The Plan denied your request. 
The Plan says the requested services are allowed one time every 60 months. 
 
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 a complete 
upper denture and a complete lower denture once every 60 months.  
 
We looked at the file and Medicare rules. The records show you received a complete upper and lower denture 
on June 7, 2018; therefore, you have exhausted the maximum benefit for these services. Based on this 
information, we decided that the Plan's rules for coverage of complete upper denture and complete lower 
denture have not been met. Therefore, we decided that the Plan does not have to pre-approve a complete upper 
denture (D5110) and a complete lower denture (D5120).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implantation of a hypoglossal nerve stimulator (HGNS) 
device. 
 
You asked the Plan to pre-approve the HGNS device procedure. You say that the enrollee has been cleared for 
this surgery, and it is medically necessary to treat sleep apnea. The Plan denied your request. The Plan says this 
cannot be approved due to the presence of an implanted defibrillator. 
 
The Plan must follow Medicare rules. Medicare rules say that HGNS placement is not considered medically 
reasonable and necessary for enrollees with other implanted devices, due to the risk of interaction between the 
device and the HGNS.  
 
We looked at the file and Medicare rules. The records show that you have an implanted defibrillator. It is also 
noted that your cardiologist does not feel that HGNS should be approved due to this implanted device. Based 
on this information, we decided that Medicare rules for coverage of the HGNS device procedure have not been 
met.  
 
 
 
 Therefore, we decided that the Plan does not have to pre-approve implantation of a hypoglossal nerve 
stimulator (HGNS) device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional accessories (E2300, E2311, E2313, E2377) 
for a power wheelchair. 
 
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is not medically necessary. 
 
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 the accessories. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has a neurologic disorder with functional deficits. The enrollee meets criteria for 
the use of a power mobility device. The requested accessories are not medically necessary as she does have use 
of her hands and can operate and control the power options using the switches that are included in the basic 
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 the accessories have not been met. Therefore, we decided that the Plan does not 
have to pre-approve additional accessories (E2300, E2311, E2313, E2377) for a power wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the hospital outpatient clinic visit (G0463) 
provided on August 3, 2021. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
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 $325 
copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including 
but not limited to hospital or other facility charges and physician or surgical charges.   
You have been asked to pay $130.46 for the Medicare-covered clinic visit provided at an outpatient hospital. 
This is the Plans allowed amount for this service which is less than the applicable copayment. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for the hospital outpatient clinic visit (G0463) provided on August 3, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shoulder orthosis rendered on May 14, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code L3650 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of these 
services have not been met. Therefore, we decided that the Plan does not have to pay for the shoulder orthosis 
rendered on May 14, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional home health physical therapy (PT) visits 
beyond March 30, 2022. 
 
You asked the Plan to pre-approve the additional home health PT services. You say that you would like more 
home physical therapy visits through April 11. The Plan denied your request. The Plan says you no longer 
require skilled therapy services as you are independent with your activities of daily living and a home exercise 
program. The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the additional home health PT services. 
Our reviewer says that the documentation provided does not support that additional home health services are 
medically reasonable and necessary. Our physician reviewer found the member is a female who suffered a left 
hip fracture and has been receiving home health PT after an inpatient rehabilitation stay. The most recent 
documentation indicates she is independent for transfers and can ambulate up to 130 feet using a wheeled 
walker. She is independent with a home exercise program. 
 
The member does not require additional skilled rehab services to effectively provide treatment, care, and/or 
services in order to improve the members condition, perform a maintenance program to maintain the 
members condition and/or prevent deterioration.  The member has been medically stable without any recent 
exacerbations of chronic medical problems or hospitalizations.  The requested home health services are not 
medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the additional home health PT services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve additional home health physical therapy (PT) visits beyond 
March 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit (99215) provided October 19, 
2021. 
 
You asked the Plan to pay for the office visit. You say that you are fully aware that the doctor is not connected 
to Medicare or any other insurance. You have known this doctor for several years. You have went out of 
network and have received some sort of reimbursement. The Plan denied your request. The Plan says if you go 
to a provider who is not eligible to participate in Medicare, you will be responsible for the full cost of the 
services you receive. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the 
outpatient office visit (99215) provided October 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the abutment (D6063), and crown (D6065), provided on 
September 15, 2021. 
 
You asked the Plan to pay for the abutment and crown. You say that you need these services. The Plan denied 
your request. The Plan says you obtained the service through an out-of-network provider. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, 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 
abutment (D6063), and crown (D6065), provided on September 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a cone beam computed tomography (CT) capture and 
interpretation with limited field of view (D0364) provided on November 11, 2021. 
 
You asked the Plan to pay for a cone beam CT capture. You say that you believe the images should be covered 
by the Plan as the service is required to qualify for dental implants. The Plan denied your request. The Plan 
says the requested service is an exclusion with 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 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 a cone 
beam computed tomography (CT) capture and interpretation with limited field of view (D0364) provided on 
November 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home health visit provided on July 30, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the home health visit. You say that the facility was responsible to obtain prior 
authorization and the service rendered was out of medical necessity. The Plan denied your request. The Plan 
says the rendering provider is an out-of-network provider and there was no approved authorization. Also, the 
service rendered was not urgent or emergent. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a home health visit provided on July 30, 2021, by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an outpatient office visit provided on March 31, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient office visit. You say that this was a follow up visit from the year 
prior so no authorization should have been needed. The Plan denied your request. The Plan says the rendering 
provider is an out-of-network provider and there was no referral from an in-network provider or an approved 
authorization. Also, the service rendered was not urgent or emergent. 
 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 an outpatient office visit provided on March 31, 
2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on September 21, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the service was rendered to the enrollee out of 
medical necessity, and you would like the claim to be paid. The Plan denied your request. The Plan says the 
rendering provider is an out-of-network provider and there was no approved authorization. 
  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 an office visit provided on September 21, 2021, by 
an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from October 
14, 2021, to November 6, 2021. 
 
You asked the Plan to pay for the SNF care provided from October 14, 2021, to November 6, 2021. You say 
that additional payment should be made. The Plan denied your request. The Plan says you are covered for up to 
100 days each benefit period for inpatient services in a skilled nursing facility (SNF). The Plan says that the 
benefit has been exhausted. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that you received 100 days of SNF care during the benefit period from April 30, 2021, to 
October 13, 2021. The Plan has covered 100 days of SNF care. 
 
Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. You will be eligible for a new benefit period when you have not been 
receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the 
Plan does not have to pay for the skilled nursing facility (SNF) care provided from October 14, 2021, to 
November 6, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eliquis 5mg tablets. 
 
You asked the Plan to pre-approve Eliquis. You say that Eliquis is medically necessary. The Plan denied your 
request. The Plan says this drug is not eligible for coverage under the Part B medical benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Eliquis 5mg tablets.  
 
Benefits for Eliquis may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapy services (97530) provided from June 8, 2021, to 
June 11, 2021. 
 
You asked the Plan to pay for code 97530. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered. 
 
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, the CPT Code Manual definition of code 97530 is Therapeutic activities, direct (one-on-one) 
patient contact (use of dynamic activities to improve functional performance), each 15 minutes. 
 
We find that CPT code 97530 is not supported in the medical record. Specifically, the records do not support 
direct patient contact with use of dynamic activities for 15 minutes each. Based on this information, we decided 
that Medicare rules for coverage of code 97530 have not been met. Therefore, we decided that the Plan does 
not have to pay for the therapy services (97530) provided from June 8, 2021, to June 11, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for procedure code 70450 billed for date of service November 
20, 2021. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for 70450 is bundled into payment for 70496. 
 
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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service November 20, 
2021.