Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on July 25, 2022. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that the services were medically 
necessary. The Plan denied your request. The Plan says 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 Plan says 
that the Plan has also determined that these services are not urgent or emergent, nor were they approved in 
advance. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for a domiciliary or rest home visit provided on July 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the extraction of tooth #3, 5, 6, 10, 11, and 
13 (D7210) and does not have to pay for an immediate maxillary denture (D5130) provided on May 5, 2022. 
 
You asked the Plan to waive the coinsurance for the extractions and to pay for an immediate denture. You say 
that you disagree with the processing of this claim. The Plan denied your request. The Plan says that the cost 
sharing was charged correctly for the extractions. The Plan also says that an immediate maxillary denture 
(D5130) is not covered by your dental benefits. 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 50% 
coinsurance for each extraction.  
 
You have been asked to pay $133.50, which is 50% coinsurance of the allowed amount for each extraction 
($267 allowed amount x 50% coinsurance = $133.50). You have been asked to pay a total of $801 for the 
extractions ($133.50 coinsurance x 6 extractions = $801). This item/service falls within the dental services 
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.  
 
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, an immediate maxillary denture is not 
among those covered under this benefit.  Therefore, we decided that the Plan does not have to waive the 
coinsurance for the extraction of tooth #3, 5, 6, 10, 11, and 13 (D7210) and does not have to pay for an 
immediate maxillary denture (D5130) provided on May 5, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on March 29, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the specimen was 
obtained in an office setting. 
 
The Plan must follow Medicare rules. Medicare rules say that, for 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. The claim in this case was billed with the laboratory POS code. The 
records do not support that the sample was taken in a laboratory setting. Based on this information, we decided 
that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan 
does not have to pay for lab services provided on March 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an oral evaluation (D0120), intraoral radiographic image 
(D0220), and an extraction (D7140) on tooth #4 provided on June 1, 2022. 
 
You asked the Plan to pay for the dental services. You say that the provider told you they were an in-network 
provider, and you would like the dental services covered. The Plan denied your request. The Plan says the 
dental services were received from an out-of-network provider and are not covered by your supplemental 
benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for an oral evaluation (D0120), intraoral radiographic image (D0220), and an extraction (D7140) on 
tooth #4 provided on June 1, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you did not get cared for at the other skilled nursing 
facility which led you back to the hospital. The Plan denied your request. The Plan says based on Medicare 
guidelines the inpatient rehabilitation facility services you are requesting do not meet the requirements for 
approval. 
 
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 your functional status and rehabilitation needs may be met at a variety of levels 
and is routinely addressed at levels of care other than an IRF. You do not require intensive, complex or 
specialized rehabilitation 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for labial veneers on tooth #8 and 9 (D9262) provided on July 
14, 2022. 
 
You asked the Plan to pay for veneers. You say that these expenses would not have happened if the dentist had 
experience with porcelain veneers. The Plan denied your request. The Plan says labial veneers (D2962) 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 pay for labial 
veneers on tooth #8 and 9 (D9262) provided on July 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the interprofessional telephone/Internet/electronic health 
record assessment and management service provided by a consultative physician (99449) provided on April 20, 
2022. 
 
You asked the Plan to pay for the evaluation and management service. You say that for years the provider 
billed the enrollee's plan as a sole proprietor. You say that the provider has since joined a group practice. You 
also say that the provider is enrolled and participating with Medicare since January 20, 2019. The Plan denied 
your request. The Plan says the provider is not certified or eligible to receive payment for this service. 
 
The Plan must follow Medicare rules. Medicare rules say that services must be provided by providers who are 
enrolled in the Medicare program.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the evaluation and management service have not been met. Therefore, we decided that the Plan 
does not have to pay for the interprofessional telephone/Internet/electronic health record assessment and 
management service provided by a consultative physician (99449) provided on April 20, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nine (9) additional physical therapy (PT) visits (97164). 
 
You asked the Plan to pre-approve 9 additional PT visits. You say that without physical therapy the enrollee is 
at a higher risk for falls. The Plan denied your request. The Plan says based on the clinical notes received, your 
mobility has not significantly changed, and detail is lacking in the skills that require further treatment of your 
condition by a physical therapist. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 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 9 additional PT visits. Our reviewer 
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the 
enrollee's condition. Our physician reviewer found that the enrollee has made some minor improvement in 
walking distance, but level of function and requirement for assistance has essentially remained the same. 
Therefore, improvement has plateaued, and additional therapy and the skills of a physical therapist are not 
needed. The enrollee will likely continue to require assistance for mobility and transfers and to minimize fall 
risk, but this can be accomplished by non-skilled personnel versus a skilled physical therapist. Therefore, the 9 
visits of additional physical therapy cannot be considered 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 9 additional PT visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve nine (9) additional physical therapy (PT) visits (97164).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the sclerotherapy (36471). 
 
You asked the Plan to pre-approve the sclerotherapy. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the enrollee's veins are not greater than 4mm in diameter. 
 
The Plan must follow Medicare rules. Medicare rules say that the treatments of the tributary veins will be 
considered medically necessary if saphenous reflux is not present or already successfully eliminated, the veins 
are greater than 4 mm in diameter and if the patient remains symptomatic after a six- week trial of conservative 
therapy.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the sclerotherapy have not been met. Therefore, we decided that the Plan does not have to pre-
approve the sclerotherapy (36471).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Zostar (shingles) vaccine (90750) and administration 
(90471) provided on February 8, 2022. 
 
You asked the Plan to pay for the immunization. You say that this is the second shingles vaccine that you have 
received. You say that the first vaccine was partially paid. You also say that this one should be covered the 
same way. The Plan denied your request. The Plan says the immunization is not covered under Medicare Part 
B. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the immunization. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the immunization. 
Therefore, we decided that the Plan does not have to pay for the Zostar (shingles) vaccine (90750) and 
administration (90471) provided on February 8, 2022.  
 
Benefits for the immunization 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the periodontal scaling and root planing of four or more 
teeth per quadrant (D4341) for the lower left quadrant, the lower right quadrant, the upper left quadrant, and the 
upper right quadrant. 
 
You asked the Plan to pre-approve the periodontal scaling and root planing of four or more teeth per quadrant 
(D4341) for the lower left quadrant, the lower right quadrant, the upper left quadrant, and the upper right 
quadrant. You say that the enrollee has areas of pocketing between the tooth and the gums and areas of 
bleeding. The Plan denied your request. The Plan says this is not medically necessary. 
 
  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 
periodontal scaling and root planing of four or more teeth per quadrant (D4341) for the lower left quadrant, the 
lower right quadrant, the upper left quadrant, and the upper right quadrant 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 the periodontal scaling and root planing 
of four or more teeth per quadrant (D4341) for the lower left quadrant, the lower right quadrant, the upper left 
quadrant, and the upper right quadrant. Our reviewer says that the service is not medically necessary. Our 
physician reviewer found as there are some noted areas of loss of bone, but not four or more in any one 
quadrant, the submission under the periodontal scaling. Our physician reviewer also found that the root planing 
of four or more teeth per quadrant (D4341) would not be proper, and would not meet the Plan criteria. Our 
physician reviewer also found that a lesser code is available for up to three teeth in a quadrant with noted areas 
of bone loss. 
 
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 the periodontal scaling and root planing of four or more teeth per quadrant 
(D4341) for the lower left quadrant, the lower right quadrant, the upper left quadrant, and the upper right 
quadrant have not been met. Therefore, we decided that the Plan does not have to pre-approve the periodontal 
scaling and root planing of four or more teeth per quadrant (D4341) for the lower left quadrant, the lower right 
quadrant, the upper left quadrant, and the upper right quadrant.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visit provided on July 15, 
2022. 
 
You asked the Plan to waive the copayment for specialist office visit. You say that this should be covered. The 
Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 
copayment for Provider office visits. 
 
You have been asked to pay a $35 copayment for specialist office visit. This item/service falls within the 
Provider office visits 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 waive the copayment for specialist office visit 
provided on July 15, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the vertiflex placement surgery (22869). 
 
You asked the Plan to pre-approve the vertiflex placement surgery. You say that the service is medically 
necessary. The Plan denied your request. The Plan says the service is experimental. 
 
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 vertiflex placement surgery. Our 
reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our 
physician reviewer found this procedure is experimental and more research is needed to show its efficacy. 
 
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 vertiflex placement surgery have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the vertiflex placement surgery (22869).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a consultation (D9310) provided on July 15, 2022. 
 
You asked the Plan to pay for the consultation. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a 
consultation (D9310) provided on July 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and a complete full 
mouth x-ray series (D0210) provided on July 8, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says your benefit for the requested items or services 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 a comprehensive oral evaluation was exhausted on date of service March 15, 2021. The 
record also shows your benefit for a full mouth x-ray was exhausted on date of service April 5, 2021. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and a 
complete full mouth x-ray series (D0210) provided on July 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for fillings (D2391, D2331, D2393, D2392) provided on 
December 6, 2021. 
 
You asked the Plan to pay for the fillings. You say that the services should be covered as you disagree with the 
denial. The Plan denied your request. The Plan says your benefit for the requested item or service has already 
been exhausted, you received and additional 9 fillings and have exceeded your benefit limit. 
 
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 December 6, 2021. 
Therefore, we decided that the Plan does not have to pay for fillings (D2391, D2331, D2393, D2392) provided 
on December 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a fixed partial denture (D9120). 
 
You asked the Plan to pre-approve the dental service. You say that you are appealing the denied dental service. 
The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the 
fixed partial denture is not covered by the 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 a 
fixed partial denture (D9120).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88305 billed for date of service July 15, 
2022. 
 
You asked the Plan to pay for procedure code 88305. 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 88305 is bundled into 
payment for code 17311. 
 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 88305 
is a column II code to column I code 17311. 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 88305 billed for date of service July 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on July 7, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service July 7, 2022. Therefore, 
we decided that the Plan does not have to pay for the dental services on July 7, 2022.