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

 
We decided that the Plan does not have to provide additional payment for the intraoral - complete series of 
radiographic images (D0210) provided on February 17, 2022, and resin-based composite - four or more 
surfaces, posterior (D2394) provided on August 25, 2022. 
 
You asked the Plan to provide additional payment for the complete series of x-rays and composite filling. You 
say that these services should be processed at the in-network rate. The Plan denied your request. The Plan says 
the claim has been re-processed as in-network. The complete series of x-rays is not covered, and the filling has 
processed with the correct coinsurance. 
 
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 composite 
filling with 50% coinsurance.  
 
We looked at the file and Medicare rules. You have been asked to pay 50% coinsurance for the composite 
filling. 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. Though the Plan offers dental benefits in excess of Medicare coverage, the complete series of x-rays is not among those covered 
services. Therefore, we decided that the Plan does not have to provide additional payment for the intraoral - 
complete series of radiographic images (D0210) provided on February 17, 2022, and resin-based composite - 
four or more surfaces, posterior (D2394) provided on August 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an extraction, erupted tooth requiring removal of bone and/or 
sectioning of tooth #'s 5 and 12 (D7210) provided on August 25, 2022. 
 
You asked the Plan to pay for the extraction, erupted tooth requiring removal of bone and/or sectioning of tooth 
#'s 5 and 12 (D7210). You say that you should be reimbursed for the total amount you paid. You also say that 
this was an emergency, and this doctor is the one that could see you the fastest. The Plan denied your request. 
The Plan says this service is not covered under the 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 pay for an 
extraction, erupted tooth requiring removal of bone and/or sectioning of tooth #'s 5 and 12 (D7210) provided 
on August 25, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH services are necessary to 
achieve a safe and sustainable discharge. The Plan denied your request. The Plan says admission to the LTACH 
is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where he/she is currently receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377), harness (E2313), 
electronic connection (E2311), power seat elevation system (E2300). 
 
You asked the Plan to pre-approve the wheelchair accessories. You say that the items are medically necessary. 
The Plan denied your request. The Plan says the items are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that items 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 wheelchair accessories. Our 
reviewer says that these items are not medically necessary. Our physician reviewer found the member has 
adequate strength to manage standard switches and does not require power tilt as they are not at high risk for 
skin breakdown. 
 
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 wheelchair accessories have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an expandable controller (E2377), harness (E2313), electronic connection 
(E2311), power seat elevation system (E2300).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergency ambulance transportation (A0428) and 
ground mileage (A0425) provided on April 28, 2022. 
 
You asked the Plan to pay for the non-emergency ambulance transportation and ground mileage. You say that 
you would like this claim to be reviewed and processed towards payment. The Plan denied your request. The 
Plan says this claim does not meet the requirements for coverage. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
 
  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 pay for the non-emergency ambulance 
transportation and ground mileage. Our reviewer says that transportation via ambulance from the hospital to the 
enrollees residence was not medically necessary. Our physician reviewer found the enrollee did not require the 
expertise of trained personnel or the equipment available only on an ambulance in order to effectuate a safe 
transport. Transportation could have been provided by other means (stretcher van, wheelchair van, private car, 
taxi) without endangering the enrollees condition. Our reviewer also found that a prudent layperson would not 
believe that immediate medical attention was required for someone who was being discharged from the 
hospital. 
 
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 non-emergency ambulance transportation and ground mileage have not been 
met. Therefore, we decided that the Plan does not have to pay for the non-emergency ambulance transportation 
(A0428) and ground mileage (A0425) provided on April 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve oncology treatment to be provided at the in-network 
benefit level by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve oncology treatment. You say that the enrollee needs to see this physician. 
The Plan denied your request. The Plan says this provider is out-of-network with the Plan and the enrollee can 
be treated within the Plan network. The enrollee may choose to see the requested physician as the out-of-
network benefit level. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that enrollees may choose to receive care from out-of-network providers that are eligible to 
participate in Medicare. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services at the in-network benefit level. The enrollee may choose to see this 
provider using out-of-network benefits. Therefore, we decided that the Plan does not have to pre-approve 
oncology treatment to be provided at the in-network benefit level by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric admission. 
 
You asked the Plan to pre-approve inpatient psychiatric admission. You say that you disagree with the denial. 
The Plan denied your request. The Plan says the medical records do not support the need for the requested 
inpatient psychiatric service admission. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
 
 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 psychiatric admission. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found based upon review of 
the records provided, it was not expected this enrollee would improve in a reasonable period of time as she did 
not have dangerousness to self or others and was not showing any auditory/visual hallucinations or any 
aggressive behaviors. It did not appear medically necessary and reasonable to have psychiatric care provided at 
the acute inpatient level of care rather than a lower level of care. The enrollee did not appear to require 
inpatient mental health treatment as she was not a danger to herself or others and was cooperative with care 
without any aggressive behaviors. It did not appear that active treatment was taking place. It did not appear that 
the services were reasonably expected to improve the enrollee's condition or for the purpose of diagnosis. Our 
doctor is unable to find an individualized treatment plan, as the entire record is not present. It did appear that 
the records were supervised and evaluated by a physician. The admission of the enrollee does not meet criteria 
for acute inpatient mental health treatment as she was not shown to be a danger to herself or others, no auditory 
or visual hallucinations. She is noted to be cooperative and compliant with treatment while not showing any 
aggressive behaviors. 
 
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 psychiatric admission. have not been met. Therefore, we decided that 
the Plan does not have to pre-approve inpatient psychiatric admission.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an insertion of pacing electrode, cardiac venous system, 
for left ventricular pacing, at time of insertion of implantable defibrillator or pacemaker pulse generator 
(33225). 
 
You asked the Plan to pre-approve a cardiac resynchronization therapy defibrillator (CRT-D) device. You say 
that you disagree with the denial. The Plan denied your request. The Plan says the enrollee has a non-LBBB 
morphology QRS with a narrow QRS duration of 96 ms, although he may be a candidate for standard ICD 
implantation, he does not meet criteria for CRT-D implantation. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a CRT-D device. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has a narrow QRS complex, less than 100ms, without left bundle branch clock. As 
such, guidelines would not support implant of a CRT-D. In summary, there is insufficient documentation to 
support the medical necessity for implantation of a CRT-D in this enrollee's management. 
 
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 CRT-D device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an insertion of pacing electrode, cardiac venous system, for left ventricular pacing, at 
time of insertion of implantable defibrillator or pacemaker pulse generator (33225).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete maxillary denture (D5110) and a mandibular 
partial denture (D5212) provided on August 22, 2022. 
 
You asked the Plan to pay for the dental services. You say that you asked your ex-boyfriend for your dentures, 
and he said he does not have them. You also say that you are trying to get another pair so that you can eat better 
and go into society. 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 June 7, 2021. Therefore, 
we decided that the Plan does not have to pay for a complete maxillary denture (D5110) and a mandibular 
partial denture (D5212) provided on August 22, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care (99308) provided on August 
18, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that you want the Plan to pay for the 
service. The Plan denied your request. The Plan says the services were not authorized. 
 
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 subsequent nursing facility care (99308) provided 
on August 18, 2022, by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) procedures (codes 64635 
and 64636). 
 
You asked the Plan to pre-approve RFA procedures. The Plan denied your request. The Plan says the enrollee 
does not meet the criteria for coverage. 
 
The Plan follows Medicare rules. Medicare rules say that repeat thermal facet joint RFA at the same anatomic 
site is considered medically reasonable and necessary provided the patient had a minimum of consistent 50% 
improvement in pain for at least six (6) months or at least 50% consistent improvement to perform previously 
painful movements and ADLs. 
 
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 RFA procedures. Our reviewer says 
that the enrollee does not meet the criteria for coverage for RFA procedures. Our physician reviewer found the 
duration of the pain relief from the RFA does not meet the 6 months of 50% parameter. Our reviewer also 
found that this request is deemed not medically reasonable and 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 RFA procedures have not been met. Therefore, we decided that the Plan does 
not have to pre-approve radiofrequency ablation (RFA) procedures (codes 64635 and 64636).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional one-way trips. 
 
You asked the Plan to pre-approve additional one-way trips. You say that you are disabled and cannot drive. 
The Plan denied your request. The Plan says there is no exception that would allow the plan to approve 
additional rides. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 one-way rides to other health care related locations (such as to the 
pharmacy or specialist appointments) trips per year.  
 
 
  We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional one-way trips.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on February 2, 2022. 
 
You asked the Plan to pay for the lab services. You say that you have provided medical records to support 
payment. 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, 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. 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 February 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on June 15, 2022. 
 
You asked the Plan to pay for the testing services. You say that the testing aids in the enrollee's cancer 
treatment. The Plan denied your request. The Plan says the claim for this molecular pathology testing did not 
include the required unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 We looked at the file and Medicare rules. The claim at issue does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the testing services 
have not been met. Therefore, we decided that the Plan does not have to pay for the lab testing services 
provided on June 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bone replacement graft (D7953) provided on August 24, 
2022. 
 
You asked the Plan to pay for dental services. You say that you would like the plan to pay for the services. The 
Plan denied your request. The Plan says this service is not covered under your 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. Bone replacement graft 
(D7953) is not covered under the Plans dental benefits. 
 
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 bone 
replacement graft (D7953) provided on August 24, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you need more inpatient therapy to help you be able 
to use the shower by going up and down the stairs. The Plan denied your request. The Plan says a SNF 
admission is not medically necessary. 
 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that 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. 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.