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

 
We decided that the Plan does not have to pay for the intravenous (IV) moderate (conscious) 
sedation/analgesia- first 15 minutes (D9239) and intravenous moderate (conscious) sedation/analgesia - each 
subsequent 15-minute increment (D9243) provided April 7, 2022. 
 
You asked the Plan to pay for IV moderate sedation. You say that sedation is necessary for tooth extractions. 
The Plan denied your request. The Plan says sedation was 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 IV moderate 
sedation 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 pay for IV moderate sedation. Our reviewer says 
that this service is not medically reasonable and necessary. Our physician reviewer found that given the lack of 
documentation from the oral surgeon, and the statement of need for the sedation from the enrollee, the Plan 
provision disallowing sedation due to apprehension as a root cause of the request precludes coverage in this 
case. 
 
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 IV moderate sedation have not been met. Therefore, we decided that the Plan 
does not have to pay for the intravenous (IV) moderate (conscious) sedation/analgesia- first 15 minutes 
(D9239) and intravenous moderate (conscious) sedation/analgesia - each subsequent 15-minute increment 
(D9243) provided April 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that this is medically necessary. The Plan denied 
your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. 
Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of 
orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve foot 
orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and x-ray provided on March 10, 2021. 
 
You asked the Plan to pay for the office visit and x-ray. You say that GW modifier was added which denotes 
the treatment is not related and the claim should be processed for payment. The Plan denied your request. The 
Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
  The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the office visit and x-ray provided on March 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prophylaxis-adult (D1110), topical application of fluoride 
varnish (D1206), and periodic oral evaluation-established patient (D0120) provided on April 7, 2022. 
 
You asked the Plan to pay for the dental services. You say that the dentist told you if you paid first the 
insurance would reimburse you, and it went perfectly last year. You say to please reconsider the claim for 
payment at the in-network rate. 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 prophylaxis-adult (D1110), topical application of fluoride varnish (D1206), and periodic oral 
evaluation-established patient (D0120) provided on April 7, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a Skilled Nursing Facility (SNF) stay 
provided from May 1, 2021, to May 15, 2021. 
 
You asked the Plan to waive the copayment for a SNF stay. You say that you were not informed that you had 
reached your maximum benefit. The Plan denied your request. The Plan says the copayment applied was 
correct. 
 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 $0 
copayment per day for days 1 to 20 and a $150 copayment per day for days 21 to 100 of a Skilled Nursing 
Facility (SNF). You were admitted to the SNF on April 24, 2021, and discharged on May 15, 2021, for a total 
of 21 days. 
 
You have been asked to pay a $150 copayment for day 21 of your SNF stay. A SNF stay falls within the 
Skilled Nursing Facility (SNF) Care 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 a 
SNF stay provided from May 1, 2021, to May 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a prefabricated post on tooth #20 (D2954) provided on 
January 18, 2022. 
 
You asked the Plan to pay for a prefabricated post. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says a prefabricated post (D2954) is 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 a 
prefabricated post on tooth #20 (D2954) provided on January 18, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the IRF services you are requesting do not meet the 
requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that an IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care. The enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. Medically necessary care can be provided in a different level of care. 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
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 
enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the 
enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an 
interdisciplinary approach to rehabilitation care. The enrollee was admitted for weakness, urinary tract infection, and falls and was discharged home on August 2, 2022. There is ongoing weakness. Medical 
problems are stable. There are no complex nursing or rehabilitation needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, in an intensive rehabilitation therapy program. While the medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that admission to the LTACH is the 
appropriate level of care to assist the enrollee in making a full recovery. The Plan denied your request. The 
Plan says based on Medicare guidelines the long-term acute care services you are requesting do not meet the 
requirements for approval. 
 
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 the enrollee was admitted with respiratory failure due to COVID-19 pneumonia in 
the setting of chronic obstructive pulmonary disease. The record indicates that the enrollee still requires acute 
care services. The enrollee continues to receive acute care services and these have not been denied. The 
medical record does not indicate that the enrollee requires services not currently receiving but that would be 
available at the LTACH facility. 
 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 the LTACH services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a therapeutic infusion and injection provided on February 1, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a therapeutic infusion and injection. You say that it was medically necessary to 
treat the enrollee and you would like reimbursement for the services provided. The Plan denied your request. 
The Plan says the rendering provider is an OON 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 a therapeutic infusion and injection provided on 
February 1, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections. 
 
You asked the Plan to pre-approve the injections. You say that the enrollee has completed 3 months of physical 
therapy. You also say that the enrollee is experiencing pain when performing facet-loading movements. The 
Plan denied your request. The Plan says the requested injections are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that facet joint injections are considered medically 
reasonable and necessary for the diagnosis and treatment of chronic pain in patients who meet all of the criteria. 
 
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 facet joint injections. Our reviewer 
says that the coverage criteria for the facet joint injections have not been met. Our physician reviewer found the documentation does not show that the facets are likely the cause of the enrollee's pain given that they have 
sharp low back pain with radiculopathy. The documentation does not support that the enrollee has trialed 
conservative care including physical therapy (PT)/chiropractic care for at least three months. Therefore, the 
reviewer found that the criteria for coverage have not been met. 
 
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 facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140), 
endodontic therapy, anterior tooth (excluding final restoration) (D3310), pulp vitality tests (D0460), treatment 
of root canal obstruction; non-surgical access (D3331) and incision and drainage of abscess - intraoral soft 
tissue (D7510) provided April 19, 2022. 
 
You asked the Plan to pay for the limited oral exam, root canal, pulp vitality tests, treatment of root canal 
obstruction and incision and drainage of abscess. You say that your dental office stated you would have a 
copayment for the services. The Plan denied your request. The Plan says the root canal has processed correctly, 
and the remaining services are not covered under your benefits. 
 Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
We looked at the file and Medicare rules. You have been asked to pay $122.50 for the root canal. This amount 
includes your $50 deductible plus 50% coinsurance. This means you have been asked to pay the correct amount 
based on your contract with the Plan. Therefore, we decided that the Plan does not have to provide additional 
payment for the endodontic therapy, anterior tooth (excluding final restoration) (D3310) provided April 19, 
2022. Though the Plan offers a dental benefit in excess of Medicare coverage, the remaining 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 limited oral evaluation - problem focused (D0140), pulp vitality tests (D0460), treatment of root 
canal obstruction; non-surgical access (D3331) and incision and drainage of abscess - intraoral soft tissue 
(D7510) provided April 19, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital care provided from January 27, 2022, 
through January 30, 2022. 
 You asked the Plan to pay for the inpatient hospital care. You say that you are requesting a reconsideration of 
the Plan's denial for payment. The Plan denied your request. The Plan says the billed services were not 
supported by the documentation provided. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, the inpatient services provided were billed with a secondary diagnosis code of J96.21, defined as 
acute and chronic respiratory failure with hypoxia. 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 inpatient hospital care provided. Our reviewer says that the documentation provided does not meet 
criteria for payment. Our physician reviewer found that the documentation provided supported an admission for 
chronic obstructive pulmonary disease with (acute) exacerbation. While acute on chronic respiratory failure 
with hypoxia is documented in the medical record, supporting medical record documentation was not found 
within the record. Treatment consistent with acute respiratory failure including the administration of oxygen,  
5 liters or more provision of bilevel positive airway pressure (BiPAP) and/or mechanical ventilation unless the 
patient is on these therapies at home or they are provided solely for other reasons such as airway protection or 
work of breathing was not within the record. As noted above, although the provider documented acute on 
chronic respiratory failure with hypoxia, reasonable support within the health record was not present. The 
review has determined that the records did not support that code J96.21 is a valid secondary diagnosis for this 
admission.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for the inpatient hospital care provided from January 27, 2022, through January 30, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospice services provided from March 23, 2021, to March 
30, 2021. 
 You asked the Plan to pay for hospice services. You say that you provided all these services and never got 
reimbursed. The Plan denied your request. The Plan says the provider does not have an active Medicare ID 
number. 
 
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.  
 
Hospice care can only be covered when the election is made, and once the election is made, the Plan is not 
responsible. Therefore, we decided that the Plan does not have to pay for hospice services provided from 
March 23, 2021, to March 30, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung 
cancer screening. 
 
You asked the Plan to pre-approve the requested LDCT scan. You say that the service is medically necessary. 
The Plan denied your request. The Plan says you do not meet criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung 
cancer screening for enrollees who meet all the criteria described in the Medicare rules section of this letter.  
 
   
We reviewed the file and the Medicare rules. We find that you do not meet criteria for coverage because you 
did not quit smoking within the last 15 years, and you are not between 55-77 years old. Therefore, we decided 
that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung cancer 
screening.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the GTC (genomic testing cooperative) Hematology Profile (81455) 
provided on July 21, 2021. 
 
You asked the Plan to pay for the GTC Hematology Profile. You say that this test was approved by the MolDX 
program and is medically necessary for this enrollee. The Plan denied your request. The Plan says that there are 
Medicare coverage determinations which indicate that panels including the FANCC and BLM genes are not 
covered. 
 
Medicare rules say that molecular diagnostic laboratory tests are subject to the MolDX application, assessment, 
and approval process. Once this is complete, the test is assigned a reimbursement rate and a unique test 
identifier. 
 
We looked at the file and Medicare rules. This test is listed in the DEX database as covered. This determination 
was made and is specific to the test at issue. Though this panel does include genes that another coverage rule 
indicates are non-covered, we find there is no basis to overrule the specific coverage decision made by the 
MolDx contractor for this particular test. Based on this information, we decided that Medicare rules for 
coverage of the GTC Hematology Profile have been met. Therefore, we decided that the Plan has to pay for the 
GTC (genomic testing cooperative) Hematology Profile (81455) provided on July 21, 2021.  
 
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.