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

 
We decided that the Plan does not have to pay for the intraoral - complete series of radiographic images 
(D0210) provided May 10, 2022. 
 
You asked the Plan to pay for the dental services. You say that there were issues with your previous dentist and 
needed new x-rays. 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 May 14, 2019. Therefore, 
we decided that the Plan does not have to pay for the intraoral - complete series of radiographic images 
(D0210) provided May 10, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an 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 the enrollee appears to be more stable and improving and should only require short-
term additional acute care services that can safely be administered at the current facility until more appropriate 
for a lower level of care. The enrollee does not require services at the LTACH that are not already available at 
the current 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 long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation (RFA). 
 
You asked the Plan to pre-approve genicular RFA. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says this procedure is experimental/investigational. 
 
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 genicular RFA. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the role of radiofrequency ablation of the genicular nerves is still being evaluated. It is 
considered to be an experimental/investigational procedure. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genicular RFA have not been met. Therefore, we decided that the Plan does not 
have to pre-approve genicular nerve radiofrequency ablation (RFA).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cone beam computed tomography (D0367), 2D 
oral/facial photographic image (D0350), and comprehensive oral evaluation (D0150) provided on May 18, 2022. 
 
You asked the Plan to pay for the dental services. You say that you had to see a new dentist and would require 
you to get another comprehensive oral evaluation. The Plan denied your request. The Plan says the cone beam 
computed tomography (D0367) and 2D oral/facial photographic image (D0350) are not covered under your 
supplemental benefit. The Plan also says the comprehensive oral evaluation (D0150) was exhausted on April 
19, 2021. 
 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 cone beam computer tomography 
and 2D oral/facial photographic images are not among those covered under this benefit. Additionally, certain 
limitations apply. The record shows your benefit for the comprehensive oral evaluation was exhausted on date 
of service April 19, 2021. Therefore, we decided that the Plan does not have to pay for the cone beam 
computed tomography (D0367), 2D oral/facial photographic image (D0350), and comprehensive oral 
evaluation (D0150) provided on May 18, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve an additional 10 miles of routine transportation. 
 
You asked the Plan to pre-approve an additional 10 miles of routine transportation. You say that you have seen 
the same doctor since 2014 and you do not want to have to switch to another doctor. The Plan denied your 
request. The Plan says that you have exceeded your benefit limit. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The provider, whom the enrollee wants to see, has multiple practice locations. 
The Plan failed to verify which location the enrollee would be going to. Since there is no proof of the mileage 
or the destination, the Plan has not proven that the requested trip is actually outside of the 75-mile limit. 
Therefore, we decided that the Plan has to pre-approve an additional 10 miles of routine transportation.  
 
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.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from February 13, 2022, 
through February 21, 2022. 
 
You asked the Plan to pay for home health services. You say that you have been reimbursed for multiple 
payments where only a RAP was sent, and you were never notified that a NOA was a requirement. You say 
that the claim should be reconsidered as services were provided in good faith with the expectation of being 
reimbursed. The Plan denied your request. The Plan says a valid Notice of Admission is required in order to 
process the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that home health services under a plan of care are 
paid based on a 30-day period of care. HHAs submit an NOA at the beginning of an admission and then submit 
one claim for each 30-day period of care. 
  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of home health services have not been met. Specifically, a NOA was not submitted. Therefore, we 
decided that the Plan does not have to pay for home health services provided from February 13, 2022, through 
February 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prefabricated Post and Core (D2954) in addition to 
crown for Tooth # 7, 8, 9 & 10 
 
You asked the Plan to pre-approve the Prefabricated Post and Core. 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 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 
Prefabricated Post and Core (D2954) in addition to crown for Tooth # 7, 8, 9 & 10.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lower and upper dentures (D5110, D5120) 
 
You asked the Plan to pre-approve the lower and upper dentures. 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 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 
lower and upper dentures (D5110, D5120)
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary denture (D5110) and a mandibular denture 
(D5120). 
 
You asked the Plan to pre-approve the dental services. You say that the prior dentures did not fit, and you 
would like the new dentures to be covered by the Plan. 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 of January 8, 2021. 
Therefore, we decided that the Plan does not have to pre-approve a maxillary denture (D5110) and a 
mandibular denture (D5120).  
 Your complaint about your experience with the prior provider is not a valid appeal for medical coverage. This 
part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services (D4265, D7261) 
 
You asked the Plan to pre-approve the dental services. 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 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 
dental services (D4265, D7261)
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the needle electromyography (95867), short-latency 
somatosensory evoked potential study (95925), and continuous intraoperative neurophysiology monitoring 
(G0453) provided on January 11, 2021. 
 
You asked the Plan to pay for the physician services. You say that the services were paid at the out-of-network 
level. You say that you would like them to be paid as in-network. You also say that the filing deadline should 
be waived as your office was greatly affected by the pandemic and had staffing issues. The Plan denied your 
request. The Plan says the claim was not received within the 12-month timeframe. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the physician services was not filed until February 25, 2022. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the needle electromyography (95867), short-latency 
somatosensory evoked potential study (95925), and continuous intraoperative neurophysiology monitoring 
(G0453) provided on January 11, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99601 billed for date of service January 28, 
2021. 
 
You asked the Plan to pay for procedure code 99601. You say that the provider is in-network, and the coding is 
valid per the contract. The Plan denied your request. The Plan says the billed code is invalid for Medicare 
purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
 
  We find that procedure code 99601 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 99601 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 99601 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99601 billed for date of service January 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator. 
 
You asked the Plan to pre-approve the requested item. You say that you are unable to lift the unit into your car. 
The Plan denied your request. The Plan says there is no medical documentation to support the request 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
We looked at the file and the rules. The file shows that you your current unit serves the same purpose as the 
requested item. Therefore, we decided that the Plan does not have to pre-approve a portable oxygen 
concentrator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a problem focused limited oral evaluation (D0140), an 
intraoral x-ray for tooth #4 (D0220), and an intraoral x-ray for tooth #6, tooth #11, and tooth #13 (D0230) 
provided on May 31, 2022. 
 
You asked the Plan to pay for a problem focused limited oral evaluation (D0140), an intraoral x-ray for tooth 
#4 (D0220), and an intraoral x-ray for tooth #6, tooth #11, and tooth #13 (D0230). You say that the personnel 
in the provider's office told you that the provider was in-network. The Plan denied your request. The Plan says 
services received form an out-of-network dentist are not covered 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 problem 
focused limited oral evaluation (D0140), an intraoral x-ray for tooth #4 (D0220), and an intraoral x-ray for 
tooth #6, tooth #11, and tooth #13 (D0230) provided on May 31, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair. You asked the Plan to pre-approve a power wheelchair. You say that your current chair does not work. The 
Plan denied your request. The Plan says the coverage criteria have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a power mobility device is only covered under certain 
medical indications.  
 
The file does not show that your condition cannot be improved by a walker, cane or manual wheelchair. Based 
on this information, we decided that the Medicare rules for coverage have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a power wheelchair.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgery services provided on March 19, 2021. 
 
You asked the Plan to pay for the billed services. You say that the documentation clearly supports the services. 
The Plan denied your request. The Plan says the codes cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 In this case, the CPT Code Manual definition of code 23472 is arthroplasty, glenohumeral joint; total shoulder 
(glenoid and proximal humeral replacement (e.g., total shoulder)). CPT code 23472 was billed with a -22 
modifier. The records provided do not show that the services were significantly greater than usual.  
 
The CPT Code Manual definition of code 23412 is repair of ruptured musculotendinous cuff (e.g., rotator cuff) 
open; chronic. This code was billed with the -59 modifier. The rules state that providers may bill services with 
a -59 modifier if the service billed with the modifier indicates a distinct procedural service. The medical 
records provided do not show that the service billed with the -59 modifier is a distinct procedural service. 
Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we 
decided that the Plan does not have to pay for the surgery services provided on March 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pathology services (88300) provided December 13, 2021. 
 
You asked the Plan to pay for the pathology services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 88300 is not supported in the medical record. Specifically, the service was billed with 
an outpatient place of service, but the record shows the enrollee was an inpatient at the time services were 
provided. Based on this information, we decided that Medicare rules for coverage of the pathology services 
have not been met. Therefore, we decided that the Plan does not have to pay for pathology services (88300) 
provided December 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on July 6, 2021. 
 
You asked the Plan to pay for the lumbar-sacral orthosis. The Plan denied your request. The Plan says the 
documentation submitted did not include proof of delivery for the lumbar-sacral orthosis. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
  The record does not contain a valid proof of delivery. The record shows that the Plan made several attempts to 
obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay 
for the lumbar-sacral orthosis provided on July 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for resin-based composites (D2332 and D2335) provided by a 
participating provider on April 27, 2022. 
 
You asked the Plan to pay for the dental services. You say that you did not think your fillings would be this 
much. 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 April 27, 2022. 
Therefore, we decided that the Plan does not have to pay for two of the four resin-based composites (D2332 
and D2335) provided by a participating provider on April 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infrared therapy (97026) provided on February 17, 2022. 
 
You asked the Plan to pay for the infrared therapy. You say that the service was medically necessary. The Plan 
denied your request. The Plan says infrared therapy is not medically reasonable and necessary by Medicare. 
The Plan also says that it is excluded from coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that infrared therapy devices and any related 
accessories is not reasonable and necessary. Therefore, we decided that the Plan does not have to pay for the 
infrared therapy (97026) provided on February 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for laboratory services provided on May 10, 
2022. 
 
You asked the Plan to waive the cost share for laboratory services. You say that you are not sure why these 
laboratory charges are denied. The Plan denied your request. The Plan says the cost share is 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 for 
functional medicine services/procedures and supplies (including labs and supplements). Functional medicine 
includes alternative, holistic and naturopathic medicine is not covered under any condition.  
 
You have been asked to pay $1167.72 for laboratory services. The laboratory services fall within the Services 
We Do Not Cover (exclusions) 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 cost share for 
laboratory services provided on May 10, 2022.