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

 
We decided that the Plan does not have to pay for the dental implant & deep sedation (D9223, D6010) 
provided on May 24, 2021. 
 
You asked the Plan to pay for the dental implant & deep sedation. You say that the services should be covered 
as you disagree with the charges. The Plan denied your request. The Plan says the services denied correctly as 
they do not fall within your dental coverage. 
 
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 the dental 
implant & deep sedation (D9223, D6010) provided on May 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve MyoPro Motion G device. 
 
You asked the Plan to pre-approve MyoPro Motion G device. You say that this is medically necessary for the 
enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
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 MyoPro Motion G device. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the clinical documentation states that the myoelectric orthosis can be 
helpful in patients with weakness. However, there is no supporting documentation of specific goals in this 
patient. Provider documentation states that patient is able to perform self-care activities and states that 
spasticity is a barrier as opposed to weakness. Additionally, there is no documentation to discuss how an 
orthosis will help this specific patient perform any specific activity goal. 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MyoPro Motion G device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve MyoPro Motion G device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive periodontal exam (D0180) provided on 
January 4, 2022. 
 
You asked the Plan to pay for an exam. You say that you want to know if the denial for code D0180 is correct. 
The Plan denied your request. The Plan says that a comprehensive periodontal exam (D0180) 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 
comprehensive periodontal exam (D0180) provided on January 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99051 billed for date of service February 5, 2022. 
 
You asked the Plan to pay for procedure code 99051. You say that these services were medically necessary. 
The Plan denied your request. The Plan says no separate payment is made for this code. 
 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 99051 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99051 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of procedure code 99051 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 99051 billed for date of service February 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive periodontal evaluation (D0180) provided 
on January 26, 2022. 
 
You asked the Plan to pay for the comprehensive periodontal evaluation. 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 
comprehensive periodontal evaluation (D0180) provided on January 26, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for long term acute care hospital (LTACH) services. 
 
You asked the Plan to pay for the LTACH services. You say that you would like to appeal the denial of the 
claim. The Plan denied your request. The Plan says There is no documentation that the enrollee will benefit 
from and improve with LTACH management. 
 
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 pay for 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 does not require services at the LTACH that are not available at the acute care 
hospital where he/she is currently receiving care. All medically necessary care is being provided in the current 
acute care facility. 
 
There are no services available at the LTACH that the enrollee requires that are not available at the health care 
setting being offered by the health plan. The health plan has approved ongoing care in the current acute care 
facility.  
The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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 pay for long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous spinal surgery. 
 
You asked the Plan to pre-approve percutaneous spinal surgery. You say that you need the minimally invasive 
surgery, otherwise are at risk of becoming septic or dying. You say that rehabilitation is very hard, and the 
requested surgery will help you continue to live. The Plan denied your request. The Plan says there are not 
enough studies to show that the requested type of spine surgery is better than regular spine surgery for the 
enrollee's problem. 
 
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 percutaneous spinal surgery. Our 
reviewer says that percutaneous spinal surgery is not considered medically reasonable and necessary in this 
case. Our physician reviewer found percutaneous spinal surgery remains experimental. More research is needed 
to show safety and 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 percutaneous spinal surgery have not been met. Therefore, we decided that the 
Plan does not have to pre-approve percutaneous spinal surgery.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost share for a comprehensive periodontal evaluation 
(D0180) provided on February 15, 2022. 
 
You asked the Plan to reduce the cost share for an evaluation. You say that you should only owe $55. The Plan 
denied your request. The Plan says you have been charged the correct cost sharing amount. 
 
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 an out-of-network comprehensive periodontal evaluation. The contract also says you may be 
billed by the out-of-network provider for any amount greater than the payment made by the Plan to the provider. 
 
The record shows you received dental services from an out-of-network provider. The record also shows that 
you are responsible for $60, which is the total billed amount minus the allowed amount ($110 total billed 
amount - $50 allowed amount = $60). You have also been asked to pay $25, which is 50% coinsurance of the 
allowed amount for an evaluation ($50 allowed amount x 50% coinsurance = $25). You have been asked to pay 
a total of $85 ($25 coinsurance + $60 billed amount above the allowed amount = $85). An evaluation 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. Therefore, we decided that the Plan does not have to reduce the cost share for a 
comprehensive periodontal evaluation (D0180) provided on February 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for orthopedic surgery provided on December 10, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for orthopedic surgery. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 orthopedic surgery provided on December 10, 
2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a dental crown and core buildup (D2740, D2950) provided 
on February 1, 2022. 
 
You asked the Plan to pay for the dental crown and core buildup. You say that the services should be covered 
as you disagree with the charges. 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 core buildup services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the core 
buildup (D2740, D2950) provided on February 1, 2022. The Plan is only obligated to pay 50% of the allowed 
amount for crowns when received from an out-of-network provider. You are responsible for any amount 
greater than the payment made by the Plan to the provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150) and 
extractions (D7140 x2) to be performed by an oral surgeon. 
 
You asked the Plan to pre-approve a comprehensive oral evaluation and extractions to be performed by an oral 
surgeon. You say that the requested services are medically necessary. The Plan denied your request. The Plan 
says the services at issue are not covered unless they are performed by a participating general dentist. Dental 
services performed by an oral surgeon are not covered. 
 
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. Based on this information, we decided that the Plan's rules for 
coverage of a comprehensive oral evaluation and extractions to be performed by an oral surgeon have not been 
met. Specifically, the services at issue are not covered unless they are performed by a participating general 
dentist. Therefore, we decided that the Plan does not have to pre-approve a comprehensive oral evaluation 
(D0150) and extractions (D7140 x2) to be performed by an oral surgeon.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 5, 2021. 
 
You asked the Plan to pay for the lab services. You say that this was medically necessary testing. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on May 5, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) coded 74178 provided on 
November 6, 2021. 
 You asked the Plan to pay for the CT. You say that you would like the plan to reconsider their denial. The Plan 
denied your request. The Plan says the services billed are not separately payable. 
 
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 74178 
is a column II code to column I code 74174. 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 the computed tomography (CT) coded 74178 provided on 
November 6, 2021.
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 an admission to an IRF is medically necessary. The 
Plan denied your request. The Plan says your needs can be met at a lower level of care. 
 
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 medical problems are stable and there are no complex nursing or rehabilitation 
needs. While you have a need for physical or occupational therapy, there is no documentation of a need for an 
intensive rehabilitation program. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), prophylaxis (D1110), 
and a panoramic x-ray (D0330) provided on February 15, 2022. 
 
You asked the Plan to pay for an evaluation, prophylaxis, and an x-ray. You say that when you signed up with 
the Plan you were told your dentist was in-network. The Plan denied your request. The Plan says the services 
are not covered when seen by an out-of-network provider. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received 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 by an out-of-network provider. Therefore, we decided that the Plan does not have to pay 
for a periodic oral evaluation (D0120), prophylaxis (D1110), and a panoramic x-ray (D0330) provided on 
February 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services provided on November 4, 2020, and 
December 7, 2020. 
 
You asked the Plan to pay for core buildup (D2950), crown porcelain/ceramic (D2740), oral evaluation 
(D0140). You say that the claims were sent via certified mail on December 16, 2021 and you believe the claim 
was submitted timely. The Plan denied your request. The Plan says The Plan says the claims were not received 
within the allowed 12 months from the date of service. 
 
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 core 
buildup (D2950), crown porcelain/ceramic (D2740), oral evaluation (D0140) was not filed until February 14, 
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 dental services provided on November 4, 
2020, and December 7, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a Tempus gene panel (81206, 81235, 81321) provided on 
September 3, 2021. 
 You asked the Plan to pay for a Tempus gene panel. You say that this was medically necessary. The Plan 
denied your request. The Plan says this was not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules also say that the submission of claims 
using individual gene CPT codes, when either 5-50 or more than 50 gene panels are ordered, is considered 
incorrect coding 
 
We find that CPT codes 81206, 81235, and 81321 are not supported in the medical record. Specifically, these 
codes were used to report components of a panel, which is considered incorrect coding. Based on this 
information, we decided that Medicare rules for coverage of a Tempus gene panel have not been met. 
Therefore, we decided that the Plan does not have to pay for a Tempus gene panel (81206, 81235, 81321) 
provided on September 3, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for routine transportation mileage. 
 
You asked the Plan to reimburse you for mileage. You say that you should be reimbursed an additional amount. 
The Plan denied your request. The Plan says routine transportation mileage is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare does not cover transport in a vehicle that is not an ambulance. 
The Plan follows the same rule.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Medicare rules for coverage of mileage have not been met. Therefore, we decided that the Plan does 
not have to reimburse you for routine transportation mileage.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for anesthesia provided on December 9, 2021. 
 
You asked the Plan to pay for anesthesia. You say that per the NPI registry, this provider is certified and able to 
perform anesthesia. The Plan denied your request. The Plan says that the Plan only reimburses to anesthesia 
providers only. 
 
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. Specifically, the Plan has not provided documentation to support the denial. 
Therefore, we decided that the Plan has to pay for anesthesia provided on December 9, 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.