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

 
We decided that the Plan does not have to pre-approve an occlusal orthotic device, by report (D7880). 
 
You asked the Plan to pre-approve the occlusal orthotic device, by report (D7880). The Plan denied your 
request. The Plan says per Medicare policy, oral occlusive appliances used to treat temporomandibular joint 
disorders are classified as dental devices and are excluded from coverage. 
 
The Plan must follow Medicare rules. The rules say that oral occlusal appliances used to treat 
temporomandibular joint (TMJ) disorders are considered to be dental devices and will be denied as non-
covered. 
 
We looked at the file and Medicare rules. The requested item is considered a dental device and is not covered. 
Therefore, we decided that the Plan does not have to pre-approve an occlusal orthotic device, by report 
(D7880).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a resin-based composite (D2335) provided by a participating 
provider on March 3, 2022. 
 
You asked the Plan to pay for a resin-based composite. You say that the enrollee needed these services done. 
The Plan denied your request. The Plan says the rendered dental services have been correct denied. 
 
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 a resin-based 
composite when the services are medically necessary and reasonable.  
 
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 a resin-based composite have not been met. Therefore, we decided that the Plan 
does not have to pay for a resin-based composite (D2335) provided by a participating provider on March 3, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve all white glass crown (D2740) Tooth #9 and partial 
upper denture (D5225). 
 
You asked the Plan to pre-approve dental services. You say that you believe you have not had the services 
previously. The Plan denied your request. The Plan says all white glass crown (D2740) was denied as limit 
reached and partial upper dentures (D5225) is not a covered benefit. 
 
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. This benefit includes 
restorative services (filings or crowns) with a limit of two teeth per year. This benefit includes only those items 
and services specifically listed in your Plan contract. Partial upper denture (D5225) is not covered under the 
Plans dental benefits. 
 
  We looked at the file, the Plans rules, and Medicares rules. You previously received covered resin-based 
composite  two surfaces, posterior and resin-based composite  three surfaces, posterior (D2393) x2 on 
January 26, 2022. Therefore, this benefit has been exhausted as of January 26, 2022. Though the Plan offers a 
dental benefit in excess of Medicare coverage, the requested partial upper denture (D5225) is not covered under 
this benefit. Therefore, we decided that the Plan does not have to pre-approve all white glass crown (D2740) 
Tooth #9 and partial upper denture (D5225).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lymphedema treatment to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the OON lymphedema treatment. You say that you wish to go to the OON 
provider because they provide specialized care for your condition. The Plan denied your request. The Plan says 
you have been approved to be seen by an in-network tertiary level specialist for your condition. This facility 
provides the same level of care as is offered by the requested OON provider. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
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 and has approved services with an in-
network tertiary provider. We found no exception that would require the Plan to pre-approve these 
items/services. Therefore, we decided that the Plan does not have to pre-approve lymphedema treatment to be 
provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the abutment supported porcelain fused to a metal 
crown (D6059) and the prefabricated abutment (D6056). 
 
You asked the Plan to pre-approve the abutment supported porcelain fused to a metal crown (D6059) and the 
prefabricated abutment (D6056). You say that you have implants, and another material should not be used. You 
say you would like to use your benefits. The Plan denied your request. The Plan says the services 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 pre-approve the 
abutment supported porcelain fused to a metal crown (D6059) and the prefabricated abutment (D6056).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for Mohs micrographic technique (procedure codes 17311, 17312) 
provided to the enrollee on December 16, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that this is not reimbursable as a separate charge. 
 
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, the CPT Code Manual definition of 
the denied codes is: 
 
CPT 17311: 
 
Mohs micrographic technique, including removal of all gross tumor, surgical excision of tissue specimens, 
mapping, color coding of specimens, microscopic examination of specimens by the surgeon, and 
histopathologic preparation including routine stain(s) (eg, hematoxylin and eosin, toluidine blue), head, neck, 
hands, feet, genitalia, or any location with surgery directly involving muscle, cartilage, bone, tendon, major 
nerves, or vessels; first stage, up to 5 tissue blocks 
 
CPT 17312: 
 
Mohs micrographic technique, including removal of all gross tumor, surgical excision of tissue specimens, 
mapping, color coding of specimens, microscopic examination of specimens by the surgeon, and 
histopathologic preparation including routine stain(s) (eg, hematoxylin and eosin, toluidine blue), head, neck, 
hands, feet, genitalia, or any location with surgery directly involving muscle, cartilage, bone, tendon, major 
nerves, or vessels; each additional stage after the first stage, up to 5 tissue blocks (List separately in addition to 
code for primary procedure) 
 
We asked our coder 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 services. Our reviewer says that the services at issue in 
this case were supported by the medical records. Our reviewer found that the medical record includes a Mohs 
procedure (stage 1 and stage 2) documenting the surgeon performed the procedure as well as the pathology 
procedure. No additional documentation was provided to support services were performed by another 
provider.  Therefore, this service should be covered. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
Mohs micrographic technique (procedure codes 17311, 17312) provided to the enrollee on December 16, 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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on October 21, 2021. 
 
You asked the Plan to pay for physician's services. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent or 
emergent, nor were they approved in advance. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for physician's services provided on October 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown - porcelain/ceramic tooth # 14 (D2740). 
 
You asked the Plan to pre-approve the crown - porcelain/ceramic tooth # 14 (D2740). You say that you have a 
broken tooth and rarely use your medical coverage. You also say that with this expensive procedure you could 
use some help. 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 pre-approve a 
crown - porcelain/ceramic tooth # 14 (D2740).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pontic (D6242) and a retainer crown (D6752) for tooth 
#8, #9, and #10. 
 
You asked the Plan to pre-approve the dental services. You say that you need these dental procedures done so 
you can restore your teeth. The Plan denied your request. The Plan says the denial of authorization for these 
services is correct, because pontics and retainer crowns are not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
pontic (D6242) and a retainer crown (D6752) for tooth #8, #9, and #10.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab pathology provided on February 9, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for lab pathology 
. You say that this was medically necessary and should be covered. The Plan denied your request. The Plan 
says there was no preauthorization by a primary care provider (this is different than a referral) for an out-of-
network (OON) provider or facility, and this was not an emergency. Therefore, the decision is upheld. 
 
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 lab pathology provided on February 9, 2022, by an 
out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan of the brain 
(78608). 
 
You asked the Plan to pre-approve a PET scan of the brain. The Plan denied your request. The Plan says the 
medical records provided do not indicate that the enrollee meets the diagnostic criteria of both AD and FTD. 
The Plan also says there is no indication that the exam is being requested in the context of a clinical trial, and 
this request does not meet the Medicare or health plan coverage criteria. 
 
The Plan follows Medicare rules. Medicare rules say that an FDG PET scan is considered reasonable and 
necessary in patients with a recent diagnosis of dementia and documented cognitive decline of at least 6 
months, who meet diagnostic criteria for both AD and FTD. 
 
 
  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 PET scan of the brain. Our reviewer 
says that the enrollee does not meet the criteria for coverage for a PET scan of the brain. Our physician 
reviewer found the records only indicate that the enrollee has a diagnosis of AD. The enrollee is not suspected 
of having FTD, nor are they noted to have clinical features of FTD. The evaluation of the enrollee did not 
clearly determine a specific neurodegenerative disease or other cause for the clinical symptoms. Our reviewer 
found that the enrollee is only suspected of having AD. The differential would be vascular changes from a prior 
stroke. Our physician reviewer also found that there is not an indication in this case to differentiate between 
FTD and AD. 
 
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 PET scan of the brain have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a positron emission tomography (PET) scan of the brain (78608).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided on January 13, 2022. 
 
You asked the Plan to pay for the home health services. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the claim submitted, the file and the Medicare rules. Medicare rules say for all enrollees receiving 
home health services in 2021 whose services will continue in 2022, the home health agency shall submit an NOA with a one-time artificial admission date corresponding to the From date of the first period of 
continuing care in 2022. Based on this information, we decided that Medicare rules for completing the claim 
for home health services have not been met. Specifically, the file shows the final claim with an admission date 
of December 14, 2021, received on February 17, 2022, was invalid. The NOA had an artificial 'admission' date 
of January 13, 2022. Therefore, we decided that the Plan does not have to pay for the home health services 
provided on January 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone replacement graft (D7953), a guided tissue 
generation (D4266), a cone beam capture (D0364), an endosteal implant (D6010), collection and application of 
autologous blood concentrate product (D7921), a prefabricated abutment (D6056), and an abutment supported 
retainer (D6068), provided by a participating provider. 
 
You asked the Plan to pre-approve dental services. You say that you would like the Plan to pay for this. The 
Plan denied your request. The Plan says the denied dental services 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 pre-approve a bone replacement graft (D7953), a guided tissue generation (D4266), a cone beam capture (D0364), an 
endosteal implant (D6010), collection and application of autologous blood concentrate product (D7921), a 
prefabricated abutment (D6056), and an abutment supported retainer (D6068), provided by a participating 
provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on July 14, 2022, billed with 
codes 87798, 87150, 87481, 87500, 87640, 87651, 87653, and 87801. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the denial. The Plan 
denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
July 14, 2022, billed with codes 87798, 87150, 87481, 87500, 87640, 87651, 87653, and 87801.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy visits provided on June 
01, 2022. 
 
You asked the Plan to waive the copayment for physical therapy visits. You say that this should be covered. 
The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for Outpatient rehabilitation services. 
 
You have been asked to pay a $40 copayment for physical therapy visits. This item/service falls within the 
Outpatient rehabilitation 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 waive the copayment for 
physical therapy visits provided on June 01, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings (E1399). 
 
You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says these items are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that elastic stockings are not covered because they are non-
reusable supply items.  
 
Although these items may be appropriate, they do not fall into a covered benefit category and cannot be paid 
for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings (E1399).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the PGx Comprehensive Panel provided on January 15, 
2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says there is no 
documentation describing the purpose for the testing or how it would affect the enrollee's treatment plan. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the testing have been met. Specifically, there are no medical records from the ordering physician. Therefore, we decided that the Plan does not have to 
pay for the PGx Comprehensive Panel provided on January 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a below-knee flexible protective outer surface cover for 
a lower limb prosthesis. 
 
You asked the Plan to pre-approve protective outer surface covering. You say that the enrollee will be outside 
frequently, so this extra covering will protect against harsh conditions. The Plan denied your request. The Plan 
says this is not needed because the already approved L5704 covering meets the enrollee's needs. 
 
The Plan follows Medicare rules. Medicare rules state that protective outer surface covering systems are used 
by a beneficiary who has special needs for protection against unusually harsh environmental situations. 
 
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 protective outer surface covering. Our 
reviewer says that the enrollee does not meet the Medicare criteria for the requested protective covering. Our 
physician reviewer found the medical record does not indicate exceptional or harsh environmental 
circumstances for the enrollee who lives in a building with a trash chute.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of protective outer surface covering have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a below-knee flexible protective outer surface cover for a lower limb 
prosthesis.