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

 
We decided that the Plan does not have to pay for an adjunctive pre-diagnostic test (D0431) provided on June 
9, 2022. 
 
You asked the Plan to pay for a pre-diagnostic test. You say that this service should be covered. The Plan 
denied your request. The Plan says an adjunctive pre-diagnostic test (D0431) 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 an 
adjunctive pre-diagnostic test (D0431) provided on June 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), complete series 
of intraoral x-rays (D0210), prophylaxis (D1110), topical application of fluoride, excluding varnish (D1208), 
crown (D2740), and core buildup, including any pins when required (D2950) provided on April 28, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the dental services. You say that you contacted the office to confirm they were 
in-network, and were advised they were. You also say that they required payment before you left, and said the 
Plan would reimburse you. The Plan denied your request. The Plan says the dental services were received from 
an OON 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 OON 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 OON provider. Therefore, we decided that the Plan does not have to pay for the 
comprehensive oral evaluation (D0150), complete series of intraoral x-rays (D0210), prophylaxis (D1110), 
topical application of fluoride, excluding varnish (D1208), crown (D2740), and core buildup, including any 
pins when required (D2950) provided on April 28, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the filling (D2391) on tooth #20 provided by an out-of-
network provider on June 17, 2022. 
 
You asked the Plan to pay for the dental services. You say that you do not believe it is possible that the 
provider is out-of-network. 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 the filling (D2391) on tooth #20 provided by an out-of-network provider on June 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for a resin-based composite filling on tooth #27 
(D2331) provided on May 4, 2022, and a resin-based composite filling on tooth #7 (D2331) and a resin-based 
composite filling on tooth #29 (D2391) provided on May 12, 2022. 
 
You asked the Plan to waive the cost share for fillings. You say that you disagree with the denial of dental 
services. The Plan denied your request. The Plan says your annual dental maximum benefit has been exhausted. 
 
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 this benefit includes 
coverage up to $1,000 for covered dental services. The contract says that you are responsible for any amount 
above the benefit maximum. 
 
The record shows your annual maximum has been exhausted. You are responsible for any amount above the 
maximum amount. Fillings fall 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 waive the cost share for a resin-based composite filling on tooth #27 (D2331) provided on May 4, 2022, and 
a resin-based composite filling on tooth #7 (D2331) and a resin-based composite filling on tooth #29 (D2391) 
provided on May 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for flow cytometry (88188) provided on April 1, 2022. 
 
You asked the Plan to pay for flow cytometry (88188). You say that medical records for the denied lab charges 
are attached. You say that the diagnosis is correct, and reimbursement is expected. The Plan denied your 
request. The Plan says manifestation diagnosis codes are never permitted to be used as first listed or principal 
diagnosis codes. 
  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 88188 is not supported in the medical record. Specifically, the diagnosis code reported 
is not an appropriate primary diagnosis code. Based on this information, we decided that Medicare rules for 
coverage of flow cytometry (88188) have not been met. Therefore, we decided that the Plan does not have to 
pay for flow cytometry (88188) provided on April 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a core buildup, including any pins when required (D2950), 
intraoral - periapical first radiographic image (D0220), additional radiographic image (D0230), and crown - 
porcelain/ceramic (D2740) provided on April 14, 2022. 
 
You asked the Plan to pay for the dental services.. You say that you cannot afford a payment for the crown 
buildup and thought the services would be covered. The Plan denied your request. The Plan says these services 
are not covered under the benefit 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 pay for a core 
buildup, including any pins when required (D2950), intraoral - periapical first radiographic image (D0220), 
additional radiographic image (D0230), and crown - porcelain/ceramic (D2740) provided on April 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care provided on May 13, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the nursing facility care. You say that the service should be covered. The Plan 
denied your request. The Plan says prior authorization was not obtained for the service in this case. 
 
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 provider in this case is not a network provider with the Plan. 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 the subsequent nursing facility care provided on May 13, 2022, 
by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for endodontic therapy on tooth #31 (D3330) provided on May 
10, 2022. 
 
You asked the Plan to pay for endodontic therapy. You say that you were not told that a root canal was not 
covered. The Plan denied your request. The Plan says endodontic therapy (D3330) 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 
endodontic therapy on tooth #31 (D3330) provided on May 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 83789-59 
 
You asked the Plan to pay for code 83789-59. You say that this service should be covered. The Plan denied 
your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789-59 have not been met. Specifically, we find that the testing described by the billed 
code is considered specimen validity testing which is not separately payable. Therefore, we decided that the 
Plan does not have to pay for procedure code 83789-59
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a standard wheelchair (K0001). 
 
You asked the Plan to pre-approve a standard wheelchair. You say that the standard wheelchair is medically 
necessary due to peripheral vascular disease. The Plan denied your request. The Plan says the medical records 
provided do not support the criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
 
 
 
 
 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a standard wheelchair. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the documentation indicates the enrollee has a mobility limitation. The 
documentation does not support that the enrollee's mobility limitation significantly impairs his ability to 
participate in one or more mobility-related activities of daily living (MRADLs) such as toileting, feeding, 
dressing, grooming, and bathing in customary locations in the home. The documentation does not support that 
his mobility limitation cannot be sufficiently resolved by the use of an appropriately fitted cane or walker or 
that his home provides adequate access between rooms, maneuvering space, and surfaces for use of the manual 
wheelchair that is requested. The documentation does not support that the use of a manual wheelchair will 
significantly improve the enrollee's ability to participate in MRADLs and he will use it on a regular basis in the 
home. 
 
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 standard wheelchair have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a standard wheelchair (K0001).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Rinvoq tablets. 
 
You asked the Plan to pre-approve self-administered drug. You say that you are appealing this denial. The Plan 
denied your request. The Plan says this drug is not covered by Medicare Part B and the Plan does not 
administer the enrollee's Medicare Part D benefits. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Rinvoq tablets.  
 
Benefits for self-administered drug may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
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 requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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 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. There are no services at the LTACH that the enrollee requires that are not already available and 
covered at the current facility. Transfer to the LTACH is not medically necessary as it would not be clinically 
advantageous at this time. Completion of treatment at the current facility is recommended. 
 
 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an extraction of tooth #7 (D7140) and an extraction of tooth 
#22 (D7210) provided on May 18, 2022. 
 
You asked the Plan to pay for the extractions. You say that you disagree with the denial of dental services. The 
Plan denied your request. The Plan says extractions (D7140, D7210) are not covered by your routine 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 an 
extraction of tooth #7 (D7140) and an extraction of tooth #22 (D7210) provided on May 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cytopathology services provided on March 3, 2022. 
 You asked the Plan to pay for the cytopathology services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services provided are not a covered benefit. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The cytopathology service at issue in this appeal was requested solely for screening purposes. Medicare does 
not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for 
the cytopathology services provided on March 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for full mouth debridement (D4355) provided on January 18, 
2022. 
 
You asked the Plan to pay for debridement. You say that you disagree with the denial of dental services. The 
Plan denied your request. The Plan says full mouth debridement (D4355) 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 full 
mouth debridement (D4355) provided on January 18, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion or replacement of spinal neurostimulator pulse 
generator or receiver, direct or inductive coupling (CPT code 63685) and percutaneous implantation of 
neurostimulator electrode array, epidural (63650). 
 
You asked the Plan to pre-approve the services. You say that you are unable to do mobile and everyday things 
due to not being able to stand up for long periods of time. You state that you have continuous chronic pain. The 
Plan denied your request. The Plan says your request is not medically necessary because your records not 
include a computed tomography (CT) scan or magnetic resonance imaging (MRI) of your lumbar spine. The 
Plan states your records do not include a note from a spine surgeon showing that you do not have a surgical 
issue and your records do not document that you have had non-surgical treatment. The Plan states your records 
do not include a psychological evaluation showing that you are a suitable candidate for a spinal cord stimulator. 
 
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 services. Our physician reviewer 
found detailed documentation is not evident regarding trial and failure of recent, reasonable, and 
comprehensive less invasive conservative care measures. This would then not be considered a late/last resort. 
Additionally, the records do not provide an objective exam, surgical evaluation, or psychological evaluation. 
There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity 
of this request as an exception. Therefore, the medical records provided do not meet the requirements listed in 
the NCD/LCD for Medicare coverage. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or 
inductive coupling (CPT code 63685) and percutaneous implantation of neurostimulator electrode array, 
epidural (63650).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided from November 17, 2021, to 
November 24, 2021, as billed with Diagnosis Related Group (DRG) 872. 
 
You asked the Plan to pay for inpatient care billed with DRG 872. You say that these services were medically 
necessary and are supported in the record. The Plan denied your request. The Plan says DRG 872 is not appropriate as the diagnosis of sepsis, unspecified organism (A41.9) is not supported in the medical record. The 
Plan argues that DRG 690 is more appropriate in this case. 
 
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. 
 
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 inpatient care billed with DRG 872. Our 
reviewer says that the diagnosis of sepsis, unspecified organism (A41.9) is not supported in the medical records 
for this inpatient admission. Our physician reviewer found the enrollee presented to the emergency department 
with a urinary tract infection. After initial treatment in the emergency department, there was one was one 
transient platelet count less than 150,000 noted on November 18th, at which time the level was 138,000. There 
were no documentation of low platelet counts or thrombocytopenia noted by providers. The enrollee has a past 
medical history of atrial fibrillation and is taking Eliquis 5 mg daily per the record. After treatment in the 
emergency department, there were no documented mean arterial pressures less than 70 mmHg or systolic blood 
pressures (MAPs) less than 90 mmHg noted in the record. Although the hospital correspondence statement and 
provider documentation of "hypotension" and listed MAPs of 67 and 69 mmHg, these were taken while the 
enrollee was still in the emergency department. Provider documentation was noted to attribute the hypotension 
to the enrollees recent change in dosage of beta blocker medication. There was no documentation of a 
Glasgow Coma Score noted in the record. There was no laboratory or clinical evidence of sepsis. The review 
has determined that the medical records did not support the billing of sepsis, unspecified organism (A41.9) 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient care billed with DRG 872 have not been met. Therefore, we decided 
that the Plan does not have to pay for inpatient hospital care provided from November 17, 2021, to November 
24, 2021, as billed with Diagnosis Related Group (DRG) 872.