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

 
We decided that the Plan does not have to pay for an intraoral x-ray (D0220), a consultation (D9310), and cone 
beam imaging (D0364) provided on March 1, 2022. 
 
You asked the Plan to pay for an x-ray, consultation, and other imaging.You say that you were shocked to only 
be reimbursed $14. The Plan denied your request. The Plan says that a consultation (D9310) and cone beam 
imaging (D0364) are not covered by your routine dental benefits. The Plan also says an intraoral x-ray (D0220) 
is not covered when received by an out-of-network provider. 
 
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, an intraoral x-ray is not covered under this benefit when 
received by an out-of-network provider and a consultation (D9310) and cone beam imaging (D0364) are not 
covered benefits. Therefore, we decided that the Plan does not have to pay for an intraoral x-ray (D0220), a 
consultation (D9310), and cone beam imaging (D0364) provided on March 1, 2022.
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 IRF care is medically necessary. The Plan denied 
your request. The Plan says IRF care is not medically necessary and the enrollee's needs can be met at a lower 
level of care such as in a skilled nursing facility. 
 
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 that while the enrollee may benefit from continued physical therapy and occupational therapy, her rehab needs can be safely provided in a lower intensity setting such as in a skilled nursing 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 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 pre-approve a porcelain crown. 
 
You asked the Plan to pre-approve a crown. You say that your previous dentist did not practice basic health 
precautions. You also say you want the temporary crown replaced with a permanent crown. The Plan denied 
your request. The Plan says this service is covered by the Plan's dental benefits; however, your benefit for one 
crown every five has 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. The Plan covers one crown 
every five years. 
 
We looked at this case file, the Plans rules, and Medicare rules. The record shows the Plan paid for a crown 
provided on October 7, 2021; therefore, the benefit for a crown has been exhausted. Therefore, we decided that 
the Plan does not have to pre-approve a porcelain crown.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for moderate sedation services (99152) provided on September 
2, 2021. 
 
You asked the Plan to pay for moderate sedation services (99152). You say that the medical records explain the 
rendered service and the claim line should be reconsidered for reimbursement. The Plan denied your request. 
The Plan says the documentation submitted did not indicate the presence of an independent trained observer. 
 
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 code 99152 is moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older.  We find that CPT code 99152 is not supported in the medical record. Specifically, the documentation does not 
support the presence of an independent trained observer as required by the CPT code billed. Based on this 
information, we decided that Medicare rules for coverage of moderate sedation services (99152) have not been 
met. Therefore, we decided that the Plan does not have to pay for moderate sedation services (99152) provided 
on September 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the consultation (D9310) provided on March 1, 2022. 
 
You asked the Plan to pay for the dental service. You say that this service was necessary to determine if you 
needed a root canal. The Plan denied your request. The Plan says consultation is not listed as a covered service. 
 
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 consultation is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the consultation 
(D9310) provided on March 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete intraoral series on February 8, 2022. 
 
You asked the Plan to pay for a complete intraoral series. You say that you would like to request 
reconsideration of the denied claim. The Plan denied your request. The Plan says the beneficiary is limited to 
one complete intraoral series every 60 months. The beneficiary received a complete intraoral series on 
February 4, 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 requested items or services are 
among those covered under this benefit once every 60 months but had already been received on February 4, 
2021. Therefore, we decided that the Plan does not have to pay for a complete intraoral series on February 8, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial hospital care (99223) provided on September 27, 
2021. 
 
You asked the Plan to pay for the evaluation and management service. You say that the enrollee was not 
enrolled in hospice on the date of service in this case. The Plan denied your request. The Plan says the 
enrollees claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits 
starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it 
is the providers responsibility to verify the enrollees coverage before rendering services and to know proper 
billing procedures for a Medicare Advantage member on hospice. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on September 25, 2021. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the initial hospital 
care (99223) provided on September 27, 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 you are trying to get discharged from the hospital to 
go to a rehabilitation facility and it is being denied. You say you do not think the social worker submitted 
authorization to medical management. The Plan denied your request. The Plan says authorization denied 
because the IRF care is not medically necessary, and the enrollee's needs can be met at a lower level of care 
such as a skilled nursing facility (SNF), 
 
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. You do not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. 
 
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 oral hygiene instructions, gingival irrigation, and oral 
antibiotics (D9630, D1330, D4921) provided on June 01, 2022. 
 
You asked the Plan to pay for the oral hygiene instructions, gingival irrigation, and oral antibiotics. 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 pay for oral 
hygiene instructions, gingival irrigation, and oral antibiotics (D9630, D1330, D4921) provided on June 01, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral - periapical first radiographic image (D9944) 
provided on October 11, 2021. 
 
You asked the Plan to pay for the intraoral image. The Plan denied your request. The Plan says intraoral images 
are not a covered service. 
 
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 
intraoral - periapical first radiographic image (D9944) provided on October 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional non-emergency transportation (A0120). 
 
You asked the Plan to pre-approve additional transportation. You say that the enrollee needs to appeal the 
Plan's denial for transportation. The Plan denied your request. The Plan says the enrollee has exhausted all of 
the allowed trips, and there are no trips remaining. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of up to 60 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional non-emergency transportation (A0120).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the patient presents with functional decline and 
inability to maintain static/dynamic balance, range of motion, self-care, ambulation, functional transfers. This 
patient has experienced significant decline in functional mobility which increases potential for long-term 
functional decline. He is at risk for multiple complications and will require close monitoring and ongoing 
assessment while activity is increased. The Plan denied your request. The Plan says the requested services are 
not reasonable and necessary, and the health plan has no contractual obligation to cover services that are not 
covered by Medicare. 
 
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 the complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted for a stroke. Medical problems are stable. There are no complex nursing or rehabilitation needs.  
 
The patient does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided in a different level of care. 
 
There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. 
 
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 small wound suture (D7910), sales tax (D9985), intraoral-
periapical x-rays (D0230 x 2), and a limited oral evaluation (D0140) provided on November 29, 2021. 
 
You asked the Plan to pay for sutures, sales tax, x-rays, and an evaluation. You say that you want these claims 
submitted under your medical benefits. You also say you did not want to go to urgent care after you fell 
because of COVID-19. The Plan denied your request. The Plan says small wound sutures (D7910) and sales tax 
(D9985) are not covered by your routine dental benefits. The Plan also says that a limited oral evaluation 
(D0140) is covered by the Plan's routine dental benefits; however, your benefits for one evaluation per calendar 
year has been exhausted. The Plan also says intraoral-periapical x-rays (D0230) are covered by the Plan's 
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 Plan's coverage rules apply in this case. The Plan covers intraoral-
periapical x-rays (D0230). The Plans also covers one limited oral evaluation (D0140) per calendar year. 
The record shows you received dental services from an out-of-network provider. According to the EOC, if you 
see an out-of-network dentist you might be billed for charges above what the Plan pays. Though the Plan offers 
a dental benefit in excess of Medicare coverage, small wound suture (D7910) and sales tax (D9985) are not 
among those covered under this benefit. We looked at this case file, the Plan's rules, and Medicare rules. The 
record also shows the Plan paid for a limited oral evaluation provided on July 6, 2021; therefore, the benefit for 
a limited oral evaluation has been exhausted.  Therefore, we decided that the Plan does not have to pay for a 
small wound suture (D7910), sales tax (D9985), intraoral-periapical x-rays (D0230 x 2), and a limited oral 
evaluation (D0140) provided on November 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (code D0150) you 
received on February 15, 2022. 
 
You asked the Plan to pay for the comprehensive oral evaluation (code D0150). You say that you had to find a 
new dentist because you did not accept the prognosis of your previous dentist. You believe that the Plan should 
process code D0150 as code D0120. The Plan denied your request. The Plan says you had already exhausted 
your benefit for a comprehensive oral exam when you had one on November 29, 2021. 
 
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. Your Plan only covers comprehensive oral exams (D0150) once every 
five years.  The Plan cannot just 'downgrade' the code to D0120 so that it will be paid.  Your dentist provided a 
comprehensive oral exam, and so the claim denied appropriately based on that. The frequency limitations for this code apply regardless of the reason for the service. Therefore, we decided that the Plan does not have to 
pay for the comprehensive oral evaluation (code D0150) you received on February 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve osseous surgery (D4260) provided by an out-of-network 
provider. 
 
You asked the Plan to pre-approve osseous surgery. You say that you would like the Plan to re-authorize these 
services. The Plan denied your request. The Plan says the requested dental service 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. 
 
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 
osseous surgery (D4260) provided by an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a tier exception for Synvisc-One. 
 
You asked the Plan to pre-approve a tier exception. You say that you do not have the money to pay for the 
drug. The Plan denied your request. The Plan says tier exceptions are not available for Part B drugs. 
 
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 20% 
coinsurance for Medicare Part B prescription drugs.  
 
The approved drug falls within the Medicare Part B prescription drugs benefit category. This means that the 
coinsurance is 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 pre-approve a tier exception for Synvisc-One.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removal of torus mandibularis (D7473). 
 
You asked the Plan to pre-approve removal of torus mandibularis. You say that this service is necessary 
because you are experiencing denture friction. The Plan denied your request. The Plan says removal of torus 
mandibularis (D7473) 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 pre-approve 
removal of torus mandibularis (D7473).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services provided on October 4, 2021. 
 You asked the Plan to pay for the genetic testing services. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says this claim has not been billed in 
accordance with Medicare coding regulations. 
 
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 looked at the file and Medicare rules. In this case, the services provided should have been billed as a single 
procedural service. Based on this information, we decided that Medicare rules for coverage of the genetic 
testing services have not been met. Therefore, we decided that the Plan does not have to pay for the genetic 
testing services provided on October 4, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services provided on October 23, 2021. 
 
You asked the Plan to pay for the genetic testing services. You say that you would like this claim reprocessed 
based on the medical documentation. The Plan denied your request. The Plan says the documentation does not 
support the services as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that panels of tests that include the FANCC gene are 
non-covered. 
 
We looked at the file and Medicare rules. Review of the file shows that the next generation sequence testing 
panel included testing for the FANCC gene. This means this entire panel is not covered. Based on this 
information, we decided that Medicare rules for coverage of the genetic testing services have not been met. 
Therefore, we decided that the Plan does not have to pay for the genetic testing services provided on October 
23, 2021.