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

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and a complete 
series of radiographic images (D0210) provided on June 2, 2022. 
 
You asked the Plan to pay for the dental services. You say that you received a denial for services that were 
already performed which you cannot afford. You say that you must get your gums taken care of so you can 
have knee replacement surgery. The Plan denied your request. The Plan says your benefit for the requested 
item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the comprehensive oral evaluation (D0150) and complete series of radiographic images 
(D0210) were exhausted on date of service January 20, 2021. Therefore, we decided that the Plan does not have 
to pay for a comprehensive oral evaluation (D0150) and a complete series of radiographic images (D0210) 
provided on June 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on May 5, 2022, to May 16, 2022. 
 
You asked the Plan to pay for the dental services. You say that the comprehensive services are covered under 
your dental 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 pay for the dental 
services on May 5, 2022, to May 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on May 21, 2021, to December 15, 2021. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. 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 dental services on May 21, 2021, to December 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 36247 billed for date of service May 27, 
2022. 
 You asked the Plan to pay for procedure code 36247. The Plan denied your request. The Plan says payment for 
code 36247 is bundled into payment for code 37224. 
 
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 36247 is a column II code to column I code 37224. 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 procedure code 36247 
billed for date of service May 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on December 15, 2021. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says one code must 
be submitted for the panel. 
 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 the gene panel testing was not billed with a single code as required. Based on this information, we 
decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that 
the Plan does not have to pay for the laboratory services provided on December 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal scaling and root planing (D4341) and drugs 
dispensed in the office for home use (D9630) provided on March 28, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says your benefit for periodontal scaling and root planing has already 
been exhausted. The Plan also says that drugs dispensed in the office for home use (D9630) are 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, certain limitations apply. The record 
shows your benefit for periodontal scaling and root planing was exhausted on date of service April 6, 2021, and 
April 13, 2021. Drugs dispensed in the office for home use are not among those covered under this benefit. 
Therefore, we decided that the Plan does not have to pay for periodontal scaling and root planing (D4341) and 
drugs dispensed in the office for home use (D9630) provided on March 28, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 27, 2022, to 
February 22, 2022. 
 
You asked the Plan to pay for the services provided. You say that the notice of admission was submitted at the 
same time as the final. The Plan denied your request. The Plan says the rules for payment have not been met. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We looked at the file and the rules. The file does not show that a notice of admission was submitted within 5 
days after the admission date. Based on this information, we decided that Medicare rules for coverage of the 
services provided have not been met. Therefore, we decided that the Plan does not have to pay for the home 
health services provided from January 27, 2022, to February 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility visit provided on March 10, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for nursing facility visit. You say that you are appealing the claim payment denial. 
The Plan denied your request. The Plan says the services were provided out-of-network and were not approved 
in advanced. 
 
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 nursing facility visit provided on March 10, 2022, 
by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee will benefit from IRF services, and it 
will allow them to optimize their level of functioning prior to returning home. The Plan denied your request. 
The Plan says the Medicare guidelines for IRF admission were not met and the enrollee can receive the 
services they need in another setting like 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 the clinical documentation shows that the enrollee has functional impairments 
and possibly an IRF compliant diagnosis however there are no active comorbidities that would require 
hospitalization during rehabilitation (only osteoporosis, hypokalemia and anemia documented). 
 
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 IRF admission and services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuation of stay at a SNF. 
 
You asked the Plan to pre-approve a continuation of stay at a SNF. You say that it is unsafe for you to return 
home and it is medically necessary to stay at the SNF. The Plan denied your request. The Plan says based on 
Medicare guidelines the enrollee no longer requires daily skilled services and it is not medically necessary to 
continue SNF care. The enrollee can safely receive the services they need at home with home health. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 continuation of stay at a SNF. Our 
reviewer says that the requested SNF care is not considered medically reasonable and necessary based on 
Medicare guidelines. Our physician reviewer found that the enrollee does not have documented skilled nursing 
needs. The enrollee does not have documented skilled therapy needs. The enrollee appears to have reached a 
plateau in function, being limited by his dementia. Daily skilled services are not required to establish a 
maintenance program or to prevent deterioration of the enrollees condition. The enrollees care needs, 
custodial and intermittent, can, as a practical matter, be provided at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a continuation of stay at a SNF.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for left hip replacement surgery provided on November 1, 2021, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for surgery. You say that you felt an urgency to have surgery, however your in-
network providers could not accommodate the timeframe you felt was appropriate. The Plan denied your 
request. The Plan says the enrollee scheduled the surgery a head of time with the out-of-area provider. The 
enrollee was notified prior to the surgery that it would not be covered under the Plan. It was noted the enrollee 
said they would pay out-of-pocket for the surgery. The Plan says they were working with the enrollee to help 
find a surgical date; however, the enrollee chose to go out of state. 
 
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 left hip replacement surgery provided on 
November 1, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care services provided on May 26, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for wound care services. You say that the services provided were medically 
necessary. 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 wound care services provided on May 26, 2022, 
by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan with 
concurrently acquired computed tomography (CT) scan. 
 
You asked the Plan to pre-approve a PET scan with CT scan. You say that the service is medically necessary. 
The Plan denied your request. The Plan says the service at issue is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
medically necessary.  
 
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 with CT scan. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found there has been no clinical or 
imaging finding to suggest occult malignancy which would be responsible for your symptoms and no equivocal 
or incomplete imaging or endoscopic findings suspicious for occult malignancy. 
 
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 with CT scan have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a positron emission tomography (PET) scan with concurrently acquired 
computed tomography (CT) scan.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on March 15, 2022. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the testing as a 
screening is 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 file shows that a tuberculosis skin test was provided. The test at issue in this appeal was requested solely 
for screening purposes. Medicare does not cover this test for screening purposes. Therefore, we decided that the 
Plan does not have to pay for the laboratory services provided on March 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the orthotic devices provided on May 31, 2022. 
 
You asked the Plan to pay for the orthotic devices. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says the provider did not order the items in 
question. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. Specifically, the medical records do not show that the provider discussed the medical need for the 
ordered equipment with the enrollee. Therefore, we decided that the Plan does not have to pay for the orthotic 
devices provided on May 31, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for a Prolia injection and the injection 
administration provided on May 12, 2022. 
 
You asked the Plan to waive the cost share for a Prolia injection and the injection administration. You say that 
you were told there would be no cost share. 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 20% 
coinsurance for Medicare Part B drugs. Your contract with the Plan also clearly says that you must pay a $300 
copayment for outpatient hospital visits.  
 
 You have been asked to pay $255.12 for a Prolia injection. You have also been asked to pay $2.76 for the 
injection administration, which is less than the standard $300 copayment. The total you owe is $257.88 
($255.22 + $2.76 = $257.88). The Prolia injection falls within the Medicare Part B prescription drugs benefit 
category. The injection administration falls within the outpatient hospital visits 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 Prolia injection and the injection administration provided on May 
12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on June 15, 2022, 
by an OON provider. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the enrollee could not choose an 
in-network provider due to COVID-19 pandemic as no other provider was allowed in the facility. The Plan 
denied your request. The Plan says the out-of-network services were not authorized. 
 
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 subsequent nursing facility care provided on June 
15, 2022, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown on tooth #15 (D2750), core build up on tooth #15 
(D2950), and a bitewing x-ray (D0270) provided on May 24, 2022. 
 
You asked the Plan to pay for the dental services. You say that this was an urgent situation, and you could not 
wait weeks for an appointment with your assigned dentist. 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 a crown on tooth #15 (D2750), core build up on tooth #15 (D2950), and a bitewing x-ray (D0270) 
provided on May 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom fabricated abutment (D6057) provided by a 
participating provider. 
 
You asked the Plan to pre-approve a custom fabricated abutment. You say that you need to finish the implant 
process because you are having a difficult time eating. 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 a 
custom fabricated abutment (D6057) provided by a participating provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oxygen and supplies (A0422) provided November 23, 2021. 
 
You asked the Plan to pay for the ambulance supplies. You say that you are appealing the claim payment 
denial. The Plan denied your request. The Plan says the cost of oxygen and supplies are included as part of the 
transport, therefore should not be billed separately. 
  The Plan must follow Medicare rules. Medicare rules say that ambulance supplies are considered part of the 
general ambulance service and payment for them is included in the payment rate for the transport. Therefore, 
we decided that the Plan does not have to pay for oxygen and supplies (A0422) provided November 23, 2021.