Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81238, 81220, 81226, 81335, 81230, 
81227, 81355, 81241, 81291, and 81240) provided on October 15, 2021. 
 You asked the Plan to pay for codes 81238, 81220, 81226, 81335, 81230, 81227, 81355, 81241, 81291, and 
81240. 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. 
Providers must report services with the appropriate CPT code. 
 
We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT code 81479. Therefore, we decided that the Plan does not have 
to pay for the laboratory services (81238, 81220, 81226, 81335, 81230, 81227, 81355, 81241, 81291, and 
81240) provided on October 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral periapical x-rays (codes D0220 and D0230) you 
received on September 23, 2021. 
 
You asked the Plan to pay for the intraoral periapical x-rays. You say that this claim was denied in error. The 
Plan denied your request. The Plan says periapical x-rays are not covered under 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. Your Plan's dental benefit 
includes coverage only for the following services: exams, bitewing x-rays, cleanings, fillings, and anesthesia.  
Periapical x-rays are not listed as covered under your dental benefit. 
 
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 x-rays (codes D0220 and D0230) you received on September 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on 
October 26, 2021. 
 
You asked the Plan to pay for the comprehensive oral evaluation. You say that you switched to a new dentist 
and the oral exam was necessary. The Plan denied your request. The Plan says your benefits for this service 
have been satisfied and the frequency limitation has been exceeded. 
 
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, comprehensive oral evaluation 
(D0150) and is limited to one procedure code every three years. The record shows that you received a 
comprehensive oral evaluation (D0150) on November 12, 2020 and your comprehensive oral evaluation 
(D0150) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the 
comprehensive oral evaluation (D0150) provided on October 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that the requested items are medically necessary. 
The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that the enrollee does not suffer from diabetic foot disease and the enrollee does not wear a leg 
brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of 
orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group two power wheelchair. 
 
You asked the Plan to pre-approve a group two power wheelchair. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says you do not meet criteria for the requested 
item. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
The file does not support that you can safely operate the PMD being requested. This means that Medicare rules 
for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
group two power wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that you fell while in the shower and had to be 
taken to the emergency room. You also say that you need this item to prevent any further falls or jeopardize 
your life. The Plan denied your request. The Plan says the requested service is not covered by Medicare or the 
Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergency ambulance transportation (A0428) and 
ground mileage (A0425) provided on January 3, 2022. 
 
You asked the Plan to pay for the non-emergency ambulance transportation and ground mileage. You say that 
this service was medically necessary. The Plan denied your request. The Plan says it does not say that the 
enrollee was bed bound. The Plan also says that transfer could have been provided with wheelchair transport. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the non-emergency ambulance 
transportation and ground mileage. Our reviewer says that transportation via ambulance from the hospital to the 
enrollees nursing facility was not medically necessary. Our physician reviewer found the enrollee did not 
require the expertise of trained personnel or the equipment available only on an ambulance in order to 
effectuate a safe transport. Our reviewer also found that transportation could have been provided by other 
means (stretcher van, wheelchair van) without endangering the enrollees condition. 
 
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 non-emergency ambulance transportation and ground mileage have not been 
met. Therefore, we decided that the Plan does not have to pay for the non-emergency ambulance transportation 
(A0428) and ground mileage (A0425) provided on January 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pontic and fixed bridge. 
 
You asked the Plan to pre-approve the pontic and fixed bridge. You say that these services are medically 
necessary. The Plan denied your request. The Plan says the requested services do not meet coverage criteria. 
 
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 the pontic and 
fixed bridge, but coverage is but is limited to anterior maxillary three unit bridges (one missing maxillary 
tooth), and anterior mandibular bridges up to four units (two missing adjacent mandibular teeth). Bridges will 
only be covered if no other teeth are missing in the same arch other than 3rd molars.  
 
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 pontic and fixed bridge. Our 
reviewer says that the fixed bridge is not medically necessary. Our physician reviewer found the documentation 
submitted does not meet the Plan's coverage criteria for a fixed bridge replacing missing tooth #24. 
 
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 the pontic and fixed bridge have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a pontic and fixed bridge.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance you received on January 24, 2022. 
 
You asked the Plan to pay for periodontal maintenance. You say that you have had this service in the past.  You 
said that neither you nor your dentist knew this was no longer covered. The Plan denied your request. The Plan 
says this service is not covered under 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. Your benefit explicitly 
excludes coverage for periodontal maintenance.  
 
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 
periodontal maintenance you received on January 24, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-emergency ambulance transportation. 
 
You asked the Plan to pre-approve non-emergency ambulance transportation. You say that you must be 
assisted to get out of your house and get to the appointment, get back home and get into the house. You also 
say that a special chair must be used to get you in and out the house. The Plan denied your request. The Plan 
says a doctor's office is not a covered location for this service. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 non-emergency ambulance 
transportation. Our reviewer says that transportation via ambulance to and from orthopedic follow-up 
appointments is not medically necessary. Our physician reviewer found you do not require the expertise of 
trained personnel or the equipment available only on an ambulance in order to effectuate a safe transport. Our 
reviewer found that transportation can be provided by other means (stretcher van, wheelchair van) without 
endangering your condition. Our physician reviewer also found that a prudent layperson would not believe that 
immediate medical attention is required for someone attending scheduled, follow-up appointments. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of non-emergency ambulance transportation have not been met. Therefore, we 
decided that the Plan does not have to pre-approve non-emergency ambulance transportation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ongoing negative pressure wound therapy (NPWT). 
 
You asked the Plan to pre-approve the therapy. You say that this should be paid for. The Plan denied your 
request. The Plan says you have exceeded four months of use. 
 
The Plan must follow Medicare rules. Medicare rules say that negative pressure wound therapy coverage will 
end when four months have elapsed using a pump in the treatment of the same wound. 
 
The records show that four months have elapsed of treatment on the same wound. Based on this information, 
we decided that Medicare rules for coverage of the therapy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve ongoing negative pressure wound therapy (NPWT).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the dental cleaning (D1110), bitewings-two 
radiographic images (D0272), and the topical application of fluoride varnish (D1206) provided on October 28, 2021. 
 
You asked the Plan to issue reimbursement. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not a covered benefit under 
your contractual policy. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to issue reimbursement for involve the care, treatment, filling, removal or 
replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not 
covered or paid for by Medicare.  Therefore, we decided that the Plan does not have to issue reimbursement for the dental cleaning (D1110), bitewings-two radiographic images (D0272), and the topical application of fluoride varnish (D1206) provided 
on October 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acupuncture services to be provided by a Licensed 
Acupuncturist (LAc). 
 
You asked the Plan to pre-approve the acupuncture services. You say that you would like reconsideration 
because the requested acupuncture is medically necessary, and this provider is the best in your area. The Plan 
denied your request. The Plan says Medicare does not cover acupuncture services provided by LAcs. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the record does not show that the requested provider is a physician, physician assistant, nurse practitioner/clinical nurse specialist or auxiliary personnel who will be 
under the supervision of a physician. Therefore, we decided that the Plan does not have to pre-approve 
acupuncture services to be provided by a Licensed Acupuncturist (LAc).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs IRF care. The Plan denied your 
request. The Plan says that IRF care is not medically necessary. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found that amputation is an IRF compliant diagnosis as the presumed rehabilitative, nursing and medical 
complexities generally warrant close medical monitoring and a multi-disciplinary approach to rehabilitation 
care. Clinical documentation supports that this enrollee warrants an inpatient stay with an interdisciplinary 
approach to rehabilitation care. Documentation supports that the enrollee would significantly benefit and be 
able to tolerate an intense rehabilitation plan of both physical therapy and occupational therapy. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on 
March 10, 2022. 
 
You asked the Plan to pay for the comprehensive oral evaluation. You say that you went to the dentist for a bi-
annual exam and teeth cleaning which is covered at the frequency of twice per year. You also say that this was 
your first visit to the dentist this year for an exam and cleaning. The Plan denied your request. The Plan says 
your benefits for this service have been satisfied and the frequency limitation has been exceeded. 
 
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, comprehensive oral evaluation 
(D0150) is limited to 1 procedure code every 3 calendar years. The record shows that you received a 
comprehensive oral evaluation (D0150) on May 27, 2021 and your comprehensive oral evaluation (D0150) 
benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive 
oral evaluation (D0150) provided on March 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the preventive procedure (D1999), periodic oral evaluation 
(D0120), and prophylaxis (D1110) provided on March 4, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the preventive procedure, periodic oral evaluation, and prophylaxis. You say that 
when you made this appointment you were told that they accepted your insurance plan and you had been there 
before. The Plan denied your request. The Plan says the preventive procedure is not a covered expense under 
your dental plan. The Plan also says that services performed by an OON provider are not covered because your 
healthcare plan does not have OON 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, unspecified preventive procedure 
(D1999) is not among those covered under this benefit. The contract also says that you are responsible for 
100% of the cost for dental services rendered by an OON provider. Therefore, we decided that the Plan does 
not have to pay for the preventive procedure (D1999), periodic oral evaluation (D0120), and prophylaxis 
(D1110) provided on March 4, 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 resin based composite (D2331) for tooth #8 provided on 
January 5, 2022. 
 
You asked the Plan to pay for the dental service. You say that the filling style that the dentist used is new. You 
say that they do not use the lead mercury amalgam anymore. You also say that a composite looks better and is 
stronger. The Plan denied your request. The Plan says the resin based composite for tooth # 8 was at the 
alternate benefit amount because the plan determined that a less expensive alternate procedure, service, or 
course of treatment can be performed in place of a proposed treatment to correct a dental condition. 
 
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 and fillings are listed as covered, they 
are paid based on the least expensive alternate procedure that can be performed to correct a dental condition. 
Additionally, there is a $100 deductible that is applied before the plan will make any payment towards the 
services you receive. The record shows that the Plan applied the $100 deductible to the filling for tooth # 8. 
Therefore, we decided that the Plan does not have to pay for the resin based composite (D2331) for tooth #8 
provided on January 5, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus gene panel provided on November 19, 2021. 
 
You asked the Plan to pay for the Tempus gene panel. You say that this testing was medically necessary for the 
enrollee's treatment. The Plan denied your request. The Plan says this is not billed correctly. 
 
The Plan must follow Medicare rules. Medicare 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 is an NGS testing panel billed with multiple codes on two 
separate claims. This is not appropriate billing. Based on this information, we decided that Medicare rules for 
coverage of the Tempus gene panel have not been met. Therefore, we decided that the Plan does not have to 
pay for the Tempus gene panel provided on November 19, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CxBladder detect test provided to the enrollee on 
November 10, 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 this is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that the current literature does not support the use of 
the CxBladder detect test. 
 
The denied test is not a covered benefit at this time. 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 pay for the 
CxBladder detect test provided to the enrollee on November 10, 2021.