Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your 
request. The Plan says that based on the documentation provided, coverage criteria has not been met. 
 
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 SNF care. Our reviewer says that the 
requested SNF care is considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have documented skilled nursing or skilled therapy needs. The 
enrollee is functioning below her baseline. As such, the health plan has failed to support its denial. The health 
plan claims that the enrollee walked 120 on November 18, 2022, but no such records have been submitted for 
review. A period of daily skilled services is reasonably required to increase the enrollees strength and 
endurance, establish a maintenance program and/or prevent deterioration of 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 SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded as 82310, 82728, 83540, 83550 
and 84100 provided May 11, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that at this time there is no contractual 
agreement which indicates these tests should be included in the dialysis rate. Please reprocess the claims for 
payment as soon as possible. The Plan denied your request. The Plan says does not meet coding standards.  
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the laboratory services have been met. 
The records show that the Plan made multiple attempts to obtain the needed medical records from the provider 
without success. Therefore, we decided that the Plan does not have to pay for the laboratory services coded as 
82310, 82728, 83540, 83550 and 84100 provided May 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction, erupted tooth requiring removal of bone 
and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210) provided on 
August 1, 2022. 
 
You asked the Plan to pay for the surgical extraction. You say that your extraction was not done by an oral 
surgeon. The Plan denied your request. The Plan says this service is not covered under your 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 
extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of 
mucoperiosteal flap if indicated (D7210) provided on August 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chronic care management services (99490) provided on July 
28, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the chronic care management services. 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 were non-emergent and prior authorization was not obtained. 
 
  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 chronic care management services (99490) 
provided on July 28, 2022, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and services with no transport 
provided on August 17, 2022. 
 
You asked the Plan to pay for the ambulance response. You say that the enrollee made multiple calls due to 
having dementia but did not require transportation. The Plan denied your request. The Plan says this service is 
not covered when there is no transport. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 The ambulance company did not provide transport services on August 17, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
The trip report in this case shows that the enrollee refused transport to the hospital and thus the wavier criteria 
is not met. Therefore, we decided that the Plan does not have to pay for the ambulance response and services 
with no transport provided on August 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided by a participating 
provider on July 18, 2022. 
 
You asked the Plan to pay for the dental services. You say that you needed a crown re-cemented. You say that 
your dentist sent you to a specialist. You say that your crown was not fixed. 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 requested item or service was exhausted on date of service July 12, 2022. Therefore, 
we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided by a participating 
provider on July 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99053 billed for date of service November 4, 
2021.  You asked the Plan to pay for procedure code 99053. You say that the physician charge was for a separate 
diagnosis and the claim should be reviewed for reprocessing. The Plan denied your request. The Plan says 
procedure code 99053 is considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99053 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99053 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99053 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99053 billed for date of service November 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on May 16, 
2022. 
 
You asked the Plan to pay for the dental service. You say that it was recommended you have your tooth 
extracted when you returned home. You say that the dentist would not remove the tooth without an initial 
consultation. You also say that it was out of your control that the tooth needed to be extracted. The Plan denied 
your request. The Plan says your benefit for the limited oral evaluation 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 limited oral evaluation was exhausted on date of service May 10, 2022. Therefore, 
we decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on May 16, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 16, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for lab services. You say that labs were needed based on medical necessity and we 
are asking the plan to reconsider payment. The Plan denied your request. The Plan says there was no 
preauthorization by a primary care provider (this is different than a referral) for an out-of-network (OON) 
provider or facility, and this was not an emergency. Therefore, the decision is upheld. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for lab services provided on June 16, 2022, by an out-
of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes A9279, S1015, S8301, A4556, A4557, 
A4649, and 99072 billed for date of service March 1, 2022. 
 
You asked the Plan to pay for procedure codes A9279, S1015, S8301, A4556, A4557, A4649, and 99072. You 
say that the codes billed are not payable. The Plan denied your request. The Plan says the billed code is invalid 
for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure codes. 
 
We find that procedure codes A9279, S1015, and S8301 have a Status Indicator of I on the Physician Fee 
Schedule. This means that procedure codes A9279, S1015, and S8301 are not valid for Medicare purposes. 
 
We find that procedure codes A4556, A4557, and A4649 have a Status Indicator of P on the Physician Fee 
Schedule. This means that procedure codes A4556, A4557, and A4649 are not separately payable. 
 
We find that procedure code 99072 has a Status Indicator of B on the Physician Fee Schedule. This means code 
99072 is not separately payable. 
 
Based on this information, we decided that Medicare rules for coverage of procedure codes A9279, S1015, 
S8301, A4556, A4557, A4649, and 99072 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes A9279, S1015, S8301, A4556, A4557, A4649, and 99072 billed for date of 
service March 1, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for endoscopy provided on from July 6, 2022, 
to September 6, 2022. 
 
You asked the Plan to waive the coinsurance for endoscopy. You say that you disagree with the copayment. 
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 $325 
copayment for in-network outpatient hospital services.  
 
You have been asked to pay a $325 copayment for endoscopy. This item/service falls within the in-network 
outpatient hospital 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 coinsurance for endoscopy 
provided on from July 6, 2022, to September 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 24, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. 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 were non-
emergent and prior authorization was not obtained. 
 
  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 an office visit provided on May 24, 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 an unspecified adjunctive procedure (D9999), nitrous oxide 
(D9230), and an intraoral imaging (D0230), provided by an out-of-network provider on May 25, 2022, to June 
17, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were given a misquote. 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 an unspecified adjunctive procedure (D9999), nitrous oxide (D9230), and an intraoral imaging 
(D0230), provided by an out-of-network provider on May 25, 2022, to June 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental core buildup (code D2950) and a limited oral 
evaluation (code D0140) provided on June 22, 2022. 
 
You asked the Plan to pay for dental core buildup and a limited oral evaluation. You say that the dental were 
medically necessary. The Plan denied your request. The Plan says dental core buildup and a limited oral 
evaluation are not covered 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 services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for dental core 
buildup (code D2950) and a limited oral evaluation (code D0140) provided on June 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the retainer crown provided on August 10, 2022. 
 
You asked the Plan to pay for the retainer crown. You say that you feel that this should be covered. The Plan 
denied your request. The Plan says though discounts are available at a network provider for this service, this is 
not a service that is covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
retainer crown provided on August 10, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the bone marrow aspirate procedure. 
 
You asked the Plan to pre-approve the bone marrow aspirate procedure. You say that this procedure is 
medically reasonable and necessary. The Plan denied your request. The Plan says the clinical value and 
effectiveness of bone marrow aspirate in the setting of spinal fusion surgery have not been demonstrated in the 
peer-reviewed literature. 
 
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 the bone marrow aspirate procedure. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the bone marrow aspirate remains experimental. In this case, more 
research is needed before coverage can be approved.  
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 bone marrow aspirate procedure have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the bone marrow aspirate procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral - complete series of radiographic images provided 
on April 12, 2022. 
 
You asked the Plan to pay for dental services. You say that you were told there was no charge for this service. 
The Plan denied your request. The Plan says this service is not covered under your 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. Intraoral - complete series of 
radiographic images are not covered under the Plans dental benefits. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested intraoral - complete 
series of radiographic images are not among those covered under this benefit. Therefore, we decided that the 
Plan does not have to pay for intraoral - complete series of radiographic images provided on April 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), and panoramic 
radiographic imaging (D0330) provided by a participating provider on July 19, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for this. 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 requested item or service was exhausted on date of service November 2, 2021. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), and 
panoramic radiographic imaging (D0330) provided by a participating provider on July 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the full cost for a guided tissue regeneration - resorbable 
barrier, per site tooth #12, 13 (D4266), extraction, erupted tooth requiring removal of bone and/or sectioning of 
tooth, and including elevation of mucoperiosteal flap if indicated tooth #'s 12, 13 (D7210), bone replacement 
graft for ridge preservation - per site tooth #s 12, 13 (D7953), intraoral - periapical first radiographic image 
(D0220), intraoral - periapical each additional radiographic image (D0230), and 2D oral/facial photographic 
image obtained intra-orally or extra-orally (D0350) provided on July 28, 2022. 
 
You asked the Plan to pay for the full cost for the dental services. You say that the dental office told you that 
everything would be covered. 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 requested item or service was exhausted on date of service July 28, 2022. Therefore, 
we decided that the Plan does not have to pay for the full cost for a guided tissue regeneration - resorbable 
barrier, per site tooth #12, 13 (D4266), extraction, erupted tooth requiring removal of bone and/or sectioning of 
tooth, and including elevation of mucoperiosteal flap if indicated tooth #'s 12, 13 (D7210), bone replacement 
graft for ridge preservation - per site tooth #s 12, 13 (D7953), intraoral - periapical first radiographic image 
(D0220), intraoral - periapical each additional radiographic image (D0230), and 2D oral/facial photographic 
image obtained intra-orally or extra-orally (D0350) provided on July 28, 2022.