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

 
We decided that the Plan does not have to pay for surgical repair of root resorption on tooth #21 (D3472) and 
does not have to pay the full amount for endodontic therapy on tooth #21 (D3320) provided on February 22, 2022. 
 You asked the Plan to pay for the dental services. You say that these services were needed to save your tooth. 
The Plan denied your request. The Plan says you have been charged the correct cost sharing amount. The Plan 
also says that surgical repair of root resorption (D3472) is not covered by your dental benefits. 
 
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 $50 
dental deductible for endodontic therapy. The contract also says that enrollees must pay 50% coinsurance for 
endodontic therapy after the dental deductible has been met. 
 
The dental deductible was not met at the time of service; therefore, $5 was applied to satisfy the deductible. 
The Plan has followed Medicare rules by clearly disclosing in the contract that there is $50 deductible which 
applies to endodontic therapy. This cost sharing is a contractual obligation that had not been met at the time the 
endodontic therapy was received on February 22, 2022.  
 
The allowed amount remaining after you paid your deductible is $681 ($731 original allowed amount - $50 
deductible paid = $681 remaining allowed amount). You have been asked to pay $340.50, which is 50% of the 
remaining allowed amount for endodontic therapy ($681 remaining allowed amount x 50% coinsurance = 
$340.50). Endodontic therapy falls within the Dental Services benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, surgical repair of root resorption 
(D3472) is not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pay for surgical repair of root resorption on tooth #21 (D3472) and does not have to pay the full amount for 
endodontic therapy on tooth #21 (D3320) provided on February 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 1, 2021, billed with 
codes 81206 and 81292. 
 
You asked the Plan to pay for the genetic testing billed. The Plan denied your request. The Plan says the 
services were billed incorrectly. 
 
The Plan must follow Medicare rules. The 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 testing was not billed with a single panel code as required. 
Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on March 1, 
2021, billed with codes 81206 and 81292.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the comprehensive pharmacogenomic testing.

You asked the Plan to pre-approve the laboratory services. You say that without taking medication it can endanger your life. You state your provider feels it is necessary due to the type of medication that you are taking. The Plan denied your request. The Plan says the Medicare rules have not been met.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. There is no documentation that a treating provider ordered these tests, you did not have any signs or symptoms to indicate these tests were medically necessary and the testing is not being used to manage or treat a specific medical problem or diagnosis. In addition, there is no indication you have met any of the Medicare criteria outlined for medical necessity of the testing, as there was no treating physician involved in the ordering of these tests. There is no documentation from the treating provider as to how the results of the testing would not directly impact your treatment. Therefore, we decided that the Plan does not have to pre-approve the comprehensive pharmacogenomic testing.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the $200 copayment for ambulance transportation on March 4,2022.
You asked the Plan to waive the $200 copayment for ambulance transportation. You say that you should not be
charged for transportation to a second facility. The Plan denied your request. The Plan says that copayment has
been applied 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 $200
copayment for Ambulance Services.
You have been asked to pay a $200 copayment for ambulance transportation. Ambulance transportation falls
within the Ambulance 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 $200 copayment
for ambulance transportation on March 4, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of the lumbar spine for the 
enrollee. 
 
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your 
request. The Plan says that there are no red flag indications for urgent MRI. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 the MRI. Our reviewer says that the 
requested MRI is medically reasonable and necessary. Our physician reviewer found that while there is no red 
flag such as absent reflex or weakness is present, the plan states that steroid usage including oral or IV is 
considered a valid reason for MRI. The enrollee has had a course of steroids and his symptoms have gotten 
worse. For that reason, the MRI is reasonable. 
 
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 MRI have been met. Therefore, we decided that the Plan has to pre-approve 
magnetic resonance imaging (MRI) of the lumbar spine for the enrollee.  
 
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: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the lab services provided on January 5, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for the lab services. You say that these services were ordered by the enrollee's 
physician. The Plan denied your request. The Plan says that the services were provided out-of-network and 
were not approved in advance. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan has not forwarded us information clarifying the network status of the 
referring physician in this case. Without this information we cannot determine if these services were plan 
directed care. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. Therefore, we decided that the Plan has to pay for the lab services provided on 
January 5, 2022, by an out-of-network (OON) provider.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the MyoPro 2, Motion G orthotic device (L8702). 
 
You asked the Plan to pay for the orthotic device. You say that the MyoPro is a covered device within the 
DME benefit category under Original Medicare. The Plan denied your request. The Plan says this item is 
considered experimental and investigational. There is insufficient evidence of its effectiveness. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the orthotic device have not been met. Therefore, we decided that the Plan does not have to pay for 
the MyoPro 2, Motion G orthotic device (L8702).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on 
January 25, 2022. 
 
You asked the Plan to pay for the dental services. You say that you did not know you could only have an oral 
exam every six months. 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 September 23, 2021. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) 
provided on January 25, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve SNF care. You say that SNF care is medically reasonable and necessary. 
The Plan denied your request. The Plan says rules for SNF care have 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 not medically reasonable and necessary. Our physician reviewer found the enrollee is an 
89-year-old female with a past medical history of hypertension and atrial flutter who presented to the acute 
hospital on July 25, 2022, with a fall resulting in pelvic and sacral fractures. In this case, there is no 
documentation that the patient requires skilled nursing services. The record does not document the need for 
intravenous medications, new tube feeding or ostomy care or daily complex wound care or respiratory care. 
While the enrollee does require skilled therapy services, these services are not required on a daily basis. The 
enrollee is walking household distances with a front wheeled walker with modified independence and is 
modified independent for transfers. Provided records do not document a significant decline in the enrollees 
functional status to necessitate daily inpatient skilled therapy 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuation of SNF care from August 2, 2022, forward. 
 
You asked the Plan to pre-approve SNF care. You say that you had had methicillin-resistant Staphylococcus 
aureus (MRSA) and have a large open wound that is still being treated. The Plan denied your request. The Plan 
says the stay is not medically necessary based on SNF criteria. 
 
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 physician reviewer 
found there is no documentation that you require the services on an inpatient basis, only in a SNF setting. 
Records do not document services in the home with home health care or in a long-term care facility on a part 
time basis are not appropriate in this case. 
 
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 continuation of SNF care from August 2, 2022, forward.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation feature (CPT code E2300) and 
reduced drive for elevating seat (K0108). 
 
You asked the Plan to pre-approve the items. You say that the items are not necessary. The Plan denied your 
request. The Plan says the items are not primarily medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.    
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a power seat elevation feature (CPT code E2300) and 
reduced drive for elevating seat (K0108).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service March 15, 
2022. 
 
You asked the Plan to pay for procedure code 76705. The Plan denied your request. The Plan says payment for 
code 76705 is bundled into payment for code 93976. 
 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 76705 
is a column II code to column I code 93976. 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 76705 billed for date of service March 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a standard manual wheelchair. 
 
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied 
your request. The Plan says the new wheelchair is not needed because of loss, theft, or irreparable damage. 
 
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 wheelchair. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that based on the medical records provided, there is no documentation that the requested new 
wheelchair meets Medicare criteria for medically reasonable and necessary. The provided records do not 
document that your present manual wheelchair has been lost, stolen, irreparably damaged or has surpassed its 
reasonable useful lifetime.  
 
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 wheelchair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a standard manual wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home PT/INR (provision of test materials and 
equipment for home INR monitoring of patient with either mechanical heart valve(s), chronic atria) testing 
supplies (G0249) 2 times a week.  
You asked the Plan to pre-approve a home PT/INR testing supplies. You say that your provider recommends 
testing once or twice each week for medical necessity. The Plan denied your request. The Plan says self-testing 
should not occur more than once a week. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Per the NCD, self-testing with the device should not occur more 
frequently than once a week. Based on this information, we decided that Medicare rules for coverage of a home 
PT/INR testing supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
home PT/INR (provision of test materials and equipment for home INR monitoring of patient with either 
mechanical heart valve(s), chronic atria) testing supplies (G0249) 2 times a week.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for topical application of fluoride (D1208) provided on 
December 13, 2021. 
 
You asked the Plan to pay for fluoride application. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says topical application of fluoride (D1208) is not covered by your 
dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for topical 
application of fluoride (D1208) provided on December 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for moderate sedation services provided to the enrollee on July 
6, 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 the place of service was inappropriate for this procedure. 
 
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 99153 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; each additional 15 minutes intraservice time (List 
separately in addition to code for primary service)." 
 
We asked our coder 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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the medical records do not 
properly document the use of CPT 99153. Where interservice time was 23 minutes with sedation, there is no 
documentation of what the provider did within that time in accordance with coding guidelines. 
 We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for moderate sedation services provided to the enrollee on July 6, 2021.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says that the stay is not medically necessary based on SNF criteria. 
 
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 physician reviewer 
found there is documentation that the enrollee requires the services on an inpatient basis in a SNF setting. The 
enrollee's baseline is reported as independent in their home with a walker or straight cane. The enrollee is 
presently only able to take a few steps with a walker with moderate assistance and is moderate to maximum 
assist for transfers and is supervision to maximum assist for activities of daily living. Provided records 
document a significant acute decline in the enrollees functional status compared to her recent baseline to 
necessitate daily inpatient skilled therapy 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 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 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.