Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infusion services (96365, 96366) and pump maintenance 
(96521) billed for date of service May 10, 2023. 
 
You asked the Plan to pay for infusion services and pump maintenance. You say that these services were billed 
correctly. The Plan denied your request. The Plan says these services are not supported in the records. 
 
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 96365 is intravenous infusion, for therapy, prophylaxis, 
or diagnosis (specify substance or drug); initial, up to 1 hour. The definition of code 96366 is intravenous 
infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour (List 
separately in addition to code for primary procedure). The definition of code 96521 is refilling and maintenance 
of portable pump.  
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 infusion services and pump maintenance. Our reviewer says 
that these codes are not supported. Our reviewer found the medical records provided indicate outpatient 
intravenous insulin treatment was performed. There is a more appropriate code for this service than codes 
96365 and 96366. Although the documentation includes a physician order for refilling and maintenance of 
portable pump, documentation does not support service was performed to support 96521. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of infusion services and pump maintenance have not been met. Therefore, we 
decided that the Plan does not have to pay for infusion services (96365, 96366) and pump maintenance (96521) 
billed for date of service May 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infusion services (96365, 96366), insulin (J1817), and pump 
maintenance (96521) billed for date of service February 27, 2023. 
 
You asked the Plan to pay for infusion services, insulin, and pump maintenance. You say that these services 
were billed correctly. The Plan denied your request. The Plan says these codes are not supported. 
 
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 96365 is intravenous infusion, for therapy, prophylaxis, 
or diagnosis (specify substance or drug); initial, up to 1 hour. The definition of code 96366 is intravenous 
infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour (List 
separately in addition to code for primary procedure). The definition of code J1817 is insulin for administration 
through durable medical equipment (i.e., insulin pump) per 50 units. The definition of code 96521 is refilling and maintenance of portable pump. 
 
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 infusion services, insulin, and pump maintenance. Our 
reviewer says that these codes are not supported. Our reviewer found the medical records provided indicate 
outpatient intravenous insulin treatment was performed. There is a more appropriate code for this service than 
codes 96365 and 96366. The medical records also state that Nova R was administered via intravenous 
treatment. J1817 is not the appropriate code to represent this service. Although the documentation includes a 
physician order for refilling and maintenance of portable pump, documentation does not support this service 
was performed to support 96521. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of infusion services, insulin, and pump maintenance have not been met. Therefore, 
we decided that the Plan does not have to pay for infusion services (96365, 96366), insulin (J1817), and pump 
maintenance (96521) billed for date of service February 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120) provided on May 10, 
2023. 
 
You asked the Plan to pay for the dental services. You say that you have no problem with limiting coverage to 
two treatments by the same dentist each plan year. You also say that however, limiting coverage to first come 
first paid does not promote proper dental care. 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 April 25, 2023. Therefore, we decided that the Plan does not have to pay for a periodic oral evaluation (D0120) provided on 
May 10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a retainer crown (D6750) for tooth #15. 
 
You asked the Plan to pre-approve D6750. You say that you need this dental work. 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 with the approval of retainer crowns for 
tooth #11, #12, #13, and #14. Therefore, we decided that the Plan does not have to pre-approve a retainer 
crown (D6750) for tooth #15.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom fabricated abutment  includes placement 
(D6057) and abutment supported porcelain/ceramic crown (D6058). 
 
You asked the Plan to pre-approve the custom fabricated abutment and abutment supported porcelain/ceramic 
crown. You say that these are crowns to be placed on top of an implant that is already in place. You also say 
that the crown, regardless of if it is placed on an actual or implant tooth should be cover per your benefits. The 
Plan denied your request. The Plan says you are only covered for the dental services, codes and limits listed in 
the medical benefits chart. 
 
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  includes placement (D6057) and abutment supported porcelain/ceramic crown 
(D6058).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for interphalangeal joint dislocation treatment (28660) billed for 
date of service February 22, 2023. 
 
You asked the Plan to pay for interphalangeal joint dislocation treatment. You say that this is supported in the 
records. The Plan denied your request. The Plan says this was not billed correctly. 
 
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 28660 is closed treatment of interphalangeal joint 
dislocation; without anesthesia. 
 
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 interphalangeal joint dislocation treatment. Our reviewer says that this code is not supported. Our reviewer found the procedure report describes digital block, and 
treatment for dislocation of great toe, so the billed procedure cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of interphalangeal joint dislocation treatment have not been met. Therefore, we 
decided that the Plan does not have to pay for interphalangeal joint dislocation treatment (28660) billed for date 
of service February 22, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation, intraoral x-ray, 2D oral/facial 
photographic image (D0140, D0220, D0350) provided on June 12, 2023. 
 
You asked the Plan to pay for the dental 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 do not fall 
within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 a limited 
oral evaluation, intraoral x-ray, 2D oral/facial photographic image (D0140, D0220, D0350) provided on June 
12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental fillings (D2330, D2391, D2392) provided on April 18, 
2023. 
 
You asked the Plan to pay for the dental 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 do not fall 
within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 dental 
fillings (D2330, D2391, D2392) provided on April 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical placement of implant body: endosteal implant 
(D6010), bone graft at time of implant placement (D6104), and extraction, erupted tooth requiring removal of 
bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210) provided 
on February 15, 2023. 
 
You asked the Plan to pay for the dental services represented by codes D6010, D6104 and D7210. You say that 
you would not have had the dentist do this work if it weren't for the $855, he estimated you would pay. The 
Plan denied your request. The Plan says you only have preventative and diagnostic dental services available. 
These services are not covered under your benefit package. 
 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 surgical 
placement of implant body: endosteal implant (D6010), bone graft at time of implant placement (D6104), and 
extraction, erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of 
mucoperiosteal flap if indicated (D7210) provided on February 15, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for FoundationOne Liquid Biopsy testing (0239U) provided on 
April 10, 2023. 
 
You asked the Plan to pay for FoundationOne Liquid Biopsy testing. You say that this was medically 
necessary. The Plan denied your request. The Plan says there is no reason the enrollee could not have had 
tissue-based testing. 
 
The Plan follows Medicare rules. Medicare rules say that Next Generation Sequencing (NGS) as a diagnostic 
laboratory test is reasonable and necessary as described in the 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 pay for FoundationOne Liquid Biopsy testing. Our 
reviewer says that this testing was not medically necessary. Our physician reviewer found although liquid 
biopsies are often used, they are recommended when there is insufficient tissue for testing and the National 
Comprehensive Cancer Network (NCCN) Guidelines state that ell-free/circulating tumor deoxyribonucleic acid 
(DNA) testing should not be used in lieu of a histologic tissue diagnosis. There is no records to explain why 
tissue-based testing could not be performed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of FoundationOne Liquid Biopsy testing have not been met. Therefore, we decided 
that the Plan does not have to pay for FoundationOne Liquid Biopsy testing (0239U) provided on April 10, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic radiographic image (D0330) provided on May 
10, 2023. 
 
You asked the Plan to pay for the dental services. You say that after experiencing many days of extreme jaw 
pain, you were examined by your dentist. You also say that a panoramic radiographic image is instrumental for 
accuracy needed for a complete and thorough diagnosis. 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 January 5, 2023. 
Therefore, we decided that the Plan does not have to pay for a panoramic radiographic image (D0330) provided 
on May 10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bitewing  single radiographic image (D0270) provided on 
May 4, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should 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 January 23, 2023. 
Therefore, we decided that the Plan does not have to pay for bitewing  single radiographic image (D0270) 
provided on May 4, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740) for tooth #9 and #11, and a core build 
up (D2950) for tooth #9. 
 
You asked the Plan to pre-approve D2740 and D2950. You say that this dental work is medically necessary. 
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 June 9, 2022, and July 1, 2022. Therefore, we decided that the Plan does not have to pre-approve a crown (D2740) for tooth #9 and #11, 
and a core build up (D2950) for tooth #9.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Stabili-teeth (implants) (D6999). 
 
You asked the Plan to pre-approve the implants. You say that you would really appreciate some sort of 
coverage for this type of procedure. You also say it would allow you to eat properly, help your gums to stop 
bleeding and digest your food properly. The Plan denied your request. The Plan says dental implants are 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 service is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve Stabili-teeth 
(implants) (D6999).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the care necessary to properly care for 
the enrollee cannot be provided to them at a level of care outside of a LTACH. The Plan denied your request. 
The Plan says the coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee appears to still be somewhat unstable and should only require short-
term acute care services that can safely be completed at the current facility until more stable and appropriate for  
 transfer. The enrollee does not require services at the LTACH that are not already available at the current 
facility.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
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 enrollee is at high risk of a hospital readmission. 
The Plan denied your request. The Plan says that the SNF services requested do not meet the requirements for 
approval. 
 
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 that the clinical documentation shows that the enrollee has had functional and clinical 
status change thus would be expected to require continued assessment by skilled therapy and skilled nursing. 
The documentation shows that the enrollee would be expected to require daily skilled services. From a practical 
standpoint, the clinical documentation supports daily skilled services on an inpatient basis in a skilled nursing 
facility are necessary. 
 
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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a core build-up (D2950). 
 
You asked the Plan to pre-approve D2950. You say that the crowns were approved, and these are part of the 
process. The Plan denied your request. The Plan says the denied 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 
core build-up (D2950).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for maxillary complete and mandibular dentures (D5110, 
D5214) provided on April 5, 2023. 
 
You asked the Plan to pay for maxillary complete and mandibular dentures. You say that this should be 
covered. The Plan denied your request. The Plan says this is not a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for maxillary 
complete and mandibular dentures (D5110, D5214) provided on April 5, 2023.