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

 
We decided that the Plan does not have to pay for prefabricated post and core in addition to crown (D2954), 
retainer crown - porcelain/ceramic(D6740), pontic - porcelain/ceramic (D6245), stress breaker (D6940), 
prophylaxis - adult (D1110), bitewings - four radiographic images (D0274), topical application of fluoride  
excluding varnish (D1208), periodic oral evaluation - established patient (D0120), and endodontic therapy, 
premolar tooth (excluding final restoration) (D3320) provided on May 24, 2022, to April 27, 2023. 
 You asked the Plan to pay for the dental services. You say that you were referred to a local dentist who dealt 
with prosthetic dental work. You also say that you were never told this provider was not in-network. 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 prefabricated post and core in addition to crown (D2954), retainer crown - 
porcelain/ceramic(D6740), pontic - porcelain/ceramic (D6245), stress breaker (D6940), prophylaxis - adult 
(D1110), bitewings - four radiographic images (D0274), topical application of fluoride  excluding varnish 
(D1208), periodic oral evaluation - established patient (D0120), and endodontic therapy, premolar tooth 
(excluding final restoration) (D3320) provided on May 24, 2022, to April 27, 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 
August 22, 2023. 
 
You asked the Plan to pay for the x-ray. You say that your dentist recommended you see a specialist due to 
pain and discomfort you are having in your upper jaw. You say you were advised by the specialist that an x-ray 
is required to determine what the issue may be. The Plan denied your request. The Plan says this service is not 
listed as 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 a 
panoramic radiographic image (D0330) provided on August 22, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on June 15, 
2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on June 15, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dupixent. 
 
You asked the Plan to pre-approve Dupixent. The Plan denied your request. The Plan says that self-
administered drugs do not fall under the Medicare Part B coverage. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Dupixent.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chair fabric (E1399), hemi-wheelchair (E1084), bedside 
rails (E0305), semi-electric hospital bed (E0260), sheets (A9270), and sales tax (S9999), purchased on June 5, 
2023. 
 
You asked the Plan to pay for the chair fabric, hemi-wheelchair, bedside rails, semi-electric hospital bed, 
sheets, and sales tax. You say that the items should be covered. The Plan denied your request. The Plan says 
This provider only accepts cash payment and does not bill insurance 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the chair fabric (E1399), hemi-
wheelchair (E1084), bedside rails (E0305), semi-electric hospital bed (E0260), sheets (A9270), and sales tax 
(S9999), purchased on June 5, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for panoramic radiographic images (D0330) provided on July 
18, 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 July 18, 2023. Therefore, 
we decided that the Plan does not have to pay for panoramic radiographic images (D0330) provided on July 18, 
2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics (L3000).  
 
You asked the Plan to pre-approve foot orthotics. You say that the enrollee does not wear a leg brace for he has 
a rod that was inserted internally that broke and slid down his leg. You also say that an orthopedic surgeon has 
added an internal slide plate with screws where he does not need to wear a brace, but his foot is not aligned 
completely and needs to be supported better. 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 you do not suffer from diabetic foot disease, and you do 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 (L3000).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the genicular nerve block. 
 
You asked the Plan to pre-approve the genicular nerve block. You say that the procedure is medically 
necessary. The Plan denied your request. The Plan says the genicular nerve block is not medically necessary. 
 
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 genicular nerve block. Our reviewer 
says that the genicular nerve block is not medically necessary. Our physician reviewer found that the enrollee 
has a history of right knee pain due to unilateral primary osteoarthritis. However, genicular nerve blocks and 
genicular nerve ablations are considered investigation and not medically necessary for the treatment of chronic 
knee pain. 
 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 genicular nerve block have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the genicular nerve block.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for the hospital services provided from July 13, 2023, to July 14, 2023. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says that a 
corrected claim is required. 
 
The Plan follows Medicare rules. Medicare rules say that providers must supply a liability notice if payment for 
services delivered to a Medicare beneficiary are to be reduced or terminated. 
 
We looked at the file and the rules.  The file does not show that the Plan provided notice that the services 
provided would not be covered. Failure to provide such notices when required means a provider will not be 
able to shift liability to a beneficiary. Under Medicare rules, this means the services provided is considered 
approved by the Plan. Therefore, we decided that the Plan has to pay for the hospital services provided from 
July 13, 2023, to July 14, 2023.  
 
 
 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: Unfavorable

 
We decided that the Plan does not have to pay for lab testing (G0483) provided on May 18, 2023. 
 
You asked the Plan to pay for the lab testing. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed service. 
 
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 G0483 is drug testing, definitive, 22 or more drug 
classes. 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, the records do not show 
results for 22 or more drug classes. Based on this information, we decided that Medicare rules for coverage of 
the lab testing have not been met. Therefore, we decided that the Plan does not have to pay for lab testing 
(G0483) provided on May 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for limited oral evaluation (D0140) and 
intraoral - periapical first radiographic image (D0220), inhalation of nitrous oxide/analgesia, anxiolysis 
(D9230), crown - porcelain/ceramic (D2740) and core buildup (D2950) provided on July 17, 2023. 
 
You asked the Plan to waive the coinsurance for a limited oral evaluation and intraoral - periapical first 
radiographic image. You say that this should be covered. The Plan denied your request. The Plan says this cost 
sharing was charged correctly. Inhalation of nitrous oxide/analgesia, anxiolysis, crown - porcelain/ceramic, and 
core buildup are not covered services. 
 
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 30% 
coinsurance for out of network dental services.   
You have been asked to pay 30% coinsurance for a limited oral evaluation and intraoral - periapical first 
radiographic image. This item/service falls within the out of network 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. Inhalation of nitrous 
oxide/analgesia, anxiolysis, crown - porcelain/ceramic, and core buildup are not covered services. Therefore, 
we decided that the Plan does not have to waive the coinsurance for limited oral evaluation (D0140) and 
intraoral - periapical first radiographic image (D0220), inhalation of nitrous oxide/analgesia, anxiolysis 
(D9230), crown - porcelain/ceramic (D2740) and core buildup (D2950) provided on July 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81408, 81407, 81249, 81320, 81406, 81405, 
81404, 81345, 81403, 81305) provided on May 19, 2023. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel constitutes a single procedural service, so 
1 procedure code must be submitted for the panel. 
 
We looked at the file and Medicare rules. Multiple unbundled codes were billed for a single panel. Based on 
this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, 
we decided that the Plan does not have to pay for lab services (81408, 81407, 81249, 81320, 81406, 81405, 
81404, 81345, 81403, 81305) provided on May 19, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 11, 2023. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on July 11, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the SNF services provided from June 26, 2023, through July 
11, 2023. 
 
You asked the Plan to pay for the SNF services. You say that the SNF services were medically necessary. The 
Plan denied your request. The Plan says the enrollee has used all 100 days of covered care. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  The file shows that the enrollee received 100 days of SNF care during the benefit period from January 19, 
2023, to June 15, 2023. The Plan has covered 100 days of SNF care.  
 
Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has 
not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided 
that the Plan does not have to pay for the SNF services provided from June 26, 2023, through July 11, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service June 18, 
2023, to July 15, 2023. 
 
You asked the Plan to pay for procedure code S9328. You say that the services were authorized. 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 code. 
 
 We find that procedure code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service June 18, 2023, to July 15, 2023.
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 LTACH services. You say that LTACH level of care is the only option for a 
safe discharge for the enrollee due to the need for frequent nursing care, physician management, and 
intravenous (IV) antibiotics. The Plan denied your request. The Plan says the enrollee is receiving appropriate 
inpatient acute care and does not require transfer to a LTACH. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is receiving appropriate care in the acute care setting as provided by the 
Plan. The documentation received does not support that LTACH services are medically necessary at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of LTACH services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87798, 87641, 87496, 87511, 87529, 87532, 
87661, 87481, 87651, 87653) provided on March 30, 2023. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components regardless of the fact that the test reports multiple individual pathogens and/or targets. 
 
We looked at the file and Medicare rules. Multiple unbundled codes were billed for a single panel. Based on 
this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, 
we decided that the Plan does not have to pay for lab services (87798, 87641, 87496, 87511, 87529, 87532, 
87661, 87481, 87651, 87653) provided on March 30, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve aquatic physical therapy. 
 
You asked the Plan to pre-approve the requested services. You say that aqua therapy has been helping. The 
Plan denied your request. The Plan says land-based exercises have not been shown to be ineffective.  
 
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 requested services. Our physician 
reviewer found that you have been attending physical therapy and doing well with improved balance. 
Aquatic therapy can be beneficial in certain conditions, such as fibromyalgia or rheumatoid arthritis.  However, you are noted to have normal range of motion and no neurological deficits. It is unclear why you 
require aquatic therapy from a functional perspective or why you cannot participate in standard land based 
physical therapy given your medical diagnoses. Therefore, the aquatic therapy is not medically 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve aquatic physical therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the specialist office visit provided on June 08, 2023. 
 
You asked the Plan to pay for the specialist office visit. You say that you are requesting reconsideration of the 
denied claim since the provider as all your previous records. The Plan denied your request. The Plan says that 
unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the specialist office visit 
provided on June 08, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided the Plan does not have to pay for a mobility scooter purchased out of network on June 30, 2023.

You asked the Plan to pay for this purchase. You say that you purchased this equipment directly because the
provider does not submit to insurance. The Plan denied your request. The Plan says you purchased this
equipment out of network from a provider who does not participate with Medicare, and you did not have prior
authorization.

The Plan is correct in this case. 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 provider in this case is not a network provider with the Plan. The provider also is not an eligible Medicare
provider. The Plan had network providers available who could have provided the item at issue in this appeal.
The Plan did not pre-approve the item at issue. We found no exception that would require the Plan to pay for
this item. Therefore, we decided that the Plan does not have to pay for a mobility scooter purchased out of
network on June 30, 2023.