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

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) and a periapical first film 
(D0220) provided on April 27, 2023.  
 
You asked the Plan to pay for the dental services. You say that you were in pain, and you needed to see a 
specialist for it. The Plan denied your request. The Plan says your benefit for the requested items or services 
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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows the Plan paid for a limited oral evaluation (D0140) and a periapical first film (D0220) on April 4, 2023; 
therefore, your benefit for the requested items or services was exhausted on the date of service of April 4, 2023. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) and a periapical 
first film (D0220) provided on April 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 31255 billed for date of service December 
13, 2022. 
 
You asked the Plan to pay for procedure code 31255. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment for code 31255 is bundled into 
payment for code 31276. 
 
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 31255 
is a column II code to column I code 31276. 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 31255 billed for date of service December 13, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the local anesthesia (D9215) provided on April 20, 2023. 
 
You asked the Plan to pay for the dental service. You say that the anesthesia was required to perform the dental 
procedure. The Plan denied your request. The Plan says the denial of payment for this service is correct, 
because the local anesthesia is not 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the local 
anesthesia (D9215) provided on April 20, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the periodontal scaling and root planing (D4342) for 2 
quadrants provided by an out-of-network provider on January 24, 2023. 
 

You asked the Plan to pay more for the dental services. You say that you thought you were using an in-network 
provider and you would have gone to a different provider if you knew they were out-of-network. The Plan 
denied your request. The Plan says you are responsible for any charged amount above the Plan's cost-sharing 
amount when your services are received from an out-of-network provider. Also, the proper cost share was 
applied. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
The total billed amount for the first periodontal scaling and root planing was $253 and the allowed amount was 
$81 leaving a difference of $172 ($253 billed - $81 allowed). The total coinsurance amount was $60.75 ($81 
allowed x 75% coinsurance). The total billed amount for the second periodontal scaling and root planing was 
$253 and the allowed amount was $81 leaving a difference of $172 ($253 billed - $81 allowed). The total 
coinsurance amount was $60.75 ($81 allowed x 75% coinsurance). The total difference amount for both dental 
services was $344 ($172 difference + $172 difference). The total coinsurance amount for both dental services 
was $121.50 ($60.75 coinsurance + $60.75 coinsurance). Your total liability for both dental services was 
$465.50 ($344 total difference amount + $121.50 total coinsurance amount). 
 
You have been asked to pay a 75% coinsurance amount and the difference between the out-of-network 
provider's charges and the Plan's payment. 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 pay more for the 
periodontal scaling and root planing (D4342) for 2 quadrants provided by an out-of-network provider on 
January 24, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for code 99215 billed for date of service May 23, 2022. 
 
You asked the Plan to pay for code 99215. You say that this service was billed correctly and is a covered 
service. The Plan denied your request. The Plan says that it didn't render a decision within the allotted 
timeframe. 
 
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. In this case, the Plan has failed to provide any specific argument as to why your 
service has been denied.  The Plan has failed to provide a citation upon which its denial was based.  The burden 
is on the Plan to show why its denial was correct.  By failing to provide any supporting arguments or 
documentation that would justify its denial, we find that the Plan has not met this burden. Therefore, we 
decided that the Plan has to pay for code 99215 billed for date of service May 23, 2022.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the records provided support the 
services. The Plan denied your request. The Plan says the enrollee is receiving appropriate in-patient 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 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 it appears that the enrollee is responding to current treatment and should only require 
short-term additional acute care services that can safely be provided at the current facility until more stable and 
appropriate for transfer to a lower level of care soon. Transfer to the LTACH is not medically necessary as it would not be clinically advantageous 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on April 6, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the physician service. You say that this was medically necessary. The Plan 
denied your request. The Plan says 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 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 the office visit provided on April 6, 2023, by an 
out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Transcutaneous Electrical Nerve Stimulators (TENS) 
supplies (A4595), purchased on October 5, 2022. 
 
You asked the Plan to pay for the TENS supplies. You say that the item should be covered. The Plan denied 
your request. The Plan says this item is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that separate allowance will be made for replacement 
supplies when they are reasonable and necessary and are used with a covered TENS. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the TENS supplies. Our reviewer says that 
the item was not medically necessary. Our physician reviewer found the enrollee does not have a Medicare 
approved TENS device as it is not medically necessary for chronic low back 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 TENS supplies have not been met. Specifically, the enrollee does not have a 
covered TENS. Therefore, we decided that the Plan does not have to pay for the Transcutaneous Electrical 
Nerve Stimulators (TENS) supplies (A4595), purchased on October 5, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continued skilled nursing facility stay. 
 
You asked the Plan to pre-approve the continued skilled nursing facility stay. You say that the enrollee's 
inability to show progress in facility care due to unresponsiveness during active divorce proceedings is cause 
for continued skilled nursing stay after April 1, 2023. The Plan denied your request. The Plan says the enrollee 
has now reached the 100 Day Skilled Benefit Exhaust. 
 
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 March 3, 2023, 
to July 16, 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 pre-approve the continued skilled nursing facility stay.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for panoramic radiographic image (D0330) provided on March 
24, 2023. 
 
You asked the Plan to pay for the dental services. You say that you do not agree with the denial of payment for 
the services you received. 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. This benefit includes the 
requested panoramic radiographic image but is limited to one procedure code every five calendar years for 
complete series or panoramic film. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows you received covered panoramic radiographic image on date of service July 8, 2022. Therefore, this 
benefit has been exhausted on date of service July 8, 2022. Therefore, we decided that the Plan does not have to 
pay for panoramic radiographic image (D0330) provided on March 24, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection (E2311), harness (E2313), 
expandable controller (E2377), reach system (K0108), gel foot plate cover (K0108), a group 3 standard power 
wheelchair (K0861), and additional items and accessories (codes E2363, E2300, E1007, E2620, E2624, E1012, 
E0957, E0955, E0960, and E1028 x3). 
 
You asked the Plan to pre-approve an electronic connection, harness, expandable controller, reach system, and 
gel foot plate cover. You say that the enrollee is not required to meet all three of the listed coverage criteria, but 
is only required to meet one of the three requirements. The Plan denied your request. The Plan says although 
there are three requested power options (tilt, recline and elevating leg rests), there is not a medical need to 
control these power options through the joystick. The Plan also says the reach system and gel foot plate cover 
do not serve medical purposes and cannot be covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that for equipment to be covered, it must primarily serve a 
medical purpose. 
 
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 an electronic connection, harness, and 
expandable controller. Our reviewer says that the electronic connection, harness, and expandable controller are 
not considered medically reasonable and necessary in this case. Our physician reviewer found the requested 
electrical accessories are not medically necessary as the enrollee does have use of the upper extremity and can 
operate and control the power options using the switches that are included in the basic wheelchair.  

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an electronic connection, harness, expandable controller, reach system, and gel 
foot plate cover have not been met. The reach system and gel foot plate cover at issue in this appeal do not 
serve a purpose that is primarily medical in nature. These items are 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 an electronic connection (E2311), harness (E2313), expandable controller (E2377), reach system 
(K0108), gel foot plate cover (K0108), a group 3 standard power wheelchair (K0861), and additional items and 
accessories (codes E2363, E2300, E1007, E2620, E2624, E1012, E0957, E0955, E0960, and E1028 x3).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lower partial denture (D5213). 
 
You asked the Plan to pre-approve this dental item. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says this dental item 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested item is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a lower partial 
denture (D5213).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing billed for date of service December 14, 2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says one code must 
be billed for the panel. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
The file shows that a comprehensive gene panel was billed with multiple codes, including CPT code 81351. 
The panel testing was not billed with a single code as required. Based on this information, we decided that 
Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan does 
not have to pay for the lab testing billed for date of service December 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on 
November 22, 2022. 
 
You asked the Plan to pay for the dental service. You say that you were not aware of any 6-month waiting 
period and the service should be covered by the Plan. 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows the Plan paid for a periodic oral evaluation (D0120); therefore, your benefit for the requested item or 
service was exhausted on the date of service of November 22, 2022. Therefore, we decided that the Plan does 
not have to pay for a comprehensive oral evaluation (D0150) provided on November 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has chronic respiratory failure from chronic obstructive pulmonary disease (COPD). The records indicate he was successfully treated 
with bi-level positive airway pressure (BiPAP) therapy. The records do not contain sufficient detailed 
information to justify the use of a home ventilator. Failure of BiPAP with average volume-assured pressure 
support (AVAPS) is not documented. The criteria for coverage are not met and the home ventilator is therefore 
not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the SNF services you are requesting 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 not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does require skilled nursing or skilled therapy services that require the 
specialized skill, knowledge, and judgement of a skilled professional nurse or therapist. The enrollee does not 
require skilled services on a daily basis. The enrollee does not require skilled services on an inpatient basis in a 
SNF setting. 
 
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 skilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee meets full IRF level of care criteria, and 
the lower level of care of a home discharge cannot provide the total interdisciplinary approach needed. You 
would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the 
enrollee does not meet Medicare guidelines for services in an IRF.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the documentation does not support the necessity for admission to an IRF. The 
complexity of the enrollee's medical, rehabilitation, and nursing needs does not require an acute hospital 
inpatient rehabilitation stay with an interdisciplinary approach to rehabilitative care. The enrollee's 
rehabilitation needs can be safely provided in an alternate and low intensity setting such as in an SNF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an IRF admission and services.