Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing. 
 You asked the Plan to pre-approve the requested testing. You say that the test is clinically indicated. The Plan 
denied your request. The Plan says the enrollee does not meet the coverage criteria. 
 
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 testing. Our physician 
reviewer found that the enrollee has left hip pain that radiates into her left groin and left lower quadrant of her 
abdomen, as well as worsening pancytopenia seen on outpatient labs. Bone marrow core biopsy showing acute 
myeloid leukemia (AML). There is no documentation in the clinical notes provided to detail the information 
required to see if the criteria are met at this point. Therefore, the request 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 testing have not been met. Therefore, we decided that the Plan 
does not have to pre-approve genetic testing.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the maxillary partial denture - cast metal framework with 
resin denture bases (D5213) provided on September 15, 2023. 
 
You asked the Plan to pay for the dental service. You say that you are not satisfied with how the denture looks 
and feels, and you are embarrassed to smile because of the appearance of your teeth. You also say that it hurts 
when you eat and there are gaps between your teeth where food gets stuck  The Plan denied your request. The 
Plan says your benefit for the requested 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 service was exhausted on date of service July 30, 2019. Therefore, we 
decided that the Plan does not have to pay for the maxillary partial denture - cast metal framework with resin 
denture bases (D5213) provided on September 15, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom fabricated abutment (D6057 x3) and an 
abutment supported porcelain/ceramic crown (D6058 x3). 
 
You asked the Plan to pre-approve the dental services. You say that you have diabetes and need the services. 
The Plan denied your request. The Plan says these services are not covered under your dental 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 
custom fabricated abutment (D6057 x3) and an abutment supported porcelain/ceramic crown (D6058 x3).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric treatment. 
 
You asked the Plan to pre-approve inpatient psychiatric treatment. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric treatment. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found based upon review 
of the records provided the enrollee does not meet the criteria for January 8, 2024 forward as this enrollee was 
not shown to be a danger to herself or others. There were no delusions noted. The nursing note showed no 
auditory or visual hallucinations although the progress note showed the enrollee to be calling out the puppies 
although no medication changes were made. She was cooperative/compliant with treatment while not showing 
any threats the safety. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric treatment have not been met. Therefore, we decided that 
the Plan does not have to pre-approve inpatient psychiatric treatment.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on September 26, 2022, billed 
with codes 81225, 81226, 81227, 81231, 81232, 81240, 81241, 81291, 81306, 81328, 81335, and 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says panel testing should be billed using one 
CPT code on the claim. 
 
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 was an NGS panel that 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 
September 26, 2022, billed with codes 81225, 81226, 81227, 81231, 81232, 81240, 81241, 81291, 81306, 
81328, 81335, and 81479.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) 
provided on September 29, 2023. 
 
You asked the Plan to pay for the limited oral evaluation. You say that you are appealing the denial because it 
concerns tooth #17 that you have had trouble with since June 6, 2023. You also say that you were referred to an 
endodontist who performed an evaluation and then you went to another provider who also performed an oral 
evaluation. The Plan denied your request. The Plan says your benefit for the limited oral evaluation has already 
been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested service was exhausted on dates of service June 21, 2023, and June 30, 
2023. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation - problem 
focused (D0140) provided on September 29, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the guided tissue regeneration, natural teeth - resorbable 
barrier, per site teeth 6 and 12 (D4266). 
 
You asked the Plan to pre-approve the guided tissue regeneration. You say that this service is medically 
necessary. The Plan denied your request. The Plan says the provider has coded for guided tissue regeneration 
with an inappropriate code for teeth 6 and 12.  

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 Plan covers the guided 
tissue regeneration when the services are medically necessary and reasonable.  
 
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 guided tissue regeneration. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found included was a full  
mouth series of x-rays that show that there are no teeth in the upper jaw. There is also a notation on the x-rays 
that state "no upper teeth to show please reprocess". Based on the information provided, D4266 is not 
medically reasonable or necessary as the criteria for this procedure has not been met. Per the American Dental 
Association coding guidelines, D4266 is performed around a  natural tooth. There are other codes that are more 
applicable for placing a resorbable barrier in the area where there is no longer a tooth present. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the guided tissue regeneration have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the guided tissue regeneration, natural teeth - resorbable barrier, per site 
teeth 6 and 12 (D4266).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the extraction, erupted tooth or exposed root (D7140) 
provided on January 26, 2023. 
 
You asked the Plan to pay more for the dental service. You say that you received a bill from a dental service for 
an extraction you received on January 26, 2023. You also say that you called to request information about a 
provider and the information was delivered incorrectly as this provider is out-of-network because you are being 
billed for the service received. The Plan denied your request. The Plan says you are responsible for any charged 
amount above the Plans cost-sharing amount when your services are received from an out-of-network 
provider.  
 
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.  
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
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 extraction, erupted tooth or exposed root 
(D7140) provided on January 26, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair.  
 
You asked the Plan to pre-approve a shower chair. You say that this item is a medical necessity. The Plan 
denied your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the palliative treatment of dental pain (D9110) and cone 
beam computed tomography (CT) capture and interpretation with limited field of view (D0364) provided on 
August 10, 2023. 
 
You asked the Plan to pay for the palliative treatment of dental pain and cone beam CT capture and 
interpretation. You say that you believe these services should be covered under your medical plan because you 
were referred to a dentist following a hip replacement to make sure you did not have an infected or cracked 
tooth. The Plan denied your request. The Plan says the services you received are not considered medical and 
were billed as dental procedures performed by a dentist therefore, they cannot be considered as medical. 
 
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 services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or 
services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pay for the palliative treatment of dental pain (D9110) and cone beam computed tomography (CT) capture and 
interpretation with limited field of view (D0364) provided on August 10, 2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the in home and inpatient care services provided on June 1, 
2023, to June 30, 2023. You asked the Plan to pay for the in home and inpatient care services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the in home and inpatient care services provided on June 1, 
2023, to June 30, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment without transport 
services received on September 22, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment without transport services. You say that 
the services were medically necessary due to your blood sugar but after treatment you declined transport. The 
Plan denied your request. The Plan says without transport services there is no payable service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on September 22, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment without 
transport services received on September 22, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the procedure codes 71046, Q0092, 93005 and R0070 
provided on August 18, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the procedure codes 71046, Q0092, 93005 and R0070. You say that the services 
were medically necessary, and you did not have time to get a prior authorization. The Plan denied your request. 
The Plan says the services were not medically necessary. Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the procedure codes 71046, Q0092, 93005 and 
R0070 provided on August 18, 2023, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation services. 
 
You asked the Plan to pre-approve the additional routine transportation services. You say that the additional 
transportation is necessary for you to get to your appointments. The Plan denied your request. The Plan says 
the yearly benefit maximum has been met for the calendar year. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation services.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital discharge services provided on May 24, 2022. 
 You asked the Plan to pay for the hospital discharge services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the hospital discharge services provided on May 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve interim crowns (D2799 x2). 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing the denied services. The 
Plan denied your request. The Plan says the requested dental procedure cannot be used in the billing of 
temporary crowns. The Plan says the temporary crowns are services included in the allowance of the permanent 
crowns. 
 
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 
interim crowns (D2799 x2).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on July 
29, 2023. 
 
You asked the Plan to pay for the ED services. You say that you would like this claim to be processed. The 
Plan denied your request. The Plan says Medicare payment cannot be made to this type of provider. 
 
The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare and 
cannot receive payment for services.  
 
 
 
 We looked at the file and Medicare rules. We find that the provider at issue is not affiliated with a hospital and 
cannot receive Medicare payment.  Therefore, we decided that the Plan does not have to pay for the emergency 
department (ED) services provided on July 29, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the heart with 
evaluation of blood vessel calcium. 
 
You asked the Plan to pre-approve the CT scan of the heart. You say that the services are medically necessary. 
The Plan denied your request. The Plan says the services are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that all services that are medically necessary are 
covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the CT scan of the heart have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a computed tomography (CT) scan of the heart with evaluation of blood vessel calcium.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor (CGM), supplies and 
accessories provided on June 23, 2023. 
 
You asked the Plan to pay for the CGM, supplies and accessories. You say that you have submitted proof of 
delivery along with other supporting documentation, but the claim keeps denying for missing this information. 
The Plan denied your request. The Plan says the provider is not a plan contract provider and is not enrolled in 
Medicare as a durable medical equipment supplier. 
 
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 continuous glucose monitor (CGM), 
supplies and accessories provided on June 23, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment without transport 
services received on October 26, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment without transport services. You say that 
you refused transport and don't understand why you must pay so much. The Plan denied your request. The Plan 
says without transport there is no payable service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on October 26, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment without 
transport services received on October 26, 2023.