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

We decided that the Plan does not have to pre-approve a consultation (D9310) and 2 extractions (D7210) with 
an oral surgeon. 
 
You asked the Plan to pre-approve the dental services. You say that you need the extractions. You say that you 
are in pain. You also say that you are a diabetic and cannot eat properly. The Plan denied your request. The 
Plan says dental services are only covered when they are performed by a participating general dentist. The Plan 
also says dental services performed by an oral surgeon are not covered. 
 
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, dental services performed by an oral 
surgeon are not covered. Therefore, we decided that the Plan does not have to pre-approve a consultation 
(D9310) and 2 extractions (D7210) with an oral surgeon.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to waive the copayment for a PET scan provided by a participating provider on 
April 14, 2020. 
 
You asked the Plan to waive the copayment for a PET scan. You say that you should not have a copayment for 
this. The Plan denied your request. The Plan says that the correct copayment has been applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that enrollees must pay a $0 copayment for outpatient diagnostic tests/radiological 
diagnostic service.  
 
The Plan says you must pay a 20% coinsurance for the services provided. Based on the Plan contract, however, 
you cannot be asked to pay more than a $0 copayment for a PET scan. Therefore, we decided that the Plan has 
to waive the copayment for a PET scan provided by a participating provider on April 14, 2020.  
 
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the established patient office or other outpatient visit (99213) 
provided on June 23, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the established patient office or other outpatient visit. You say that the services 
provided were medically necessary. The Plan denied your request. The Plan says prior authorization was not 
obtained by the facility or the provider; therefore, payment has been correctly denied. 
 
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 has network providers 
available who can provide 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 established patient office or other outpatient 
visit (99213) provided on June 23, 2020, by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (CPT 27901) provided on September 26, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a column II 
code. 
 
The Plan must follow Medicare rules. Medicare rules say that if a provider reports the two codes of an edit pair, 
the column two code is denied, and the column one code is eligible for payment. Procedure code 27091 is part 
of an edit pair with procedure code 27295. Procedure code 27295 is a column one code, and procedure code 
27091 is a column two code. Procedure code 27295 has been billed on this date of service, which means that 
procedure code 27091 is not eligible for payment. Therefore, we decided that the Plan does not have to pay for 
the services (CPT 27901) provided on September 26, 2019.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility visit (99308) provided on 
June 16, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the subsequent nursing facility visit. You say that the services provided were 
medically necessary. The Plan denied your request. The Plan says prior authorization was not obtained by the 
facility or the provider; therefore, payment has been correctly denied. 
 
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 has network providers 
available who can provide 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 subsequent nursing facility visit (99308) 
provided on June 16, 2020, by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prefabricated post and core in addition to a crown 
(D2954 x 2) and the root canal (D3310) for tooth # 9 provided on July 8, 2020. 
 
You asked the Plan to pay for the dental services. You say that you were told by the plan and the dental office 
that your treatment plan was covered 100%. You say that the dental office called to tell you, you had a balance 
due. You also say that you have lupus and need to eat. The Plan denied your request. The Plan says 
prefabricated post and core in addition to a crown is not listed as a covered service. The Plan says 1 root canal 
per calendar year is covered. The Plan also says the frequency limit for root canal has been exceeded. 
 
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 prefabricated post and core in 
addition to addition to a crown is not among those covered under this benefit. Additionally, the frequency limit 
of 1 root canal per calendar year has been exceeded. The record shows that the Plan paid for a root canal that 
you received for tooth # 8 on this date of service.  Therefore, we decided that the Plan does not have to pay for 
the prefabricated post and core in addition to a crown (D2954 x 2) and the root canal (D3310) for tooth # 9 
provided on July 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete upper denture and lower partial denture 
provided by an out-of-network provider on July 7, 2020. 
 
You asked the Plan to pay for the complete upper denture and lower partial denture. You say that you received 
a letter of denial. The Plan denied your request. The Plan says out-of-network dental services are not covered 
benefits. 
 
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, out-of-network dental services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
complete upper denture and lower partial denture provided by an out-of-network provider on July 7, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the telehealth facility fee (Q3014) provided on May 5, 2020, 
by an out of network (OON) provider. 
 
You asked the Plan to pay for the telehealth facility fee. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained by the 
facility or the provider; therefore, payment has been correctly denied. 
 
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 has network providers 
available who can provide 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 telehealth facility fee (Q3014) provided on 
May 5, 2020, by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from May 30, 
2020 to June 4, 2020. 
 
You asked the Plan to pay for SNF care. You say that you would like Medicare payment for these services. The 
Plan denied your request. The Plan says the services provided were custodial. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above 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 daily 
skilled services are not necessary. Our physician reviewer found the enrollee was not expected to make 
measurable gains within a reasonable and predictable period of time or require skilled therapy to prevent 
deterioration with mobility or ADLs. The member did not require skilled therapy to establish a safe and 
effective maintenance program. As a practical matter, the member did not require any skilled services on an 
inpatient basis, at a SNF level of care during the period of care under review. 

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 pay for skilled nursing facility (SNF) care provided from May 30, 2020 to June 4, 2020.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve endovascular repair of visceral aorta and infrarenal abdominal 
aorta (34848) and spinal puncture for drainage of cerebrospinal fluid (62272). 
 
You asked the Plan to pre-approve endovascular repair of visceral aorta and infrarenal abdominal aorta and 
spinal puncture for drainage of cerebrospinal fluid. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that the enrollee does not meet Medicare criteria for coverage of these 
services. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services are covered when medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve endovascular repair of visceral aorta 
and infrarenal abdominal aorta and spinal puncture for drainage of cerebrospinal fluid. Our reviewer says that 
the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the documentation supports the medical necessity of the procedure in question.  The patient has 
a complex, large, aortic aneurysm that is a proximal threat to her life. There is satisfactory documentation of 
the elevated risk with open surgery. There is satisfactory documentation that the procedure in question was 
planned after a very thoughtful analysis and that the procedure is both medically necessary and appropriate. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of endovascular repair of visceral aorta and infrarenal abdominal aorta and spinal 
puncture for drainage of cerebrospinal fluid have been met. Therefore, we decided that the Plan has to pre-
approve endovascular repair of visceral aorta and infrarenal abdominal aorta (34848) and spinal puncture for 
drainage of cerebrospinal fluid (62272).  
 
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: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit provided by a 
participating provider on July 6, 2020. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that you went to have your 
glucose levels checked. You say that you left before seeing a doctor. The Plan denied your request. The Plan 
says the correct copayment has been applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 
copayment for emergency care.  
 
You have been asked to pay a $90 copayment for an emergency room visit. The correct copayment has been 
applied since an emergency room visit was provided. An emergency room visit falls within the emergency care 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for an emergency room visit 
provided by a participating provider on July 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the alveoloplasty. 
 
You asked the Plan to pre-approve the alveoloplasty. You say that complications of decay include pain and 
infection. You say that you are finally stable and can get the necessary dental work. The Plan denied your 
request. The Plan says code D7310 is not allowed in the same quadrant as a surgical extraction. 
 
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 
alveoloplasty 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 alveoloplasty. Our reviewer says 
that the criteria for coverage has not been met. Our physician reviewer found that removal of residual roots 
(cutting procedure) has been approved for teeth #'s 9, 10, 11, 12 and 13. Our reviewer says that the 
alveoloplasty in conjunction with extractions would accomplish the same results, therefore, both procedures in 
the same area are not medically reasonable nor necessary. 
 
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 alveoloplasty have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the alveoloplasty.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an x-ray of the upper extremity (73110) provided May 1, 
2020. 
 
You asked the Plan to pay for the x-ray. You say that the service was medically necessary. The Plan denied 
your request. The Plan says a required modifier was not included on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 73110 is not supported in the medical record. Specifically, the claim form did not 
include a required anatomical modifier. Based on this information, we decided that Medicare rules for coverage 
of the x-ray have not been met. Therefore, we decided that the Plan does not have to pay for an x-ray of the 
upper extremity (73110) provided May 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the crown (D2750) and core buildup (D2950). 
 
You asked the Plan to pre-approve the crown (D2750) and core buildup (D2950). You say that your dentist 
recommends the tooth needs to be covered to protect the remaining roots and tooth. You say that both 
procedures will prevent more serious dental work in the future. The Plan denied your request. The Plan says the 
services are not covered benefits. 
 
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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
crown (D2750) and core buildup (D2950).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on July 14, 
2020. 
 
You asked the Plan to pay for the dental service. You say that you had a tooth extracted in May 2020. You say 
that you have continued to have ongoing tooth problems. You also say that this service should be covered. The 
Plan denied your request. The Plan says 1 limited oral evaluation is covered per plan year. The Plan also says 
that the frequency limit has been exceeded. 
 
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 frequency limit of 1 limited oral 
evaluation per plan year has been exceeded. The record shows that the Plan paid for a limited oral evaluation 
that you received on May 14, 2020. Therefore, we decided that the Plan does not have to pay for the limited 
oral evaluation (D0140) provided on July 14, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs (Aspirin, Tramadol) received 
June 27, 2020, in the emergency room. 
 
You asked the Plan to pay for the self-administered drugs. You say that you could not bring medicine from 
home and would like the plan to pay for these drugs. The Plan denied your request. The Plan says these 
medications do not qualify for reimbursement under the member's Part A and B benefits. 
 
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 pay for the self-administered drugs 
(Aspirin, Tramadol) received June 27, 2020, in the emergency room.  
 
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for medical equipment (L8000, L8030) provided February 4, 
2020. 
 
You asked the Plan to pay for the medical equipment. You say that the items were medically necessary. The 
Plan denied your request. The Plan says the enrollee was covered under a Part A SNF stay when the items were 
provided. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that the medical equipment was used in a SNF or hospital. Therefore, we decided that the Plan 
does not have to pay for medical equipment (L8000, L8030) provided February 4, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for self-administered drugs provided on July 8, 2020 through 
July 10, 2020 while under emergency room observation. 
 
You asked the Plan to pay for self-administered drugs. You say that the services were medically necessary. The 
Plan denied your request. The Plan says self-administered drugs are not covered by Part B. 
 
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 pay for self-administered drugs provided 
on July 8, 2020 through July 10, 2020 while under emergency room observation.  
 
Benefits for self-administered drugs may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home infusion therapy (S9328) received November 20, 
2019, to April 22, 2020. 
 
You asked the Plan to pay for the home infusion therapy. You say that the services provided were medically 
necessary. The Plan denied your request. The Plan says the request for this payment as your provider has coded 
it is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code S9328 is not supported for payment. Specifically, this code is not valid for Medicare 
purposes. Medicare uses another code for reporting of, and payment for, these services. Based on this 
information, we decided that Medicare rules for coverage of home infusion therapy have not been met. Based 
on this information, we decided that Medicare rules for coverage of the home infusion therapy have not been 
met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy (S9328) received 
November 20, 2019, to April 22, 2020.