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

 
We decided that the Plan does not have to pay for the first intraoral periapical x-ray provided on July 16, 2020. 
 
You asked the Plan to pay for the first intraoral periapical x-ray. You say that you were under the impression 
that the treating provider was in-network. The Plan denied your request. The Plan says first intraoral periapical 
x-ray 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the first 
intraoral periapical x-ray provided on July 16, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on July 10, 
2020. 
 
You asked the Plan to waive the copayment for ambulance services. You say that the enrollee could not be 
transported by car because they required oxygen. The Plan denied your request. The Plan says the claims were 
processed correctly and the enrollee is being charged the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees 
must pay a $275 copayment for ambulance services.  
 
The enrollee has been asked to pay the allowed amount of $228.40, which is less than the $275 copayment for 
ambulance services. Ambulance services fall within the ambulance services benefit category. This means that 
the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a 
contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for ambulance services provided on July 10, 2020.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pay for the physical therapy services rendered on May 27, 2020. 
 
You asked the Plan to pay for these services. You say that the services should be covered. The Plan denied 
your request. The Plan says that the allowed amount was reached for therapy. 
 
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. The Plan states that the allowed amount has been reached for therapy. While 
there is a Medicare therapy cap, the services may be allowed if medically necessary. The Plan has not provided 
any medical records to show that the services were not medically necessary and eligible for the therapy cap. 
Therefore, we decided that the Plan has to pay for the physical therapy services rendered on May 27, 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: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for the electrical stimulator supplies (A4595) provided to the enrollee on 
March 26, 2020. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says that that this is not covered. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for these services by the provider. The provider is a contract provider. The file does 
not show that the plan provided notice that these services would not be covered. Under Medicare rules, this 
means these services is considered approved by the plan. Therefore, we decided that the Plan has to pay for the 
electrical stimulator supplies (A4595) provided to the enrollee on March 26, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Entyvio (J3380). 
 
You asked the Plan to pre-approve Entyvio. You say that this is medically necessary. The Plan denied your 
request. The Plan says step therapy requirements have not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Entyvio. Our reviewer says that the 
criteria for coverage of Entyvio have not been met. Our physician reviewer found the Plan requires a trial of 
Stelara and either Inflectra or Remicade before they will approve the requested drug, Entyvio. Based on the 
medical records provided the patient has not tried and failed the required drugs. There is also no indication that 
the plan's required drugs would likely be less effective or have adverse effects for the patient. 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Entyvio have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Entyvio (J3380).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two periodontal maintenance services (D4910 x2) and 
gingival flap procedure (D4241) provided from April 24, 2019, to September 20, 2019. 
 
You asked the Plan to pay for the periodontal maintenance services and gingival flap procedure. You say that 
the same treatments were paid for in 2020 that you received in 2019. The Plan denied your request. The Plan 
says these services are not covered under your dental 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the two 
periodontal maintenance services (D4910 x2) and gingival flap procedure (D4241) provided from April 24, 
2019, to September 20, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on July 
8, 2020. 
 
You asked the Plan to pay for the comprehensive oral evaluation. You say that the dentist determined it was 
necessary to redo the exam in order to treat your dental needs. The Plan denied your request. The Plan says this 
service exceeds the frequency limitation in your benefit plan. 
 
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, comprehensive oral evaluation 
(D0150) is limited to one procedure every three plan years. The record shows that you received a 
comprehensive oral evaluation (D0150) on March 9, 2020, and your comprehensive oral evaluation (D0150) 
benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive 
oral evaluation (D0150) provided on July 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay the full amount for the periodontal maintenance (D4910) 
provided on December 18, 2019. 
 
You asked the Plan to pay the full amount for the dental service. You say that you were advised that unless 
previous record of periodontal work had been received, it would not be covered. You say that your provider 
sent in records as proof to the plan. You say that the full amount should be paid for the service. The Plan 
denied your request. The Plan says there is a 50% coinsurance for periodontal maintenance received in 
network. The Plan also says that the claim was processed correctly. 
 
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, there is a 50% coinsurance for 
periodontal maintenance. The record shows that the Plan paid 50% of the allowed amount of $142. You are 
responsible for the remaining 50%. Cost sharing is a contractual obligation under the plan and cannot be 
waived. Therefore, we decided that the Plan does not have to pay the full amount for the periodontal 
maintenance (D4910) provided on December 18, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation and prophylaxis provided on July 
15, 2020 by an OON provider. 
 
You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that the Plan pays for these 
services, so you have a $0 copay in-network and out-of-network. The Plan denied your request. The Plan says 
the total liability amount of $80.00 was applied correctly per your plan benefits. The Plan also says that 
enrollee liability is a contractual obligation under the plan and cannot be waived. 
 
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, you are responsible for the difference 
between the billed amount and allowed amount. Therefore, we decided that the Plan does not have to pay for 
the periodic oral evaluation and prophylaxis provided on July 15, 2020 by an OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the blood smear services coded 85060 provided on May 3, 
2020. 
 
You asked the Plan to pay for the blood smear services. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the services were billed incorrectly. 
 
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 85060 is Blood smear, peripheral, interpretation by 
physician with written report. 
 
We find that CPT code 85060 is not supported in the medical record. Specifically, this code was billed with 
place of service 22, on campus-outpatient hospital. The PC/TC indicator for CPT code 85060 is 8. This value 
identifies the only payment made for the professional component of the code is for hospital inpatient. Based on 
this information, we decided that Medicare rules for coverage of the blood smear services have not been met. 
Therefore, we decided that the Plan does not have to pay for the blood smear services coded 85060 provided on 
May 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care services (99291) provided on June 15, 2020. 
 
You asked the Plan to pay for the critical care services. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says the documentation does not support the 
service billed. 
 
The Plan must follow Medicare rules. Medicare rules say that critical care is a time- based service, and for each 
date and encounter entry, the physician's progress note(s) shall document the total time that critical care 
services were provided. 
 
We find that CPT code 99291 is not supported in the record. Specifically, the record does not indicate the 
amount of time spent rendering the critical care services. Based on this information, we decided that Medicare 
rules for coverage of the critical care services have not been met. Therefore, we decided that the Plan does not 
have to pay for critical care services (99291) provided on June 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the placement of an endosteal implant (D6010) provided on 
August 6, 2020. 
 
You asked the Plan to pay for the dental service. You say that the implant for tooth # 14 was necessary for 
proper function to allow you to chew on both sides of your mouth. You say that since you lost tooth # 15, you 
are not able to chew on that side. You also say that only chewing on one side of your mouth for the rest of your 
life would impair function and increase wear on your teeth and jaw. The Plan denied your request. The Plan 
says the placement of an endosteal implant 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 Pls 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 the 
placement of an endosteal implant (D6010) provided on August 6, 2020.
Appeal type: Outpatient Therapies
Decision: Favorable

 We decided that the Plan has to pay for the physical therapy services rendered on January 23, 2020. 
 
You asked the Plan to pay for these services. You say that the services should be covered. The Plan denied 
your request. The Plan says that the allowed amount was reached for therapy. 
 
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. The Plan states that the allowed amount has been reached for therapy. While 
there is a Medicare therapy cap, the services may be allowed if medically necessary. The Plan has not provided 
any medical records to show that the services were not medically necessary and eligible for the therapy cap. 
Therefore, we decided that the Plan has to pay for the physical therapy services rendered on January 23, 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 medical services provided to the enrollee by an out-of-
network provider on May 28, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the enrollee does not 
have out-of-network benefits. 
 
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 services at issue in this appeal. The Plan did not pre-approve the services at 
issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that 
the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider 
on May 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug provided on May 
26, 2020. 
 
You asked the Plan to waive the coinsurance for a Medicare Part B drug. You say that the Medicare Part B 
drug injection should be covered 100%. The Plan denied your request. The Plan says the claims were processed 
correctly and you are being charged the correct amount. 
 
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 20% 
coinsurance for Medicare Part B prescription drugs.  
 
You received a Medicare Part B drug on May 26, 2020. The total allowed amount is $1160.28 and 20% of that 
is $232.06. 
 
You have been asked to pay the total coinsurance amount of $232.06 for a Medicare Part B drug. A Medicare 
Part B drug falls within the Medicare Part B prescription drugs 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 coinsurance for a Medicare Part B drug provided on May 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services provided on July 17, 2020. 
 
You asked the Plan to pay for dental services. You say that you were told this procedure was covered by the 
Plan with some out-of-pocket expense to you. The Plan denied your request. The Plan says the denial of 
payment for these services is correct, because the Plan has paid the full $1,000 annual maximum benefit and 
you are responsible for any charges beyond this amount. 
 
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 dental 
services up to an annual maximum benefit of $1,000. 
 
We looked at the file, the Plan's rules, and Medicare rules. The Plan has paid the $1,000 annual maximum 
benefit for dental coverage, so you are responsible for any additional charges beyond this. Based on this 
information, we decided that the Plan's rules for coverage of dental services have not been met. Therefore, we 
decided that the Plan does not have to pay for dental services provided on July 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for unspecified preventive procedure (D1999) provided August 
27, 2020. 
 
You asked the Plan to pay for unspecified preventive procedure. You say that you would like to file an appeal 
as the services have not been exceeded. The Plan denied your request. The Plan says this service is not covered 
under the plan 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. Services not listed as a 
covered service is not covered by the plan. 
 
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 
unspecified preventive procedure (D1999) provided August 27, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services rendered on June 18, 2020 to June 
19, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 99291 is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, there is no documentation of 
critical care services of 30-74 minutes spent on the enrollee. 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 pay for the critical care services rendered on June 18, 2020 to June 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the neuromuscular stimulator provided to the enrollee on 
June 15, 2020. 
 
You asked the Plan to pay for the neuromuscular stimulator. You say that the documentation clearly shows 
medical necessity. The Plan denied your request. The Plan says that the documentation indicates services are 
not necessary for treatment of the enrollees condition. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
 
 
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are 
likewise noncovered. Therefore, we decided that the Plan does not have to pay for the neuromuscular 
stimulator provided to the enrollee on June 15, 2020.