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

We decided that the Plan does not have to pay for the 8 extractions (D7140) provided on September 9, 2020. 
 
You asked the Plan to pay for the dental services. You say that page 27 of your book says up to $1,000 is 
covered and anything over than amount you are responsible for. You also say that an additional $400 should be 
paid. The Plan denied your request. The Plan says there is a $600 allowance every year for non-Medicare 
covered preventive and comprehensive dental services combined. The Plan also says that the allowance has 
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, the $600 annual allowance has been 
exhausted. The record shows that the Plan paid $600 for the immediate upper denture that you received on this 
date of service, thus exhausting the allowance. Although the 2021 benefits allow for $1,000 for covered dental 
services, you received the services in this claim in 2020 and therefore they must be processed based on the 
2020 dental benefits. Therefore, we decided that the Plan does not have to pay for the 8 extractions (D7140) 
provided on September 9, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient surgery received on August 18, 
2020, and August 26, 2020. 
 
You asked the Plan to waive the copayment for the services. You say that you cannot afford two bills for the 
same surgery. The Plan denied your request. The Plan says the copayment was applied correctly according to 
your benefits and the services rendered. 
 
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 $225 
copayment for outpatient surgery.  
 
You have been asked to pay a $225 copayment for each of the dates of service. The services fall within the 
outpatient surgery 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 outpatient surgery 
received on August 18, 2020, and August 26, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the echocardiography (CPT Code 93306). 
 
You asked the Plan to pre-approve the echocardiography. You say that the services are necessary. The Plan 
denied your request. The Plan says the services are not necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the echocardiography. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the review has determined that the services are 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 echocardiography have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the echocardiography (CPT Code 93306).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the arthrocentesis provided on September 
29, 2020. 
 
You asked the Plan to waive the copayment for the arthrocentesis. You say that this procedure was not surgery. 
You say this should be considered the same as labs, with no additional copayment due. The Plan denied your 
request. The Plan says you have been charged the correct cost sharing 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 a $100 
copayment for outpatient surgery for each in-network specialist's office.  
 
You have been asked to pay a $100 copayment for the arthrocentesis. The arthrocentesis falls within the 
?Outpatient surgery, including services provided at hospital facilities and ambulatory surgical centers? benefit 
category. The record shows that arthrocentesis is considered a surgical procedure. 
 
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 the arthrocentesis provided on September 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a dental consultation visit (D9310) provided on October 5, 
2020. 
 
You asked the Plan to pay for dental service. You say that you did not have the money to afford the needed 
procedure, so would like to have the cost of this consultation refunded. The Plan denied your request. The Plan 
says the denial of payment for this service is correct, because this service is not covered by the Plan's dental 
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 a dental 
consultation visit (D9310) provided on October 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the gingival irrigation (D4921 x 3) provided on 
March 2, 2020. 
 
You asked the Plan to reimburse you for the gingival irrigation. You say that the provider refuses to reimburse 
what you overpaid via Care Credit. The Plan denied your request. The Plan says gingival irrigation 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 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. Additionally, the record shows that you spend $176.40 for purchasing 
products. Therefore, we decided that the Plan does not have to reimburse you for the gingival irrigation (D4921 
x 3) provided on March 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the dialysis services provided from June 
16, 2020, to September 29, 2020. 
 
You asked the Plan to waive the coinsurance for the dialysis services. You say that you cannot afford this 
treatment. You say you have never had to pay for dialysis treatment in the past. The Plan denied your request. 
The Plan says you have been charged the correct cost sharing 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-covered dialysis services within the service area when ordered by your PCP.  
 
You have been asked to pay $65 which is 20% of the allowed amount for the dialysis on each date of service. 
The allowed amount is $325. ($325 x 20% = $65). ($65 x 42 dates of service = $2,730). The dialysis services 
fall within the "Services to treat kidney disease" 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 the dialysis services provided from June 16, 2020, to September 29, 2020. 
  
Our decision is only about the 2020 services. If you have any questions about prior years billing, please contact 
the plan directly.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on August 28, 
2020. 
 
You asked the Plan to pay for the dental service. You say that you say that you received oral exams on July 7, 
2020, and September 17, 2020. You say that because the exam on August 28, 2020 was performed before the 
September 17, 2020 exam, it should be covered. You also say that you did not know you had an oral exam on 
September 17, 2020. The Plan denied your request. The Plan says 2 oral exams are covered per year. The Plan 
says that the frequency limit has been reached with the exams that you received on July 7, 2020, and September 
17, 2020. The Plan says that claims are processed based on the order they are received. The Plan also says that 
the claim for August 28, 2020 was not received until after the claims for dates of service July 7, 2020, and 
September 17, 2020 had been received, therefore the the frequency limit had 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, the frequency limit of 2 oral exams per 
year has been exceeded. The record shows that the Plan paid for the oral exams that you received on July 7, 
2020, and September 17, 2020, thus exhausting the benefit. Therefore, we decided that the Plan does not have 
to pay for the limited oral evaluation (D0140) provided on August 28, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary. 
 
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 the documentation does not support that the enrollee in this case requires services at 
the LTACH that are not available at the acute care hospital where they are currently receiving care. There are 
no required medical services identified that are available at the LTACH, that are not available at the current 
health care setting being offered by the health plan. Consequently, the requested LTACH services are not 
medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 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 LTACH services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the echocardiography (CPT Code 93306). 
 
You asked the Plan to pre-approve the echocardiography. You say that the services are necessary. The Plan 
denied your request. The Plan says the services are not necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the echocardiography. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found based on the provided documentation, the enrollee does not have signs or symptoms 
of a new or worsening cardiac condition to justify repeat TTE at this time. Therefore, this request for such will 
be considered 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 echocardiography have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the echocardiography (CPT Code 93306).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary. 
 
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 the documentation does not support that the enrollee in this case requires services at 
the LTACH that are not available at the acute care hospital where he is currently receiving care. The clinical 
assessment in the case file does not support that the enrollee is reasonably expected to benefit from, and 
improve with, LTACH services. Consequently, the requested LTACH services are not medically necessary, 
reasonable, and appropriate for the diagnosis and condition of the enrollee 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 LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit (99214) provided August 24, 
2020. 
 
You asked the Plan to waive the copayment for the office visit. You say that the copayment should be waived. 
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 $65 
copayment for out-of-network office visits.  
 
You have been asked to pay a $65 copayment for the office visit. The office visit falls within the out-of-
network office visits 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 office visit 
(99214) provided August 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services (D2740, D2954) provided February 19, 2020. 
 
You asked the Plan to pay for the dental services. You say that the injuries were the result of a fall and should 
be covered. The Plan denied your request. The Plan says the enrollee's dental insurer has already paid their 
portion. The services at issue are not medical in nature and are not covered by the plan. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
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. Therefore, we decided that the Plan does not have to pay for dental services (D2740, D2954) 
provided February 19, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for large right pleural effusion and new axial skeletal and liver metastasis, thought secondary to 
neuroendocrine tumor. Medical conditions are stable. There are no medical needs requiring inpatient 
admission. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. While the medical record documents a need for physical and occupational therapy, it does not 
document a need for an intensive rehabilitation program. There is not a reasonable expectation that this enrollee 
will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an 
IRF. 
 
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 acute IRF admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided May 1, 
2020 to May 31, 2020. 
 
You asked the Plan to pay for the SNF services. You say that the denial states not covered because it is not 
medically reasonable or necessary and then states something about an endoscopic facility fee. This claim is for 
room and board. The Plan denied your request. The Plan says the services are not covered under the plan 
benefits. The claim was processed and the correct cost share was applied per the Evidence of Coverage. 
 
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 $0 per 
day for days 1-20 $50 per day for days 21-100 for skilled nursing facility (SNF) care.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
You have been asked to pay $5,990.04 for the SNF services. The SNF services falls within the skilled nursing 
facility (SNF) 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 pay for the skilled nursing facility (SNF) 
services provided May 1, 2020 to May 31, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
hepatic encephalopathy and lower gastrointestinal (GI) bleed after a recent admission for sepsis and colitis. 
Medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex 
nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record 
documents a need for physical and occupational therapy, it does not document a need for an intensive 
rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and 
benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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 acute IRF admission and services.