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

 
We decided that the Plan does not have to pre-approve the computed tomography (CT) scan of both legs 
(73701). 
 
You asked the Plan to pre-approve the CT scan of both legs. You say that the services requested are medically 
necessary. The Plan denied your request. The Plan says the CT scan of both legs are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 the CT scan of both legs. Our reviewer 
says that the service requested is not medically or reasonable. Our physician reviewer found there is no 
documentation provided that necessitate the requested CT scans. There is no documentation of change in size 
of the lesions on the legs and no documentation of resulting musculoskeletal signs or symptoms or results of 
plain X-rays. 
 
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 CT scan of both legs have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the computed tomography (CT) scan of both legs (73701).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services (S9122) provided June 3, 2020. 
 
You asked the Plan to pay for the home health services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the claim was filed 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. 
 
We find that CPT code S9122 is not supported in the medical record. Specifically, a UB-04 form was not 
submitted as required. Based on this information, we decided that Medicare rules for coverage of the home 
health services have not been met. Therefore, we decided that the Plan does not have to pay for home health 
services (S9122) provided June 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the boarding rings. 
 
You asked the Plan to pre-approve the boarding rings. You say that you would like reconsideration because this 
equipment is medically necessary to treat your motion sickness. The Plan denied your request. The Plan says 
this is not a Medicare covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve the boarding rings.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2751) for tooth # 13. 
 
 
You asked the Plan to pre-approve the dental service. You say that the crown is necessary. The Plan denied 
your request. The Plan says the x-rays do not show that you have a cavity under the cap on your tooth. The 
Plan also says that the crown is not medically necessary. 
 
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 dental 
service 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 dental service. Our reviewer says 
that the crown is not medically necessary. Our physician reviewer found the provided documentation shows 
there is broken porcelain on the existing crown. The reviewer found the provider has not given any narrative as 
to the need for replacement of the crown. The reviewer found there is no indication of food impaction or 
occlusal issues. The reviewer found that without a clear indication by way of x-ray or narrative of the specific 
issue that necessitates replacement a crown, there is no necessity for the crown. 
 
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 dental service have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a crown (D2751) for tooth # 13.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the removal of residual tooth roots (D7250), reline 
complete mandibular denture (D5751), reline complete maxillary denture (D5750), immediate denture - 
mandibular (D5140), and immediate denture - maxillary (D5130). 
 
You asked the Plan to pre-approve the removal of residual tooth roots, reline complete mandibular denture, 
reline complete maxillary denture, immediate denture - mandibular, and immediate denture - maxillary. You 
say that these services are medically necessary. The Plan denied your request. The Plan says these services are 
not a covered benefit under your supplemental 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 pre-approve the 
removal of residual tooth roots (D7250), reline complete mandibular denture (D5751), reline complete 
maxillary denture (D5750), immediate denture - mandibular (D5140), and immediate denture - maxillary 
(D5130).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the full mouth debridement (D4355) provided on September 
24, 2020. 
 
You asked the Plan to pay for the full mouth debridement. You say that you were provided with a cleaning. 
You also say that this service is covered under your plan. The Plan denied your request. The Plan says this 
service is not a covered benefit under your dental plan. The Plan also says that you were not enrolled in the 
Platinum Dental Benefit Rider on this date of 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. Therefore, we decided that the Plan does not have to pay for the full 
mouth debridement (D4355) provided on September 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve One Touch brand test strips. 
 
You asked the Plan to pre-approve One Touch brand test strips. You say that you would like the Plan to 
reconsider their denial. The Plan denied your request. The Plan says One Touch test strips are not a preferred 
brand of diabetic supplies covered by the Plan. 
 
The Plan must follow Medicare rules. The rules say that a Medicare Health Plan must disclose to its members 
the benefits offered under the plan including applicable conditions and limitations. 
 
We looked at the file, the Plan's contract and Medicare rules. The Plan contract clearly states alternate non-
preferred brand diabetic supply products are not covered unless a doctor provides adequate information that the 
use of an alternate brand is medically necessary in the enrollee's specific situation. The file does not provide 
documentation from your treating physician that the requested non-preferred brand, One Touch test strips are 
medically necessary. Based on this information, we decided that Medicare rules for coverage of One Touch test 
strips have not been met. Therefore, we decided that the Plan does not have to pre-approve One Touch brand 
test strips.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital discharge services (99239) provided on March 5, 
2020. 
 
You asked the Plan to pay for hospital discharge services. You say that these medically necessary service were 
provided to the enrollee in good faith. The Plan denied your request. The Plan says rules for payment have not 
been met. 
 
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 date of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for hospital discharge services (99239) provided on March 5, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for specialist services provided on July 7, 2020, to August 4, 
2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for specialist services. You say that you would like this claim reprocessed and paid. 
The Plan denied your request. The Plan says there are in-network providers available who could have provided 
these services. 
 
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. 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 
specialist services provided on July 7, 2020, to August 4, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the collection of venous blood by venipuncture and Vitamin 
D testing provided on June 15, 2020. 
 
You asked the Plan to pay for the collection of venous blood by venipuncture and Vitamin D. You say that you 
would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed 
are not a covered benefit. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The collection of venous blood by venipuncture and Vitamin D testing at issue in this appeal were requested 
solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we 
decided that the Plan does not have to pay for the collection of venous blood by venipuncture and Vitamin D 
testing provided on June 15, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a tendon injection provided on June 2, 
2020. 
 
You asked the Plan to waive the copayment for a tendon injection. You say that you disagree with the charges 
because you were not aware that the service was considered a surgery and that it was an outpatient hospital 
facility. 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 a $245 
copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and 
ambulatory surgical centers.  
 
The record shows that you received a tendon injection at an outpatient hospital facility on June 2, 2020. 
Therefore, you are responsible to pay the $245 copayment.  
 
You have been asked to pay a $245 copayment for a tendon injection. A tendon injection falls within the 
outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical 
centers 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 a tendon injection provided on 
June 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve specialist services to be provided by an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve specialist services. You say that you would like to continue to see this 
provider. The Plan denied your request. The Plan says there are in-network providers available for these 
services. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers.  
 
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. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
specialist services to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ear thermometer covers and an electric toothbrush 
replacement head. 
 
You asked the Plan to pre-approve the ear thermometer covers and an electric toothbrush replacement head.. 
You say that these items should be covered by the over-the-counter benefit. The Plan denied your request. The 
Plan says only items available through the plan contract supplier are covered. The requested items are not a 
covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Furthermore, the 
requested items are not among the items covered by the plan's over-the-counter benefits. Therefore, we decided 
that the Plan does not have to pre-approve ear thermometer covers and an electric toothbrush replacement head.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crowns (D2750) for teeth # 28 and 29. 
 
You asked the Plan to pre-approve the dental services. You say that the x-rays lack information. You say that 
your crowns were done 25 years ago. You also say that you have bleeding gums and decay. The Plan denied 
your request. The Plan says the x-rays do not indicate the need for replacement crowns alone. 
 
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 dental 
services 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 dental services. Our reviewer says 
that the crowns are not medically necessary. Our physician reviewer found the provided documentation 
indicates the presence of crowns on teeth # 28 and 29. The reviewer found there was no narrative as to why the 
crowns needed to be replaced. The reviewer found that, radiographically, the crowns appeared functionally 
adequate. Therefore, the reviewer found that the requested crowns are not medically reasonable or 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 dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve crowns (D2750) for teeth # 28 and 29.
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 
August 13, 2020 by an OON. 
 
You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that you were not aware 
that this provider is no longer in-network with your plan. The Plan denied your request. The Plan says the 
treating provider is not a participating provider with your plan. The Plan also says that this 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, 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 August 13, 2020 by an OON.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140), the core build up 
(D2950), unspecified preventive service (D1999), and the root canal (D3320) provided on August 18, 2020. 
 
You asked the Plan to pay for the dental services. You say that you were advised that the Plan would pay 30% 
for the services. You say that you paid your portion. You say that after you received the services, you were 
advised that the dental coverage had changed and no longer covers crowns and root canals. You also say that 
this is a financial hardship for you. The Plan denied your request. The Plan says there is no coverage for the 
services that you received. 
 
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. The record shows that you contacted the Plan on December 2, 2019 to 
discuss the difference between the 2019 and 2020 Evidence of Coverage. The record also shows that you 
contacted the Plan on May 19, 2020 to find a plan that covers a root canal. Therefore, we decided that the Plan 
does not have to pay for the limited oral evaluation (D0140), the core build up (D2950), unspecified preventive 
service (D1999), and the root canal (D3320) provided on August 18, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing services provided on March 11, 2020 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for skilled nursing services. You say that you would like this claim reprocessed and 
paid. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the 
referring provider is also out-of-network. 
 
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 skilled nursing services provided on March 11, 
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 cone beam CT capture and interpretation provided on 
September 28, 2020. 
 
You asked the Plan to pay for the cone beam CT capture and interpretation. You say that due to the nature of 
this procedure, it should have been filed under your medical insurance and not your dental insurance. The Plan 
denied your request. The Plan says this service is 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, the requested items or services are not 
among those covered under this benefit. This service is dental in nature. Therefore, we decided that the Plan 
does not have to pay for the cone beam CT capture and interpretation provided on September 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee orthosis (L1833) and the suspension sleeve (L2397) 
provided on August 26, 2020. 
 
You asked the Plan to pay for these items. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says the record provided does not support the billed items 
in this case. 
 
The Plan follows Medicare rules. Medicare rules say that records from suppliers or healthcare professionals 
with a financial interest in the claim outcome are not considered sufficient by themselves for determining that 
an item is reasonable and 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 pay for these items. Our reviewer says that the 
record does not support the medical necessity of the billed items. Our physician reviewer found that the 
enrollee's chief complaint was chronic pain in the left knee. The documentation in the case file does not support 
that the knee orthosis and suspension sleeve provided were medically reasonable and necessary for the enrollee 
in this case. There is insufficient documentation of an examination of the enrollee, and there is insufficient 
credible objective documentation of joint laxity.  
Additionally, the suspension sleeve is not separately payable when the base item is not covered. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these items have not been met. Therefore, we decided that the Plan does not 
have to pay for the knee orthosis (L1833) and the suspension sleeve (L2397) provided on August 26, 2020.