Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician's services to be provided by the requested 
out-of-network provider. 
 
You asked the Plan to pre-approve physician's services to be provided by the requested out-of-network 
provider. The Plan denied your request. The Plan says the services are available in-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 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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve 
physician's services to be provided by the requested out-of-network provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on December 
29, 2021. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you do not agree with and are 
upset by the cost applied to the services you received. The Plan denied your request. The Plan says the 
copayment was applied correctly in accordance with your contract with the Plan. 
 
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 $365 
copayment for each Medicare-covered, one-way ambulance trip.  
 
You have been asked to pay a $365 copayment for ambulance services. The Plan allowed the provider to bill 
$435.46 for the service. However, the Plan paid $70.46, which left a cost share of $365 as member 
responsibility ($435.46 - $70.46 = $365).  
 
 The service at issue falls within the Ambulance Services 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 ambulance services provided on December 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown - porcelain/ceramic (D2740) provided October 12, 2021. 
 
You asked the Plan to pay for the crown. You say that you were unaware that you would be responsible for this 
cost, and it will be a hardship to pay. The Plan denied your request. The Plan says you have exceeded the 
frequency limit for this 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. The Plan covers two crowns 
per calendar year. 
 
We looked at the file and Medicare rules. The Plan provided documentation showing that two crowns were 
covered on the same date of service. Based on this information, we decided that the Plan's frequency limit for 
coverage of the crown has been exceeded. Therefore, we decided that the Plan does not have to pay for the 
crown - porcelain/ceramic (D2740) provided October 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation rendered on December 1, 2021. 
 
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 the services exceed the benefit limit. 
 
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 one limited 
oral evaluation per calendar year.  
 
We looked at the file and the Plan's rules. The file shows that you previously had a limited oral evaluation on 
October 18, 2021 that was covered by the Plan. The evaluation on December 1, 2021 was performed less than 
one calendar year from your previously covered exam. Based on this information, we decided that the Plan's 
rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to 
pay for the limited oral evaluation rendered on December 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services rendered on December 15, 2021. 
 
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 the services 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 Plans coverage rules apply in this case. The Plan contract says that 
enrollees pay 100 percent for out-of-network dental benefits. 
 
We looked at the file and the Plans rules. The file shows that you received services from an out-of-network 
provider. Based on this information, we decided that the Plan's rules for coverage of these services have not 
been met. Therefore, we decided that the Plan does not have to pay for the dental services rendered on 
December 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and the adult cleaning 
(D1110) provided by an out-of-network provider on February 9, 2022. 
 
You asked the Plan to pay for the periodic oral evaluation (D0120) and the adult cleaning (D1110). You say 
that you were never notified that the dental office stopped taking your insurance. You say you should not be 
responsible for the claim. 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the periodic oral evaluation (D0120) 
and the adult cleaning (D1110) are not among those covered under this benefit. The record shows the services 
were rendered by an out-of-network provider. Therefore, we decided that the Plan does not have to pay for the 
periodic oral evaluation (D0120) and the adult cleaning (D1110) provided by an out-of-network provider on 
February 9, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for an electroencephalogram provided to the enrollee on April 23, 2021. 
 
You asked the Plan to pay for the services. You say that the documentation supports the services as billed. The 
Plan denied your request. The Plan says that this does not meet coding standards. 
 
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 95813 is "Electroencephalogram (EEG) extended monitoring; 61-119 minutes." 
 
We asked our coder 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 the services. Our reviewer says that the services at issue in 
this case were supported by the medical records. Our reviewer found the documentation supports extended 
electroencephalogram monitoring of one hour and 32 minutes. There were no CPT guidelines were found to 
support that this procedure should not be reported with other procedures reported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
an electroencephalogram provided to the enrollee on April 23, 2021.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction, erupted tooth requiring removal of bone 
and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210) provided 
January 10, 2022. 
 
You asked the Plan to pay for the surgical tooth extraction. You say that you feel you had a simple extraction, 
not a surgical extraction. The Plan denied your request. The Plan says this service is not covered under your 
benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services, as 
billed by the provider, are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and 
including elevation of mucoperiosteal flap if indicated (D7210) provided January 10, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a breast ultrasound provided on January 20, 
2022. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that the ultrasound should be part of 
the mammogram and should be covered. 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 $25 
copayment for each ultrasound provided at a free-standing provider.  
 
You have been asked to pay a $25 copayment for the ultrasound. Please note that this is a separate imaging 
procedure from the mammogram. The ultrasound falls within the Outpatient Diagnostic Tests and Therapeutic 
Services and Supplies 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 breast 
ultrasound provided on January 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown - porcelain/ceramic (D2740) provided October 21, 2021. 
 
You asked the Plan to pay for the crown. You say that this same service was covered in 2020. The Plan denied 
your request. The Plan says this service is not covered under your 2021 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 pay for the crown 
- porcelain/ceramic (D2740) provided October 21, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an implantable loop recorder.

You asked the Plan to pre-approve implantable loop recorder. You say that this device is necessary for the well-being of the patient. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this is not medically 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 implantable loop recorder. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided to suggest a history of unexplained syncope, cryptogenic stroke, or any other apparent indication for an implantable loop recorder.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of implantable loop recorder have not been met. Therefore, we decided that the Plan does not have to pre-approve an implantable loop recorder.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bilateral transforaminal epidural steroid injections at an 
additional level (64484). 
 
You asked the Plan to pre-approve bilateral transforaminal epidural steroid injections. You say that this is 
medically necessary for the enrollee's condition. The Plan denied your request. The Plan says Medicare 
coverage rules say that the requested additional injections will exceed Medicare limits on coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that no more than two transforaminal injections may 
be performed at a single setting. 
 
We looked at the file and Medicare rules. In this case, the Plan has already agreed to coverage of two 
transforaminal injections. Additional injections will not be covered at this time. Based on this information, we 
decided that Medicare rules for coverage of bilateral transforaminal epidural steroid injections have not been 
met. Therefore, we decided that the Plan does not have to pre-approve bilateral transforaminal epidural steroid 
injections at an additional level (64484).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a punch biopsy of the skin performed on 
November 9, 2021. 
 
You asked the Plan to reduce the copayment for the skin biopsy. You say that the provider informed you there 
was only a $50 copayment. 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 $370 
copayment for surgery or other services provided at an outpatient hospital.  
 
You have been asked to pay $220.75, which is less than the $370 copayment for the skin biopsy. The skin 
biopsy falls within the Outpatient Surgery, Including 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 reduce the copayment for a punch 
biopsy of the skin performed on November 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown repair necessitated by restorative material failure 
(D2980) provided on January 18, 2022. 
 
You asked the Plan to pay for the dental service. You say that you have purchased a plan with full dental 
coverage including crowns and fillings. You say that you do not understand how a filling is not covered when 
repairing the crown after a root canal. You also say that the charge should be covered. The Plan denied your 
request. The Plan says crown repair necessitated by restorative material failure 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 crown repair necessitated by 
restorative material failure is not among those covered under this benefit. Therefore, we decided that the Plan 
does not have to pay for the crown repair necessitated by restorative material failure (D2980) provided on 
January 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus Xf test (81206 and 81301) provided on 
December 13, 2021. 
 
You asked the Plan to pay for the Tempus Xf test. You say that you would like this claim reprocessed for 
payment based on medical necessity. The Plan denied your request. The Plan says the test at issue is not 
covered by Medicare or the Plan. 
 
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 pay for the Tempus Xf test. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee is a 69-year-old male with metastatic castrate resistant prostate cancer. In this case, 
The Tempus Xf test is not medically necessary under Medicare because it has not been FDA approved, nor met 
the technical validation assessment protocols required by Medicare for coverage. Payment for this service 
cannot be made. 
 
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 Tempus Xf test have not been met. Therefore, we decided that the Plan does 
not have to pay for the Tempus Xf test (81206 and 81301) provided on December 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 2 gum surgery (D4266), and 2 implant placements (D6010). 
 
You asked the Plan to pre-approve the dental services. You say that you were denied for implants that were 
requested by your dentist. You say that your dentures are bothering you. You say that you are unable to eat and 
are losing weight. You also say that your dentures will not stay in your mouth. The Plan denied your request. 
The Plan says the services are not listed as 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 gum surgery and implant 
placements are not among those covered under this benefit. Therefore, we decided that the Plan does not have 
to pre-approve 2 gum surgery (D4266), and 2 implant placements (D6010).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the expandable controller and accessories (E2377, 
E2311, E2313), power seat elevation feature (E2300), power standing system (E2301), and chest support 
system (K0108). 
 
You asked the Plan to pre-approve the requested parts for a power wheelchair. You say that this equipment is 
medically necessary. The Plan denied your request. The Plan says the criteria for coverage of these items have 
not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a power seat elevation feature (E2300) and power 
standing feature (E2301) are non-covered because they are not primarily medical in nature. The rules also say 
that an expandable controller is subject to the criteria listed in the Medicare rules section.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the requested parts for a power 
wheelchair. Our reviewer says that the requested expandable controller is not medically reasonable and 
necessary. Our physician reviewer found the documentation does not support that there is a medical need to 
control the power options on the power wheelchair through a joystick. The documentation indicates that the 
enrollee's right upper extremity strength should be adequate to control the power options using their own 
switches. 
 
In addition, the power seat elevation feature and power standing feature are both statutorily noncovered 
according to Medicare rules. As the chest support system is to be used with the power standing system, this is 
not medically necessary as well. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested parts for a power wheelchair have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the expandable controller and accessories (E2377, E2311, 
E2313), power seat elevation feature (E2300), power standing system (E2301), and chest support system 
(K0108).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pontics (code D6240) and crowns (code D6750) you 
received from an out-of-network dentist on August 2, 2020. 
 
You asked the Plan to pay for the pontics and crowns. You say that you were unaware that this provider did not 
accept your dental plan.  You believe that a portion of this claim should be paid. The Plan denied your request. 
The Plan says out-of-network dental services are not covered under your dental benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Specifically, your Plan does 
not cover dental services you get from an out-of-network dental provider.  In addition, the codes for the pontics 
and crowns you received are not listed as covered services in your Dental Benefit chart for 2020. 
 
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 pontics (code D6240) and crowns (code D6750) you received from an out-of-network dentist on August 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the filling (D2335) provided on February 2, 2022. 
 
You asked the Plan to pay for the dental service. You say that you need this service. The Plan denied your 
request. The Plan says filling 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested filling is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the filling (D2335) 
provided on February 2, 2022.