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

 
We decided that the Plan does not have to pre-approve incisional biopsy of oral tissue-soft (D7286), excision of 
benign lesion greater than 1.25 cm (D7411), therapeutic parenteral drugs, two or more administrations, 
different medications (D9612), deep sedation/general anesthesia  first 15-minutes (D9222) and deep 
sedation/general anesthesia  each subsequent 15-minute increment (D9223). 
 
You asked the Plan to pre-approve dental services. You say that you really need the requested services 
approved for your dental health. The Plan denied your request. The Plan says these services are not covered 
under your 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. The requested D7286, D7411, 
D9612, D9222 and D9223 are not covered under the Plans dental benefits. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D7286, D7411, D9612, 
D9222 and D9223 are not among those covered under this benefit. Therefore, we decided that the Plan does not 
have to pre-approve incisional biopsy of oral tissue-soft (D7286), excision of benign lesion greater than 1.25 
cm (D7411), therapeutic parenteral drugs, two or more administrations, different medications (D9612), deep 
sedation/general anesthesia  first 15-minutes (D9222) and deep sedation/general anesthesia  each subsequent 
15-minute increment (D9223).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custom fabricated abutment - includes placement for 
teeth #28, #30 (D6057), abutment supported porcelain/ceramic crown for teeth # 28, #30 (D6058), pontic - 
porcelain/ceramic for tooth #29 (D6245) and interim crown for teeth #19, 20, 28, 29 and #30 (D2799). 
 
You asked the Plan to pre-approve the dental services. You say that this should be covered. The Plan denied 
your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service . Therefore, we decided that the Plan does not have to pre-approve custom fabricated abutment - includes placement for teeth #28, #30 
(D6057), abutment supported porcelain/ceramic crown for teeth # 28, #30 (D6058), pontic - porcelain/ceramic 
for tooth #29 (D6245) and interim crown for teeth #19, 20, 28, 29 and #30 (D2799).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve acupuncture treatments. 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says that you do not meet criteria for coverage of the 
requested services. 
 
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. Specifically, the Plan has stated that you do not meet criteria for coverage of the 
requested services in this case as you do not have chronic low back pain. However, the Plan offers 
supplemental coverage for acupuncture services through the Wellness allowance benefit. The Plan has not 
stated why you do not meet criteria for coverage of acupuncture services through this benefit. The Plan has not 
substantiated their denial; therefore, we must find in your favor. Therefore, we decided that the Plan has to pre-
approve acupuncture treatments.  
 
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: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 continuous glucose monitor (CGM) 
and supplies. 
 
You asked the Plan to pre-approve the CGM and supplies. You say that the CGM is a medical necessity as it is 
difficult for the enrollee to test her blood glucose levels manually three times a day. The Plan denied your 
request. The Plan says the enrollee does not require insulin three or more times daily. 
 
 
 The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
the CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Freestyle Libre 2 continuous glucose monitor (CGM) and supplies.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pontics (D6245) for tooth #8 and #9. 
 
You asked the Plan to pre-approve the dental services. You say that you have never had this procedure done 
before and it is an urgent procedure. The Plan denied your request. The Plan says your benefit for the requested 
items or services has already been exhausted. 
 
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, certain limitations apply. The record 
shows the Plan pre-approved pontics (D6245) for tooth #7 and #10 and retainer crowns (D6740) for tooth #6 
and #11 on February 14, 2023; therefore, your benefit for the requested items or services was exhausted on the 
date of approval of February 14, 2023. Therefore, we decided that the Plan does not have to pre-approve 
pontics (D6245) for tooth #8 and #9.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care supplies provided on October 10, 2022. 
 
You asked the Plan to pay for wound care supplies. You say that these items/services do not require 
authorization. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for wound care supplies 
provided on October 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive series of radiographic images (D0210), a 
2D oral imaging (D0350), periodontal scaling and root planing (D4341), gingival irrigation (D4921), fluoride 
varnish (D1206), oral hygiene instructions (D1330), saliva sample for diagnostic testing (D0417), and analysis 
of saliva sample (D0418), provided on December 13, 2022. 
 
You asked the Plan to pay for the dental services. You say that you feel like you were misled with dental 
information. The Plan denied your request. The Plan says the rendered dental services are not covered benefits. 
 Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans 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 
comprehensive series of radiographic images (D0210), a 2D oral imaging (D0350), periodontal scaling and 
root planing (D4341), gingival irrigation (D4921), fluoride varnish (D1206), oral hygiene instructions (D1330), 
saliva sample for diagnostic testing (D0417), and analysis of saliva sample (D0418), provided on December 13, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a C scan of the heart. 
 You asked the Plan to pre-approve a CT scan of the heart. You say that your cholesterol is continuing to rise 
and are needing a CT scan as soon as possible. The Plan denied your request. The Plan says a CT scan of the 
heart is 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 a CT scan of the heart. Our reviewer 
says that the requested CT scan of the heart is not medically necessary. Our physician reviewer found that there 
is insufficient support in the documentation demonstrating a benefit of a CT scan of the heart with quantitative 
evaluation of coronary calcium in guiding optimal management. The CT scan of the heart without contrast 
material with quantitative evaluation of coronary calcium is considered experimental or investigational for the 
evaluation and management of your medical condition. 
 
   
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a CT scan of the heart have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a C scan of the heart.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an occlusal guard (D9944) provided on November 1, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the dental services were received from an out-of-
network provider and are not covered by your supplemental 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. 
 
 
  The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for an occlusal guard (D9944) provided on November 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (procedure code 99205) rendered on October 
27, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) code 99205 (1 unit) remains 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 99205 is "Office or other outpatient visit for the 
evaluation and management of a new patient, which requires a medically appropriate history and/or 
examination and high level of medical decision making. When using time for code selection, 60-74 minutes of 
total time is spent on the date of the encounter." 
 
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 not supported by the medical records. Our reviewer found that the records did not support a high 
level of decision making and 60-74 minutes of services rendered.  
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 not been met. Therefore, we decided that the Plan does not 
have to pay for an office visit (procedure code 99205) rendered on October 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the surgical procedure to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the surgical procedure. You say that you would like to see this out-of-
network provider. The Plan denied your request. The Plan says you must receive your care from a network 
provider. 
 
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 
the surgical procedure to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided on September 19, 2022. 
 
You asked the Plan to pay for imaging services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says this add on code was billed without an appropriate 
primary procedure. 
 
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 77001 is Fluoroscopic guidance for central venous access 
device placement, replacement (catheter only or complete), or removal (includes fluoroscopic guidance for 
vascular access and catheter manipulation, any necessary contrast injections through access site or catheter with 
related venography radiologic supervision and interpretation, and radiographic documentation of final catheter 
position) (List separately in addition to code for primary procedure). 
 We find that CPT code 77001 is not supported in the medical record. Specifically, the records do not support 
that fluoroscopic guidance was used in relation to the placement of a central venous access device. Based on 
this information, we decided that Medicare rules for coverage of imaging services provided have not been met. 
Therefore, we decided that the Plan does not have to pay for imaging services provided on September 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the walker provided on December 21, 2021. 
 
You asked the Plan to pay for the walker. You say that the equipment was medically necessary. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the walker provided on 
December 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for debridement procedures on the skin provided on November 
16, 2022. 
 
You asked the Plan to pay for debridement procedures on the skin. You say that the records attached support 
the services provided. The Plan denied your request. The Plan says that unauthorized, out-of-network care is 
not covered. 
 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for debridement procedures 
on the skin provided on November 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on November 30, 2022. 
 
You asked the Plan to pay for the office visit. You say that the services were medically necessary. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the office visit provided 
on November 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation, periapical first x-ray, two 
periapical additional x-rays, prophylaxis and bitewing x-rays provided on November 17, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are appealing the denial. The Plan denied 
your request. The Plan says the dental services were received from an out-of-network provider and are not 
covered by your supplemental 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. 
 
 
  The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for the periodic oral evaluation, periapical first x-ray, two periapical additional x-rays, prophylaxis and 
bitewing x-rays provided on November 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive periodontal evaluation - new or established 
patient (D0180) and cone beam CT capture and interpretation with field of view of both jaws; with or without 
cranium (D0367) provided on November 22, 2022. 
 
You asked the Plan to pay for dental services. You say that this was a diagnostic service, so you do not 
understand why it would not be covered. The Plan denied your request. The Plan says these services are not 
covered under your 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. Comprehensive periodontal 
evaluation - new or established patient (D0180) and cone beam CT capture and interpretation with field of view 
of both jaws; with or without cranium (D0367) are not covered under the Plans dental benefits. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D0180 and D0367 are 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
comprehensive periodontal evaluation - new or established patient (D0180) and cone beam CT capture and 
interpretation with field of view of both jaws; with or without cranium (D0367) provided on November 22, 
2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room visit provided on June 
21, 2022. 
 
You asked the Plan to waive the copayment for the emergency room visit. You say that you only went to the 
ER to receive an antibody injection, as it was the only facility that had it. The Plan denied your request. The 
Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 
copayment for emergency care. 
 
You have been asked to pay a $90 copayment for the emergency room visit. This item/service falls within the 
emergency care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayment for the emergency room visit 
provided on June 21, 2022.