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

 
We decided that the Plan does not have to reimburse you for the comprehensive oral evaluation (D0150), 
complete series x-ray (D0210), full mouth debridement (D4355), occlusion adjustment (D9910), extraction 
(D7210), and bone replacement graft (D7953) provided from May 26, 2021, to June 17, 2021. 
 
You asked the Plan to reimburse you for the dental services. You say that you called several in network dentists 
to make an appointment. You say that none of them had openings sooner than 3 to 4 weeks out. You say that 
you were in need of immediate care due to severe pain and swelling. You also say that the in network provider 
you saw initially was not able to provide the care you needed after waiting 2 hours in the office. The Plan 
denied your request. The Plan says the provider in this case is out of network. The Plan also says you must visit 
a participating dental network provider to receive dental 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 dental services you received are not 
among those covered under this benefit when received out of network. Therefore, we decided that the Plan does 
not have to reimburse you for the comprehensive oral evaluation (D0150), complete series x-ray (D0210), full 
mouth debridement (D4355), occlusion adjustment (D9910), extraction (D7210), and bone replacement graft 
(D7953) provided from May 26, 2021, to June 17, 2021.  
 
Your complaint about having to wait 2 hours at the in network dental office is not a valid appeal for medical 
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not 
permit us to make a decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on January 13, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services provided are not a covered benefit. 
 
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 the laboratory services provided on January 13, 
2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab services you received on June 16, 2021. 
 
You asked the Plan to waive the copayment for the lab services. You say that this lab service should be 
considered part of your annual physical. The Plan denied your request. The Plan says you were charged this 
copayment 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 $10 
copayment for lab services.  
 
The Plan contract says that an annual physical exam includes a bodily systems examination, measurement and 
recording of vital signs, a complete prescription medication review, and a review of recent hospitalizations.  It 
does not include lab services. You have been asked to pay a $10 copayment for the lab services. 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 lab services you received on 
June 16, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for an office visit (99214) provided on March 19, 2020.
You asked the Plan to pay for the office visit. You say that you would like reconsideration because the follow-up services were medically necessary. The Plan denied your request. The Plan says that payment for this service is included in the global surgery payment.
The Plan must follow Medicare rules. Medicare rules say that Medicare approved amount for these procedures includes payment for postoperative visits. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the office visit have been met. Specifically, the Plan has indicated that the surgery rendered on March 16, 2020 has been processed and denied. Payment for this service cannot be bundled into the global surgery package if the surgery has not been paid. Therefore, we decided that the Plan has to pay for an office visit (99214) provided on March 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the wound care supplies provided on June 29, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the wound care supplies. You say that you provide medically necessary surgical 
dressings for treatment. The Plan denied your request. The Plan says no prior authorization was obtained. 
 
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 did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The 
records provided for review do not show that the services at issue were urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for the wound care supplies provided on June 29, 2021, by an out-of-
network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for gingivectomy or gingivoplasty (D4211) provided on June 3, 
2021. 
 
You asked the Plan to pay for dental services. You say that you have an auto-immune disease which 
contributes to an acceleration of enamel breakdown. You also say that you would like the Plan to consider 
paying the denied services which were performed to prevent gumline infection. The Plan denied your request. 
The Plan says this service in question is not covered under any normal circumstance. 
 
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 records show that the Plan offers a dental Plan rider, and you were 
not enrolled in this rider at the date of service. Therefore, we decided that the Plan does not have to pay for 
gingivectomy or gingivoplasty (D4211) provided on June 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral exam (D0150), panoramic x-ray 
(D0330), five simple extractions (D7140 x5), resin-based composite of one surface (D2330), and resin-based 
composite of two surfaces (D2331) provided from March 18, 2021, to May 20, 2021, by an OON provider. 
 
You asked the Plan to pay for the comprehensive oral exam, panoramic x-ray, extractions, and resin-based 
composites. You say that you were told that this provider was OON, but the provider would receive a check for 
$897.00. The Plan denied your request. The Plan says these services were rendered by an OON provider. The 
Plan also says that prior authorization was not obtained. 

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 
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the 
comprehensive oral exam (D0150), panoramic x-ray (D0330), five simple extractions (D7140 x5), resin-based 
composite of one surface (D2330), and resin-based composite of two surfaces (D2331) provided from March 
18, 2021, to May 20, 2021, by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a prosthetic leg with an advanced foot, ankle, vertical 
loading pylon and other parts (L5968, L5981, L5988). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says a request for K3 prosthesis exceeds the enrollee's medical need. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the vertical loading pylon and other parts (L5968, L5981, L5988) exceeds your medical need. The 
physician documentation does not indicates that you are a K3 ambulator or require these requested items. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a prosthetic leg with an advanced foot, ankle, vertical loading pylon and other parts 
(L5968, L5981, L5988).
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve light therapy. 
 
You asked the Plan to pre-approve the light therapy. You say that you would like reconsideration because you 
have an autoimmune disorder and your physician recommended light therapy for your skin. The Plan denied 
your request. The Plan says that you do not have a covered indication for the requested light therapy. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 light therapy. Our reviewer says that 
the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found light therapy is the standard of care for your 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 the light therapy have been met. Therefore, we decided that the Plan has to pre-
approve light therapy.  
 
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 pay for the lead wires coded A4557 provided on March 18, 2021. 
 
You asked the Plan to pay for the lead wires. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the items provided are not separately payable. 
 
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 A4557 is lead wires, (e.g., apnea monitor), per pair. 
 
We find that CPT code A4557 is not supported in the medical record. Specifically, this code has a status code 
of "P". This means that payment for these items is always bundled into payment for other services not specified 
and no separate payment is made. Based on this information, we decided that Medicare rules for coverage of the lead wires have not been met. Therefore, we decided that the Plan does not have to pay for the lead wires 
coded A4557 provided on March 18, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on April 26, 2021. 
 
You asked the Plan to pay for the ambulance services. The Plan denied your request. The Plan says Original 
Medicare would be responsible for payment of all Medicare covered services related or unrelated to the 
member?s terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all 
hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-
for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until 
the first day of the month following the month in which hospice was revoked or discharged.  
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on April 2, 2021. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for ambulance services 
provided on April 26, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an auricular nerve stimulator. 
 
You asked the Plan to pre-approve an auricular peripheral nerve stimulator. You say that this requested device 
is medically necessary. The Plan denied your request. The Plan says this device is not eligible for coverage 
under Medicare rules. 
  
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. Medicare rules say that auricular peripheral nerve stimulation will be denied as 
noncovered. 
 
We looked at the file and Medicare rules. This service is not a covered Medicare benefit because acupuncture 
for auricular stimulation does not meet the definition of reasonable and necessary. Based on this information, 
we decided that Medicare rules for coverage of an auricular peripheral nerve stimulator have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an auricular nerve stimulator.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the visit you had at an otolaryngology 
office on July 20, 2020. 
 
You asked the Plan to waive the copayment for the otolaryngology visit. You say that you were only seen by a 
nurse practitioner, not a physician, so you don't think you should have to pay this copayment. The Plan denied 
your request. The Plan says you were charged this copayment 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 $40 
copayment for physician/practitioner specialist visits.  
 
 You have been asked to pay a $40 copayment for the otolaryngology visit. This copayment applies to both 
physician and practitioner specialists. 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 visit you had at 
an otolaryngology office on July 20, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removal/revision of a sacral nerve stimulator. 
 
You asked the Plan to pre-approve removal/revision of a sacral nerve stimulator. You say that the services are 
necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, 
coverage criteria have not been met. 
 
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 removal/revision of a sacral nerve 
stimulator. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the medical information provided is insufficient to 
determine whether removal/revision of sacral nerve stimulator is 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 removal/revision of a sacral nerve stimulator have not been met. Therefore, we 
decided that the Plan does not have to pre-approve removal/revision of a sacral nerve stimulator.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient facility services provided on May 4, 2021 by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient services. You say that you had to go to this clinic because they 
were the one who put the shunt in your liver, so you had to go back to them to deal with any issues with your 
liver. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-
network provider with the exception being urgent or emergent services. Non-emergent services with non-
contracted providers require prior authorization before services being rendered. 
 
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 the outpatient facility services provided on May 4, 
2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment testing provided on 
February 4, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that coverage for all CV risk assessment panels, 
except the basic lipid panel, is denied for symptomatic (with signs and symptoms) patients with suspected or 
documented CV disease because panel testing is not specific to a given patient?s lipid abnormality or disease.  
 
We looked at the file and Medicare rules. Per LCD L36358, the requested cardiovascular risk assessment panel 
is not a covered service. Based on this information, we decided that Medicare rules for coverage of the testing 
have not been met. Therefore, we decided that the Plan does not have to pay for the cardiovascular risk 
assessment testing provided on February 4, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing or 
skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter, 
you do not require the necessary services on an inpatient basis, in a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the duplex scan of extremity veins including responses to 
compression and other maneuvers (93971) provided on June 14, 2021, by an OON provider. 
 
You asked the Plan to pay for the extremity study. You say that the service was medically necessary. The Plan 
denied your request. The Plan says prior authorization was not obtained prior to the services being rendered to 
the enrollee. The Plan also says that the service was not urgent or emergent in nature. 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 in this case is not a network provider with the Plan.  The Plan did not pre-approve the extremity 
study. We found no exception that would require the Plan to pay for the extremity study. Therefore, we decided 
that the Plan does not have to pay for the duplex scan of extremity veins including responses to compression 
and other maneuvers (93971) provided on June 14, 2021, by an OON provider.