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

 
We decided that the Plan does not have to waive the copayment for an arthrocentesis provided on October 5, 
2022. 
 
You asked the Plan to waive the copayment for an arthrocentesis. You say that you have not been charged this 
copayment amount for this service in the past. 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 $390 
copayment for outpatient surgery.  
 
You have been asked to pay a $287.58, which is less than the standard $390 copayment for an arthrocentesis. 
This item/service falls within the outpatient surgery benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for an arthrocentesis provided on October 5, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollees needs a SNF due to lack of awareness 
and risk of falling. The Plan denied your request. The Plan says a SNF admission is not medically necessary, 
and the enrollee's needs can be met at an alternate level of care. 
 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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing or skilled therapy on an inpatient basis in a SNF 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 SNF care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on September 
20, 2022. 
 
You asked the Plan to pay for the dental service. You say that you were told the service being provided would 
be a routine cleaning. 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 Plan 
previously paid for periodontal maintenance on December 8, 2021, and May 3, 2022. The record shows your 
benefit for the requested item or service was exhausted on date of service May 3, 2022. Therefore, we decided 
that the Plan does not have to pay for the periodontal maintenance (D4910) provided on September 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that this item is medically necessary. The Plan 
denied your request. The Plan says this item is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our reviewer says 
that this item is not medically necessary. Our physician reviewer found this patient has severe obesity and 
obesity hypoventilation syndrome. There is no diagnosis of COPD, thoracic restrictive disease, or 
neuromuscular disease. The patient was recently hospitalized, and arterial blood gas was consistent with acute 
on chronic hypercarbic respiratory failure. This patient may benefit from bi-level positive airway pressure (BiPAP) during sleep. There is no evidence in the record that this has been tried and failed as an outpatient. 
Medicare does not cover a home ventilator for the treatment of obesity hypoventilation syndrome, or when 
used at settings that can be provided with BiPAP. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown restoration (D2740). 
 
You asked the Plan to pre-approve a crown restoration. You say that you need this, so your bite does not move. 
The Plan denied your request. The Plan says the medical criteria for D2740 have not been met. 
 
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 covers a crown 
restoration 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 a crown restoration. Our physician 
reviewer found the documentation provided does not meet the criteria for coverage for a crown restoration 
(D2740) for tooth #2 to allow for a permanent retainer attachment. 
  
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 a crown restoration have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a crown restoration (D2740).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic radiographic image (D0330) provided on 
October 19, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are requesting reconsideration of the cost 
share towards the services rendered. 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 November 18, 2020. 
Therefore, we decided that the Plan does not have to pay for a panoramic radiographic image (D0330) provided 
on October 19, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for vertebral corpectomy (procedure code 63081) provided to 
the enrollee on July 3, 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 the records do not support the services billed. 
 
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 63081 is "Vertebral corpectomy (vertebral body 
resection), partial or complete, anterior approach with decompression of spinal cord and/or nerve root(s); 
cervical, single segment." 
 
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 operative note does not 
document the performance of a vertebral corpectomy. CPT 63081 is not supported. 
 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 vertebral corpectomy (procedure code 63081) provided to the enrollee on July 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120) provided on September 
13, 2022. 
 
You asked the Plan to pay for the dental service. You say that you would like the dental service authorized and 
paid. 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 Plan paid 
for oral evaluations on January 11, 2022, and February 14, 2022; therefore, the record shows your benefit for 
the requested item or service was exhausted on date of service February 14, 2022. Therefore, we decided that 
the Plan does not have to pay for a periodic oral evaluation (D0120) provided on September 13, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance emergency transport provided on September 
11, 2021. 
 
You asked the Plan to pay for the ambulance emergency transport. You say that the medical records provided 
support the need for the ambulance transport. The Plan denied your request. The Plan says the claim was not 
received within the allowed 12 months from the date of service. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the ambulance emergency transport was not filed until October 6, 2022. This 
means that more than one calendar year from the date of service had passed before a claim was filed. 
Therefore, we decided that the Plan does not have to pay for the ambulance emergency transport provided on 
September 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation, bitewing x-ray, intraoral x-rays, 
and dental cleaning (D0120, D0274, D0230, D0220, D1110) provided on December 27, 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. The bitewing and intraoral x-rays 
(D0274, D0230, D0220) denied correctly as they do not fall under your dental 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 a periodic oral evaluation, bitewing x-ray, intraoral x-rays, and dental cleaning (D0120, D0274, 
D0230, D0220, D1110) provided on December 27, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the chest x-ray (71045) provided on July 30, 2021. 
 
You asked the Plan to pay for the chest x-ray. You say that this claim was filed to the insurance on August 24, 
2021. You also say that you would like this to be reviewed and for payment to be issued on this claim. The 
Plan denied your request. The Plan says that the initial claim submission must be received within 180 days 
from the service date. 
 
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. The records do not support that the initial claim submission must be received 
within 180 days from the service date. This means that the Plan has not provided a valid reason for denying 
payment of the chest x-ray. It is the burden of the Health Plan to substantiate their denial with evidence. In this 
case, the denial has not been substantiated so we must find in your favor. Therefore, we decided that the Plan 
has to pay for the chest x-ray (71045) provided on July 30, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the combinatorial pharmacogenomic test (81479) provided 
on September 27, 2022. 
 
You asked the Plan to pay for the combinatorial pharmacogenomic test. You say that this testing was medically 
necessary. The Plan denied your request. The Plan says the claim for this molecular pathology testing did not 
include the required unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the combinatorial 
pharmacogenomic test have not been met. Therefore, we decided that the Plan does not have to pay for the 
combinatorial pharmacogenomic test (81479) provided on September 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the refraction provided on October 27, 2022. 
 
You asked the Plan to pay for the refraction. You say that you have never had to pay for an eye exam. The Plan 
denied your request. The Plan says the refraction is not a covered benefit.  
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when eye refractions are performed during a routine exam. 
 
We looked at the file and the Plan's rules. Specifically, the refraction was not performed with a routine eye 
exam. The medical record shows diagnoses of dry eye syndrome and the presence of intraocular lens which 
makes the exam medical in nature. Based on this information, we decided that the Plan's rules for coverage of 
the refraction have not been met. Therefore, we decided that the Plan does not have to pay for the refraction 
provided on October 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete maxillary denture (D5110) provided on August 
29, 2022. 
 
You asked the Plan to pay for a complete maxillary denture. You say that you have a $1,000 allowance for 
dental services. The Plan denied your request. The Plan says dentures are not a covered benefit. 
 
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 
complete maxillary denture (D5110) provided on August 29, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan 
provided on February 25, 2021, to July 13, 2022. 
 
You asked the Plan to waive the copayment for CT scan. You say that you disagree with the copayment. 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 $250 
copayment for outpatient diagnostic test/for Diagnostic Radiology services (CT, MRI, PET) in other facilities.  
 
You have been asked to pay a $250 copayment for CT scan. This item/service falls within the outpatient 
diagnostic test/for Diagnostic Radiology services (CT, MRI, PET) in other facilities 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 computed tomography (CT) scan provided on February 
25, 2021, to July 13, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee cannot walk or use their hands and 
needs assistance while doing activities of daily living. The Plan denied your request. The Plan says a SNF 
admission is not medically necessary. 
 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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing or skilled therapy on an inpatient basis in a SNF 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 SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intraosseous ablation of the basivertebral nerve (64628). 
 
You asked the Plan to pre-approve an Intracept procedure. You say that the enrollee needs this procedure due 
to chronic back pain. The Plan denied your request. The Plan says unproven and not medically necessary 
procedures are not covered by Medicare. 
 
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 an Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Intracept procedure is experimental and investigational. There is more research 
needed due to insufficient evidence of efficacy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve intraosseous ablation of the basivertebral nerve (64628).