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

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140), periapical x-ray (D0220), 
an additional periapical x-ray (D0230), bitewing x-rays (D0274), and prophylaxis (D1110) provided on January 
24, 2022. 
 
You asked the Plan to pay for the dental services. You say that the office manager told you that the provider 
was in-network. 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 a limited oral evaluation (D0140), periapical x-ray (D0220), an additional periapical x-ray (D0230), 
bitewing x-rays (D0274), and prophylaxis (D1110) provided on January 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic radiographic image (D0330) and oral hygiene 
instructions (D1330) provided June 22, 2021. 
 
You asked the Plan to pay for the dental services. You say that this dentist is in-network. The Plan denied your 
request. The Plan says your benefit for the x-ray has already been exhausted. The oral hygiene instructions are 
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, certain limitations apply. The record 
shows your benefit for the panoramic x-ray was exhausted on date of service July 28, 2021. The oral hygiene 
instructions are not covered under your benefits.  Therefore, we decided that the Plan does not have to pay for 
the panoramic radiographic image (D0330) and oral hygiene instructions (D1330) provided June 22, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical 
record supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a 
reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2740), prophylaxis (D1110), and oral hygiene 
instructions (D1330) provided on February 10, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says your annual maximum dental benefit has been exhausted. 
 
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 the Plan covers up to $1,500 
every year for non-Medicare covered preventive dental services and non-Medicare covered 
comprehensive dental services combined. The contract also says you are responsible for any amount above the 
dental coverage limit.  
 
The record shows you have exhausted your annual dental maximum amount during the processing of this 
claim. You have been asked to pay a total of $111 for dental services over the annual maximum amount. The 
dental services fall within the Dental 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 pay for a crown 
(D2740), prophylaxis (D1110), and oral hygiene instructions (D1330) provided on February 10, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from 
March 23, 2022, to March 28, 2022. 
 
You asked the Plan to waive the copayment for the inpatient care. You say that you were diagnosed with 
appendicitis and did not have surgery until April 25, 2022. 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 $315 per 
day for days 1-6 and $0 per day after day 6 for each inpatient stay.  
 
The file shows that you were in the hospital from March 23, 2022, to March 28, 2022, but there is no 
copayment for the discharge date. Therefore, you have been asked to pay $315 per day for 5 days of inpatient 
care. The total for your stay is $1,575 ($315 copayment x 5 days = $1,575). The inpatient care falls within the 
Inpatient Hospital 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 inpatient 
hospital care provided from March 23, 2022, to March 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a guided tissue regeneration (D4266) provided by a 
participating provider. 
 
You asked the Plan to pre-approve a guided tissue regeneration. You say that you would like the plan to pay for 
this. The Plan denied your request. The Plan says the requested dental service is 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 pre-approve a 
guided tissue regeneration (D4266) provided by a participating provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the sleep study (CPT code 95811). 
 
You asked the Plan to pre-approve the sleep study. You say that the enrollee has been diagnosed with 
obstructive sleep apnea (OSA). You state that the enrollee has had some weight loss, is experiencing 
headaches, increased daytime sleepiness, as well as an increase in high blood pressure and you are concerned. 
The Plan denied your request. The Plan says a sleep study has already been performed prior and at that time 
sleep parameters were established. The Plan states there is no information that supports a repeat study. 
 
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 sleep study. Our physician reviewer 
found repeat sleep study is requested for retitration of CPAP. However, there was no detail documented 
describe the enrollee having worsening signs or symptoms of sleep apnea since the 2017 titration and the 
enrollee had only gained 5 pounds. The details of how the CPAP was malfunctioning were not described in the 
notes. Therefore, without sufficient support made for this request, the repeat sleep study will be considered not 
medically necessary at this time. 
 
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 sleep study have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the sleep study (CPT code 95811).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve guided tissue regeneration (D4266) and bone 
replacement graft for ridge preservation (D7953) for tooth # 3. 
 
You asked the Plan to pre-approve the dental services. You say that the services are medically necessary. The 
Plan denied your request. The Plan says the requested 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested guided tissue 
regeneration and bone replacement graft for ridge preservation for tooth # 3 are not among those covered under 
this benefit. Therefore, we decided that the Plan does not have to pre-approve guided tissue regeneration 
(D4266) and bone replacement graft for ridge preservation (D7953) for tooth # 3.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76942 billed for date of service March 11, 
2022. 
 
You asked the Plan to pay for procedure code 76942. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76942 is bundled into payment for 
code 90553. 
 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, we have confirmed that code 76942 
is a column II code to column I code 90553. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 76942 billed for date of service March 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for electrical stimulation you received from a chiropractor on 
May 3, 2022. 
 
You asked the Plan to pay for the electrical stimulation. You say that your chiropractor recommended this 
service and it helped with your pain.  You said that you did not know that this service would not be covered. 
The Plan denied your request. The Plan says this is not a covered service. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for electrical stimulation you received from a chiropractor on May 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for endodontic therapy (D3320), internal root repair (D3333), 
and a diagnostic consultation (D9310), provided by a participating provider on March 24, 2022. 
 
You asked the Plan to pay for dental services. You say that you would like the plan to pay for half of this. The 
Plan denied your request. The Plan says the rendered dental work is 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 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 endodontic therapy (D3320), internal root repair 
(D3333), and a diagnostic consultation (D9310), provided by a participating provider on March 24, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve fam-trastuzumab deruxtecan-nxki (J9358). 
 
You asked the Plan to pre-approve fam-trastuzumab deruxtecan-nxki. You say that this is medically necessary. 
The Plan denied your request. The Plan says the requested use is not supported. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 fam-trastuzumab deruxtecan-nxki. Our 
reviewer says that the requested use of fam-trastuzumab deruxtecan-nxki is not supported. Our physician 
reviewer found the record indicates that the enrollee has a diagnosis of recurrent uterine serous carcinoma. The 
Food and Drug Administration has not stated that the requested drug is indicated for the enrollee's condition. 
The Medicare-approved cancer drug compendia do not support the use of the requested drug in the enrollee's 
clinical situation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of fam-trastuzumab deruxtecan-nxki have not been met. Therefore, we decided 
that the Plan does not have to pre-approve fam-trastuzumab deruxtecan-nxki (J9358).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service February 26, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that this claim was denied as a duplicate in error. 
The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for code 70496. 
 
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, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 70450 billed for date of service February 26, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) and fluoride varnish 
(D1208), provided by a participating provider on April 20, 2022, to April 26, 2022. 
 
You asked the Plan to pay for dental services. You say that you would like the plan to pay for this. The Plan 
denied your request. The Plan says the rendered dental work is 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 limited 
oral evaluation (D0140) and fluoride varnish (D1208), provided by a participating provider on April 20, 2022, 
to April 26, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not require treatment by multiple therapies, including either physical therapy 
or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a 
need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided in a different level of care. There is not a reasonable 
expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 2D oral/facial photographic images (D0350 x 4) provided on 
April 14, 2022. 
 
You asked the Plan to pay for the images. You say that you were told that x-rays were covered. The Plan 
denied your request. The Plan says 2D oral/facial photographic images (D0350) are not covered by 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. 
 
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 2D 
oral/facial photographic images (D0350 x 4) provided on April 14, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a joint injection performed on March 31, 
2022. 
 
You asked the Plan to waive the copayment for the injection. You say that you feel the copayment amount is 
incorrect. 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 $350 
copayment per visit for surgery or services at a hospital outpatient facility.  
 
You have been asked to pay $297.77, which is less than the $350 copayment for the injection. The injection 
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 waive the copayment for a joint 
injection performed on March 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral exam (D0120), bitewings (D0274), and 
prophylaxis (D1110), provided by an out-of-network provider on April 7, 2022. 
 
You asked the Plan to pay for dental services. You say that you needed these services done. The Plan denied 
your request. The Plan says services provided by an out-of-network provider 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 covers covered 
dental services when the services are provided by a participating provider. 
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of dental services have not been met. Therefore, we decided that the Plan does not have to pay for a 
periodic oral exam (D0120), bitewings (D0274), and prophylaxis (D1110), provided by an out-of-network 
provider on April 7, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI) you 
had on January 24, 2022. 
 
You asked the Plan to waive the copayment for the MRI. You say that this amount is a financial hardship for 
you and you believe the Plan should pay for this service in full. 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 $50 
copayment for diagnostic radiology and complex imaging services.  
 
You have been asked to pay a $50 copayment for the MRI. The MRI falls within the diagnostic radiology and 
complex imaging 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 the 
magnetic resonance imaging (MRI) you had on January 24, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Repatha Sureclick. 
 
You asked the Plan to pre-approve Repatha Sureclick. The Plan denied your request. The Plan says Repatha 
Sureclick is a self-administered drug. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Repatha Sureclick.  
 
Benefits for Repatha Sureclick may be available under Medicare Part D. Contact the Plan that administers Part 
D benefits for further information concerning any benefits and appeal rights.