Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care from June 10, 2022, 
through June 14, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that the enrollee shouldn't have 
to pay these charges. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $390 copayment per day for days 1-5 for inpatient hospital care.  
 
The enrollee has been asked to pay a $1560 ($390 x 4 = $1560) copayment for inpatient hospital care. This 
item/service falls within the inpatient hospital care benefit category. This means that the enrollee has been 
asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual 
obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not 
have to waive the copayment for inpatient hospital care from June 10, 2022, through June 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on June 28, 2022. 
 
You asked the Plan to pay for the dental services. You say that you don't recall any other visits with code 
D0150. 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 September 1, 2020. 
Therefore, we decided that the Plan does not have to pay for the dental services on June 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high dose rate electronic brachytherapy (0394T) and 
therapeutic radiology simulation-aided field setting (77280). 
 
You asked the Plan to pre-approve brachytherapy. You say that Brachytherapy is the best option for the 
enrollee since it delivers high dose of radiation directly to the tumor while sparring healthy tissues nearby. 
Brachytherapy patients have minimal recovery time and typically experience few or no side effects that can be 
associated with the treatment. The Plan denied your request. The Plan says the enrollee does not meet 
guidelines for medical necessity. 
 
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 brachytherapy. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has a diagnosis of basal cell carcinoma on the left forearm. It is documented that 
the BCC could be removed via multiple methods, including surgical excision and radiation therapy. NCCN 
states that radiation therapy should be utilized for poorly vascularized or cartilaginous area. There are 
insufficient long-term efficacy and safety data to support the routine use of electronic surface brachytherapy.  
Radiation therapy is generally to be avoided for lesions located on the trunk or extremities. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of brachytherapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a high dose rate electronic brachytherapy (0394T) and therapeutic radiology simulation-
aided field setting (77280).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve rebase mandibular partial denture tooth #17 and 32 
(D5721). 
 
You asked the Plan to pre-approve dental services. You say that it does not make sense that the Plan would tell 
you to go the most expensive route and have new dentures made. It would cost less if the Plan would allow you 
to get your dentures fixed. The Plan denied your request. The Plan says this service is 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. Rebase mandibular partial 
denture (D5721) is not covered under the Plans dental benefits. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested rebase mandibular partial 
denture tooth #17 and 32 (D5721) is not among those covered under this benefit. Therefore, we decided that 
the Plan does not have to pre-approve rebase mandibular partial denture tooth #17 and 32 (D5721).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve osseous surgery (D4261). 
 
You asked the Plan to pre-approve osseous surgery. You say that this service is medically necessary. The Plan 
denied your request. The Plan says osseous surgery (D4261) is not covered by your supplemental 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 pre-approve 
osseous surgery (D4261).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the Cerebral perfusion analysis using computed tomography (0042T) 
provided on May 6, 2022. 
 
You asked the Plan to pay for procedure code 0042T. You say that the provided Cerebral perfusion analysis 
using computed tomography on May 6, 2022, was medically necessary. The Plan denied your request. The Plan 
says that the enrollee does not meet criteria for the Cerebral perfusion analysis using computed tomography 
provided on May 6, 2022. 
 
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 pay for procedure code 0042T. Our reviewer says 
that the enrollee does not meet criteria for the Cerebral perfusion analysis using computed tomography 
provided on May 6, 2022. Our physician reviewer found the enrollee had acute aphasia. Stroke code was 
initiated, and CT perfusion was requested due to clinical symptoms which ultimately had resolved. The use of 
CT perfusion to search for penumbra or brain at risk for ischemia is typically a standard of practice in stroke 
protocols. This should be approved. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 0042T have been met. Therefore, we decided that the Plan has 
to pay for the Cerebral perfusion analysis using computed tomography (0042T) provided on May 6, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal scaling and root planing - four or more teeth per 
quadrant (D4341) provided on April 27, 2022, to May 18, 2022. 
 
You asked the Plan to pay for dental services. You say that you have paid your premiums so the service should 
be covered under your plan. The Plan denied your request. The Plan says this service is 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. Periodontal scaling and root 
planing - four or more teeth per quadrant (D4341) is not covered under the Plans dental benefits. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested periodontal scaling and 
root planing - four or more teeth per quadrant (D4341) is not among those covered under this benefit. 
Therefore, we decided that the Plan does not have to pay for periodontal scaling and root planing - four or more 
teeth per quadrant (D4341) provided on April 27, 2022, to May 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral x-ray and crown (D0220, D2750) provided on 
July 7, 2022 to July 8, 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. 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 intraoral x-ray and crown (D0220, D2750) provided on July 7, 2022 to July 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wheelchair accessory, power seat elevation system 
(E2300). 
 
You asked the Plan to pre-approve a wheelchair accessory. You say that the enrollee requires the requested 
wheelchair and all recommended components to meet his mobility, medical and functional needs in his home. 
The Plan denied your request. The Plan says the requested seat elevation system does not serve a primary 
medical purpose and is statutorily non-covered. 
 The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a wheelchair accessory, power seat elevation system 
(E2300).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electric stimulation therapy (97014) provided from  
June 1, 2022, through June 8, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not covered under your 
contractual policy or by Medicare. 
 
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 services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the electric stimulation therapy (97014) provided from June 1, 2022, 
through June 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation - problem focused (D0140), and 
intraoral - periapical first radiographic image (D0220) provided on April 26, 2022. 
 
You asked the Plan to pay for a limited oral evaluation - problem focused (D0140), and intraoral - periapical 
first radiographic image (D0220). You say that the receptionist at the dental office told you that the services 
were covered and not to worry. The Plan denied your request. The Plan says these services are not covered 
under the benefit package. 
 
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 - problem focused (D0140), and intraoral - periapical first radiographic image (D0220) 
provided on April 26, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an IRF after October 24, 2022.

You asked the Plan to pre-approve IRF care. You say that at issue is an IRF admission. The Plan denied your request. The Plan says IRF is not medically necessary.

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 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.

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 admission to an IRF after October 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided from March 15, 2022, to 
March 20, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for inpatient hospital care. You say that the services were medically necessary The 
Plan denied your request. The Plan says the enrollee must receive 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 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 inpatient hospital care provided from March 15, 
2022, to March 20, 2022 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve deep sedation/general anesthesia (D9223, D9222) 
 
You asked the Plan to pre-approve the deep sedation/general anesthesia. You say that the services should be 
covered as you disagree with the charges and denial. The Plan denied your request. The Plan says the services 
denied correctly as they do not fall within 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 pre-approve deep 
sedation/general anesthesia (D9223, D9222)
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the treatment of post-surgical complications of teeth #19 
and #20 (D9930). 
 
You asked the Plan to pre-approve the dental services. You say that the enrollee experiences anxiety with 
dental procedures and prefers sedation rather than local anesthetic. The Plan denied your request. The Plan says 
the enrollees dental benefit does not allow for coverage of dental code D9930, treatment of post-surgical 
complications.  
 
The Plan also states that codes D9222 and D9223 for general anesthesia have been approved. The Plan 
provided an authorization number for these services. Please contact the Plan for further information regarding 
these approved codes. 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 the 
treatment of post-surgical complications of teeth #19 and #20 (D9930).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an occlusal guard (D9944). 
 
You asked the Plan to pre-approve an occlusal guard. The Plan denied your request. The Plan says this service 
is 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. 
 
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 an 
occlusal guard (D9944).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pathology services provided on April 26, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for pathology services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 pathology services provided on April 26, 2022, by 
an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer. 
 
You asked the Plan to pre-approve Injectafer. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee has been taking oral iron. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Injectafer. Our reviewer says that the 
requested Injectafer is not medically necessary. Our physician reviewer found the record indicates that the 
enrollee has a diagnosis of iron deficiency and thrombocytosis. The enrollee has a normal hemoglobin and 
takes oral iron daily. Injectafer is not indicated for the enrollee's 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 Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical implants (D6190), an endosteal implant 
(D6010), an extraction (D7210), a bone replacement graft (D7953), a guided tissue regeneration (D4267), and a 
sinus augmentation (D7951), provided by an out-of-network provider. 
 
You asked the Plan to pre-approve surgical implants, an endosteal implant), an extraction, a bone replacement 
graft, a guided tissue regeneration, and a sinus augmentation. You say that you need these services. The Plan 
denied your request. The Plan says the enrollee does not have a platinum dental rider; therefore, these services 
have been correctly denied. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement 
of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or 
paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve surgical implants 
(D6190), an endosteal implant (D6010), an extraction (D7210), a bone replacement graft (D7953), a guided 
tissue regeneration (D4267), and a sinus augmentation (D7951), provided by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the home ventilator (CPT code E0466).

You asked the Plan to pre-approve the home ventilator. You say that the DME is medically necessary. The Plan denied your request. The Plan says the Medicare rules have not been met.

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 the home ventilator. Our physician reviewer found Medicare does not cover a home ventilator for the treatment of obesity hypoventilation syndrome (OHS), or when used as bi-level positive airway pressure (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 the home ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve the home ventilator (CPT code E0466).