Persius/hicric huggingface dataset:
Appeal type: ER
Decision: Partially Favorable

 
We decided that the Plan has to pay for the emergency department visit (99285). We decided that the Plan does 
not have to pay for the service(s) provided between 10:00 PM and 8:00 AM at 24-hour facility (99053).  
 
You asked the Plan to pay for the emergency department visit (99285). You say that you would like 
reconsideration based on the records submitted. The Plan says that CPT code 99053 has a status indicator of B 
 
We decided that the Plan has to pay for the emergency department visit (99285).  
 
The Plan follows Medicare rules. Medicare rules say that Medicare plans must make reasonable and diligent 
efforts to gather and forward information to the Independent Review Entity (IRE). 
 
We looked at your request, the file and Medicare rules. Based on this information we have determined that 
criteria for coverage of the emergency department visit (99285) have been met. Specifically, the Plan has not 
forwarded any evidence as to why this service has been denied. It is the burden of the Health Plan to 
substantiate their denial with evidence. In this case, the Plan's denial has not been substantiated so we must find 
in your favor. Therefore, we decided that the Plan has to pay for the emergency department visit (99285).  
 
We also decided that the Plan does not have to pay for the service(s) provided between 10:00 PM and 
8:00 AM at 24-hour facility (99053). 
 
The Plan follows Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at your request, the file and Medicare rules. Based on this information we have determined that 
Medicare criteria for the the service(s) provided between 10:00 PM and 8:00 AM at 24-hour facility have not 
been met. Specifically, CPT code 99503 has a status indicator of B. This means that payment for this service is 
always bundled into the payment for another service or procedure. Therefore, we decided that the Plan does not 
have to pay for the service(s) provided between 10:00 PM and 8:00 AM at 24-hour facility (99053). 
 
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 laboratory services provided on September 30, 2021 by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed as 
extra specimens required testing. The Plan denied your request. The Plan says prior authorization was not 
obtained for these services rendered by an OON 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 the laboratory services provided on September 30, 
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 laboratory services provided on May 2, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says there is no coverage available for this 
service when provided to asymptomatic patients. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the laboratory services provided on 
May 2, 2021. have been met. In this case, there is no clinical information to determine why the testing was 
ordered or how the results would affect the enrollee's treatment. Therefore, we decided that the Plan does not 
have to pay for the laboratory services provided on May 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) 
provided on November 15, 2021. 
 
You asked the Plan to pay for the problem focused limited oral evaluation. You say that the oral evaluation 
seemed necessary to you because the crown came off and it could have become infected or developed rotting 
underneath. You also say that it was not a scheduled evaluation, but an emergency situation that required 
immediate attention and you feel payment should be granted. The Plan denied your request. The Plan says this 
service exceeds the frequency limitation in your benefit plan. 
 
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, problem focused limited oral 
evaluation (D0140) is limited to one procedure per plan year. The record shows that you received a problem 
focused limited oral evaluation (D0140) on April 22, 2021 and your problem focused limited oral evaluation 
(D0140) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the problem 
focused limited oral evaluation (D0140) provided on November 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periapical x-ray (D0220) provided on January 4, 2022. 
 
You asked the Plan to pay for the dental service. You say that an exception should be made. You say that you 
were not aware that your dental coverage only covers two x-ray exams to occur in the same calendar year. The 
Plan denied your request. The Plan says 2 dental x-rays are covered per calendar year. The Plan also says that 
the frequency limit has been exceeded. 
 
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 and periapical x-ray is listed as 
covered, the frequency limit has been exceeded.  
The record shows that the Plan paid for a periapical x-ray that you received on January 3, 2022, and bitewing 
x-rays you received on January 4, 2022. Therefore, we decided that the Plan does not have to pay for the 
periapical x-ray (D0220) provided on January 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prophylaxis (D1110) provided on November 9, 2021. 
 
You asked the Plan to pay for the prophylaxis. You say that you have severe gum loss, and the additional 
cleaning helps you to keep your gums healthy so that you do not have problems to maintain your teeth. The 
Plan denied your request. The Plan says this procedure exceeds the frequency limitations 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, prophylaxes are covered twice per 
year. The record shows that you received prophylaxes (D1110) on March 11, 2021, and July 13, 2021 and your 
prophylaxis (D1110) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for 
the prophylaxis (D1110) provided on November 9, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on October 5, 2021. 
 
You asked the Plan to pay for the lab services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says the lab tests are the responsibility of the 
dialysis center. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the 
lab services provided on October 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mandibular partial denture (D5214). 
 
You asked the Plan to pre-approve the mandibular partial denture. You say that the bridge you have had for a 
while is broken and you have tried to glue it together. You also say that you cannot eat properly, and your 
inside lip is raw from not being able to chew properly. The Plan denied your request. The Plan says this service 
is not covered under your benefit 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. 
 
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 
mandibular partial denture (D5214).
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the filling (D2394) provided on August 16, 2021. 
 
You asked the Plan to pay for the dental service. You say that this should be covered. The Plan denied your 
request. The Plan says that the provider in this case has opted out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the correct Evidence of Coverage was not provided. As a result, we 
cannot determine that the service is covered or not. Additionally, there is no documentation provided to support 
that the provider in this case has opted out of Medicare. Therefore, we decided that the Plan has to pay for the 
filling (D2394) provided on August 16, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture (D5213). 
 
You asked the Plan to pre-approve the maxillary partial denture. You say that you need a new denture because 
the teeth you had to sustain your previous bridge were removed. The Plan denied your request. The Plan says 
this service is not covered due to frequency. 
 
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, you are limited to one (1) denture per 
arch every five (5) years. The record shows that you received a maxillary partial denture (D5213) on October 
12, 2018 and your maxillary denture benefit has been exhausted. Therefore, we decided that the Plan does not 
have to pre-approve a maxillary partial denture (D5213).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says a review of the current medical literature indicates that this service is considered 
experimental and investigational as it is not identified as widely used and generally accepted for the proposed 
use as reported in nationally recognized peer-reviewed medical literature. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found current evidence based medical guideline and peer reviewed literature do not fully support the spinal 
decompression device procedure over the gold standard of lumbar laminectomy. There is a lack of large 
volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollees medical 
condition as discussed above. FDA indications include implantation of the Superion device at one or two 
adjacent lumbar levels in patients with moderate spinal stenosis in whom operative treatment is indicated at no 
more than two levels, from L1 to L5.  This enrollee has multiple degrees of spinal stenosis, many not at FDA indicated levels of moderate spinal 
stenosis (including the planned level of implantation L3-4). FDA contraindications include spinal instability, 
scoliosis, obesity, and osteoporosis, and which have not been adequately addressed in the medical records. 
(Height is  5 feet 3.25 inches; weight 242 pounds; and body mass index 42.53 kg/m2.) There is imaging 
evidence of scoliosis of the lumbar spine, with no documentation of the Cobb angle. There is no compelling 
rationale presented or extenuating circumstances noted to support the medical necessity of this request as an 
exception to guidelines. Therefore, the request for Vertiflex Superion interspinous device at L3/4 is not 
medically reasonable or 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 the device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Vertiflex device for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the re-cement or re-bond of a crown (D2920) provided on 
November 4, 2021. 
 
You asked the Plan to pay for the re-cement or re-bond of a crown. You say that when you were in the dental 
office you were told there was no copay for this service. 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 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 the re-
cement or re-bond of a crown (D2920) provided on November 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 requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 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 you do not have a need for intravenous 
medications, new tube feeding, ostomy care or daily complex wound care. You are walking household 
distances with contact guard assistance with a wheeled walker and is minimum assist for transfers. Provided 
records do not document a significant decline in your functional status compared to your recent baseline to 
necessitate daily inpatient skilled therapy services. You do not require the services on an inpatient basis, only in 
a skilled nursing facility setting. Services in the home with home health care or in a long-term care facility on a 
part time basis appear appropriate in this case. 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service September 4, 
2021. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for 70450 is bundled into payment for 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 September 4, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the comprehensive oral evaluation (D0150), bitewing 
x-rays (D0274), prophylaxis (D1110), resin-based composite (D2392), and core buildup, including any pins 
when required (D2950) provided on October 7, 2021, and October 12, 2021 by an out-of-network (OON) 
provider. 
 
You asked the Plan to pay more for the comprehensive oral evaluation, bitewing x-rays, prophylaxis, resin-
based composite, and core buildup. You say that you would like the Plan to pay a reasonable share, if not all of 
the costs for these services. The Plan denied your request. The Plan says the total liability amount applied 
correctly as your liability. The Plan also says that cost sharing is a contractual obligation under the Plan and 
cannot be waived. 
 
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, you are responsible for the difference 
between the billed amount and allowed amount for covered dental services that are received OON. Therefore, 
we decided that the Plan does not have to pay more for the comprehensive oral evaluation (D0150), bitewing x-
rays (D0274), prophylaxis (D1110), resin-based composite (D2392), and core buildup, including any pins when 
required (D2950) provided on October 7, 2021, and October 12, 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 the implant supported crown (D6065) provided on 
September 29, 2021. 
 
You asked the Plan to pay for the dental service. You say that the cost of the crown placement is the same 
regardless of what the crown is placed upon. You also say that this should be covered. The Plan denied your 
request. The Plan says implant supported crown is not listed as a covered service. 
 
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 implant supported crown is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
implant supported crown (D6065) provided on September 29, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services provided to the enrollee on August 4, 
2021. 
 
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 this service is not supported without the required documentation. 
 
The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the services have not been met. Specifically, the record does not include documentation of a 
consultation or an attempt to consult the enrollee's primary/attending physician as required by Medicare rules. 
Therefore, we decided that the Plan does not have to pay for psychotherapy services provided to the enrollee on 
August 4, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the individual psychotherapy services (90834) provided 
August 12, 2021. 
 
You asked the Plan to pay for the psychotherapy services. You say that this appeal should be granted because 
the services provided were medically necessary and meet all applicable professionally recognized standards of 
healthcare. The Plan denied your request. The Plan says the service is not supported without the required 
documentation.  
The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the psychotherapy services have not been met. Specifically, the record does not include 
documentation of a consultation or an attempt to consult the enrollee's primary/attending physician as required 
by Medicare rules. Therefore, we decided that the Plan does not have to pay for the individual psychotherapy 
services (90834) provided August 12, 2021.