Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an emergency room visit (G8427, 99284, G9744) provided January 9, 2021.
You asked the Plan to pay for the emergency room visit. You say that this service was medically necessary. The Plan denied your request. The Plan says the diagnosis code submitted indicates that this service was a dental service and is non-covered.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of the enrollee's teeth or the structures directly supporting the enrollee's teeth.
These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for an emergency room visit (G8427, 99284, G9744) provided January 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown (D2740) provided on May 3, 2021.
You asked the Plan to pay for the crown. You say that this procedure was medically necessary to prevent the spreading of infection. The Plan denied your request. The Plan says this service is not covered. The Plan also says that during your call with the Plan, you were advised that crowns are not a covered benefit 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 crown (D2740) provided on May 3, 2021
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric care from September 12, 2021, 
forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from September 12, 2021, forward.. You say that 
the services at issue were medically necessary. The Plan denied your request. The Plan says the services at 
issue were not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric care from 
September 12, 2021, forward. Our reviewer says that the enrollee does not meet the criteria for treatment in an 
acute inpatient mental health treatment beyond the date in question of September 12, 2021, forward. Our 
physician reviewer found the enrollee did not require inpatient mental health treatment beyond September 12, 
2021, as she was not a danger to herself or others and did not have any delusions, auditory or visual 
hallucinations. It did not appear that active treatment was taking place beyond the date in question. It did not 
appear that the services for the dates in question were reasonably expected or medically necessary to improve 
the enrollee's condition or for the purpose of diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care from September 12, 2021, forward. have not been 
met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from 
September 12, 2021, forward.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite (D2392) provided on April 21, 
2021 by an OON provider. 
 
You asked the Plan to pay for the resin-based composite. You say that you were told that this treating provider 
was in-network. The Plan denied your request. The Plan says this service was rendered by a non-participating 
provider. Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the resin-
based composite (D2392) provided on April 21, 2021 by an OON provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Restasis. 
 
You asked the Plan to pre-approve Restasis. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee has a medical only policy which does not include Part D prescription 
coverage, therefore the criteria for self-administered drug coverage has not been met. 
 
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 Restasis.  
 
Benefits for Restasis may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the portable oxygen provided on March 25, 2021.
You asked the Plan to waive the coinsurance for the portable oxygen. You say that you believed you would not have any liability for your oxygen tank for two years. The Plan denied your request. The Plan says you have been asked to pay 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 20% coinsurance for durable medical equipment, oxygen/oxygen equipment and related supplies.
You have been asked to pay $10.70 which is 20% of the allowed amount for the portable oxygen. The allowed amount is $53.51. ($53.51 x 20% = $10.70). The portable oxygen falls within the "Durable medical equipment (DME) and related supplies" 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 coinsurance for the portable oxygen provided on March 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the prophylaxis and comprehensive oral evaluation 
provided on April 27, 2021. 
 
You asked the Plan to pay more for the prophylaxis and comprehensive oral evaluation. You say that there is 
no money left over after the rent and electric bills are paid. You say that you want to know if you should have 
paid this bill. The Plan denied your request. The Plan says the procedures codes were processed correctly 
according to your out-of-network benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the Plan is only obligated to pay the 
allowed amount for the prophylaxis and comprehensive oral evaluation from an out-of-network provider. You 
are responsible for any amount greater than what the Plan pays. Therefore, we decided that the Plan does not 
have to pay more for the prophylaxis and comprehensive oral evaluation provided on April 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the core build up (D2950 x 2) provided on March 22, 2021. 
 
You asked the Plan to pay for the dental services. You say that you did not get a crown. You also say that you 
though this was covered at the dentist office. The Plan denied your request. The Plan says core build up 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the core build up are not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the core build up 
(D2950 x 2) provided on March 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220) and panoramic x-ray (D0330) provided on April 19, 2021.
You asked the Plan to pay for the first intraoral periapical x-ray and panoramic x-ray. You say that the Plan advised that you had a dental cleaning and x-rays at no cost to you. You also say that you told the provider the same. The Plan denied your request. The Plan says these services are not covered by your benefits. The Plan also says that during your call with the Plan on April 19, 2021, you were given no misinformation.
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 first intraoral periapical x-ray (D0220) and panoramic x-ray (D0330) provided on April 19, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the comprehensive oral evaluation (D0150) provided on March 31, 
2021. 
 
You asked the Plan to pay for the dental service. You say that you have moved to a different state since your 
last dental appointment. You say that you had to see a new dentist since you moved. You also say that this 
should be covered. The Plan denied your request. The Plan says that 1 comprehensive or periodontal evaluation 
is covered every 3 years. 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. The Plan covers the dental 
service when the services are medically necessary and reasonable. 
 
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of the dental service have been met. Specifically, the frequency limit has not been exceeded for this 
service. The record shows that the comprehensive oral evaluation you received on August 21, 2020, was paid 
while you were enrolled in a different plan. Therefore, we decided that the Plan has to pay for the 
comprehensive oral evaluation (D0150) provided on March 31, 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for chemodenervation of muscle provided on 
March 29, 2021. 
 
You asked the Plan to waive the copayment for chemodenervation of muscle (64612). You say that you have 
never been charged an extra room fee for the injection and the charge was cleared earlier this year. The Plan 
denied your request. The Plan says the waiver of the copayment for services on December 11, 2020, was a one-
time exception as explained in the decision letter. 
 
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 $100 
copayment for Outpatient Surgery and Other Medical Services. You have been asked to pay a $100 copayment for chemodenervation of muscle (64612). Chemodenervation of 
muscle (64612) falls within the Outpatient Surgery and Other Medical 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 chemodenervation of muscle provided on March 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed.
You asked the Plan to pre-approve total electric hospital bed. You say that the enrollee has difficulty getting up
or out of his semi-electric hospital bed and will benefit from having a full electric hospital bed. The Plan denied
your request. The Plan says the denial of authorization for this item is correct, because a total electric hospital
bed is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered by
Medicare.
We looked at the file and Medicare rules. The requested total electric hospital bed is not covered by Medicare.
Based on this information, we decided that Medicare rules for coverage of total electric hospital bed have not
been met. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital bed.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for acute inpatient rehabilitation facility (IRF) admission and
services.
You asked the Plan to pay for IRF care. You say that the enrollee needs inpatient rehabilitation to regain their
prior level of function. The Plan denied your request. The Plan says the criteria for an IRF are not met. This
enrollee would be safely and equally well served with skilled nursing and therapy services at a lower level of
care.
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 pay for 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 that the complexity of the enrollee's nursing, medical and rehabilitation needs does
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the
documentation does support a need for physical and/or occupational therapy, there is no documented need for
an intensive, multi-disciplinary rehabilitation program. 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 pay for acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided on April 14, 2021, and April 15, 2021.
You asked the Plan to pay for the self-administered drugs. You say that the prescription drugs in the hospital are the same drugs that you have at home. You also say that you were not allowed to bring your own drugs to the hospital. The Plan denied your request. The Plan says self-administered drugs are not covered under your plan.
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 pay for the self-administered drugs provided on April 14, 2021, and April 15, 2021.
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for pathology services (88307) provided April 23, 2021. 
 
You asked the Plan to pay for the pathology services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the billed services. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 88307 is not supported in the medical record. Specifically, D37.6 is not a valid primary 
diagnosis code for the CPT code billed. Based on this information, we decided that Medicare rules for coverage 
of the pathology services have not been met. Therefore, we decided that the Plan does not have to pay for 
pathology services (88307) provided April 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the full mouth debridement (D4355) or pay more for the 
complete series of intraoral x-rays (D0210) provided on May 27, 2021 by an OON provider. 
 
You asked the Plan to pay for the full mouth debridement and to pay more for the complete series of intraoral 
x-rays. You say that you were told by the Plan and the dental provider that the treating provider was in-
network. The Plan denied your request. The Plan says these services were rendered by an OON provider. The 
Plan also says that you did not contact the Plan to verify the provider's network status. 
 
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 full mouth debridement (D4355) is 
not among those covered under this benefit. The contract also says that you may pay more for dental services 
that are received OON. Therefore, we decided that the Plan does not have to pay for the full mouth 
debridement (D4355) or pay more for the complete series of intraoral x-rays (D0210) provided on May 27, 
2021 by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite (D2330) provided on May 4, 
2021. 
 
You asked the Plan to pay for the resin-based composite. You say that your dentist called the Plan and was 
advised this service would be covered. The Plan denied your request. The Plan says benefits for this service 
have been satisfied and the frequency limitation has been exceeded. The Plan also says that you did not contact 
the Plan prior to this date of service to verify benefits and provider eligibility.  
 
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, restorations (fillings) are limited to two 
on April 13, 2021 and your restorations benefit has been exhausted. Therefore, we decided that the Plan does 
not have to pay for the resin-based composite (D2330) provided on May 4, 2021. procedure codes per calendar year. The record shows that you received two resin-based composites (D2330 x2)
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the removal of residual tooth roots (cutting procedure) 
(D7250) provided on April 26, 2021. 
 
You asked the Plan to pay for the dental service. You say that the extraction was coded incorrectly. You say 
that this should be corrected, and payment be made immediately. You also say that you will terminate your 
account if this is not resolved. The Plan denied your request. The Plan says the claim was processed correctly. 
The Plan says that removal of residual tooth roots 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the removal of tooth roots is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
removal of residual tooth roots (cutting procedure) (D7250) provided on April 26, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services provided on March 24, 2021, by
an OON provider.
You asked the Plan to pay for the psychotherapy services. You say that the service was provided with no
adequate time frame to obtain authorization for the service. You say the service was medically necessary. The
Plan denied your request. The Plan says no prior authorization was obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The
records provided for review do not show that the services at issue were urgent or emergent. Therefore, we
decided that the Plan does not have to pay for the psychotherapy services provided on March 24, 2021, by an
OON provider.