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

 
We decided that the Plan does not have to pre-approve a percutaneous transcatheter closure of the left atrial 
appendage with endocardial implant, including fluoroscopy, transseptal puncture, catheter placement(s), left 
atrial angiography, left atrial appendage angiography, when performed, and radiological supervision and 
interpretation (33340). 
 
You asked the Plan to pre-approve a percutaneous transcatheter closure. You say that the procedure is 
necessary for the well-being of the enrollee. The Plan denied your request. The Plan says the requested 
procedure is not medically necessary. 
 
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 a percutaneous transcatheter closure. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found there is a current dental abscess and bleeding requiring intervention, 
serving as a temporary contraindication to anticoagulation; however, LAAC is not indicated for the 
performance of this dental procedure. As such, guidelines would not support implantation of a LAAC in this 
setting. In summary, LAAC placement would not be considered reasonable or medically necessary in the 
enrollees clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a percutaneous transcatheter closure have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a percutaneous transcatheter closure of the left atrial appendage with 
endocardial implant, including fluoroscopy, transseptal puncture, catheter placement(s), left atrial angiography, 
left atrial appendage angiography, when performed, and radiological supervision and interpretation (33340).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services with an oral surgeon. 
 
You asked the Plan to pre-approve the dental services with an oral surgeon. You say that your medical 
insurance should cover the cost of extractions. You say that you had cancer and that the chemotherapy 
damaged your teeth. The Plan denied your request. The Plan says the requested services are not a covered 
benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
dental services with an oral surgeon.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for office visit on March 01, 2022. 
 
You asked the Plan to waive the deductible for office visit. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says the cost sharing you are being charged is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $203 deductible which applies to Physician/Practitioner services, 
including doctor's office visits.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category 
Physician/Practitioner services, including doctor's office visits. The Plan has followed Medicare rules by 
clearly disclosing in the contract that there is a $203 deductible which applies to Physician/Practitioner 
services, including doctor's office visits. This cost sharing is a contractual obligation that had not been met at 
the time office visit was received on March 1, 2022. Therefore, we decided that the Plan does not have to waive 
the deductible for office visit on March 01, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve vestibular therapy to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve vestibular therapy. You say that you were referred to this provider. The Plan 
denied your request. The Plan says these services can be provided in-network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
vestibular therapy to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay for periodontal maintenance. We decided that the Plan does not have to 
pay for topical application of fluoride.  
 You asked the Plan to pay for periodontal maintenance. You say that you disagree with the denial of these 
services. The Plan says that periodontal maintenance is only allowed when the enrollee has had a deep cleaning 
done in the past. The Plan says that topical application of fluoride is not a covered benefit. 
 
We decided that the Plan has to pay for periodontal maintenance.  
 
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. 
 
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of periodontal maintenance have been met. The EOC states that periodontal maintenance is covered 
twice every calendar year. It does not mention a requirement that a deep cleaning must be administered prior to 
these services. Therefore, we decided that the Plan has to pay for periodontal maintenance.  
 
We also decided that the Plan does not have to pay for topical application of fluoride. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, topical application of fluoride is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for topical 
application of fluoride. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for portable oxygen equipment provided on 
June 23, 2021. 
 
You asked the Plan to waive the coinsurance for the portable oxygen equipment. You say that you were not 
informed of any monthly costs for the equipment. The Plan denied your request. The Plan says the correct 
coinsurance was applied. 
 
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 20% coinsurance for durable medical equipment (DME) items, including oxygen equipment. 
 
Item Allowed Amount 20% Coinsurance 
Oxygen Concentrator $123.75 $24.75 
Portable Oxygen Machine $22.30 $4.46 
Total:  $29.21 
 
You have been asked to pay a total of $29.21, which is 20% of the allowed amount for the portable oxygen 
equipment. The portable oxygen equipment 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 portable oxygen 
equipment provided on June 23, 2021.
Appeal type: Other
Decision: Favorable

 
We decided that the Plan has to pre-approve facet joint injections. 
 
You asked the Plan to pre-approve facet joint injections. You say that the services are necessary. The Plan 
denied your request. The Plan says that based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan follows Medicare rules. Medicare rules say that diagnostic facet joint procedure will be considered 
medically reasonable and necessary when specific criteria are met. 
 
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 facet joint injections. Our reviewer says 
that the services are medically necessary. Our physician reviewer found the enrollee meets the LCD criteria for 
repeat diagnostic medial branch blocks (MBBs). The request is medically reasonable and 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 facet joint injections have been met. Therefore, we decided that the Plan has to 
pre-approve facet joint injections.  
 
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: Partially Favorable

 
We decided that the Plan has to pay for the upper partial denture. We decided that the Plan does not have to 
pay for periodontal scaling and root planning, irrigation of gingival pockets with medicinal agent, complete 
upper denture, and lower partial denture.  
 
You asked the Plan to pay for the upper partial denture. You say that you were not happy with the service you 
received from the provider, and you do not want the Plan to pay for these services. The Plan says that irrigation 
of gingival pockets with medicinal agent is not a covered benefit. The cost shares were applied correctly for 
periodontal scaling and root planning and dentures. 
 
We decided that the Plan has to pay for upper partial denture.  
 
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 failed to request medical records from their contractual provider that would support that this service 
wasnt necessary. The Plan has not supported the reason why they aren't paying for the upper partial denture. 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Therefore, we decided that the Plan has to pay for upper partial denture.  
 
We also decided that the Plan does not have to pay for periodontal scaling and root planning, irrigation 
of gingival pockets with medicinal agent, complete upper denture, and lower partial denture. 
 
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, irrigation of gingival pockets with 
medicinal agent are not among those covered under this benefit. 
 
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 $25 
copayment for periodontal scaling and root planning and a 50% coinsurance for dentures. 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 periodontal scaling and root planning, irrigation of gingival pockets with medicinal 
agent, complete upper denture, and lower partial denture. 
 
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 issue additional payment for the extraction, of an erupted tooth 
requiring removal of bone and/or sectioning of tooth (D7210), bone replacement graft for ridge preservation-
per site (D7953), and the guided tissue regeneration-resorbable barrier, per site (D4266) provided on  
February 3, 2022. 
 
You asked the Plan to issue additional payment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the cost share has been applied correctly to the 
services provided. 
 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 $115 for 
the extraction of an erupted tooth requiring removal of bone and/or sectioning of tooth. You must pay $384 for 
a bone replacement graft-ridge preservation-per site. Additionally, you must pay $238 for a guided tissue 
regeneration-resorbable barrier.    
 
You have been asked to pay $737 ($115 + $384 + $238) for the dental services provided. This includes the 
amount of $115 for the extraction of an erupted tooth, $384 for a bone replacement graft, and $238 for the 
guided tissue regeneration-resorbable barrier. 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 issue additional payment for the 
extraction, of an erupted tooth requiring removal of bone and/or sectioning of tooth (D7210), bone replacement 
graft for ridge preservation-per site (D7953), and the guided tissue regeneration-resorbable barrier, per site 
(D4266) provided on February 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an addition to lower extremity, socket insert, below 
knee (L5655), an addition to lower extremity, below knee/above knee, custom fabricated from existing mold or 
prefabricated, socket insert, silicone gel, elastomeric or equal, for use with locking mechanism (L5673x2), an 
all-lower extremity prosthesis, foot, flexible keel (L5972) and an addition to lower limb prosthesis, multiaxial 
ankle with swing phase active dorsiflexion feature (L5968). 
 
You asked the Plan to pre-approve prosthetics. You say that if your prosthesis is not replaced, you are at risk 
for increased pressure over intolerant areas, increasing distal limb pressure which will contribute to worsening 
pain, wound/skin break down. The Plan denied your request. The Plan says the requested items exceed your 
needs and cannot be covered under the Medicare criteria of reasonable and necessary. 
 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 prosthetics. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found clinical documentation states that your problem is with the fit of the socket thus a new socket 
would be medically necessary. L5629 an acrylic socket was approved by the plan. It is unclear in clinical 
documentation why L5655, L5673 X2 were requested but since a new socket was approved, L5655 and L5673 
X2 are not medically necessary. Per clinical documentation, you wish to continue K3/K4 level activities thus a 
K3/K4 level foot/ankle system is medically necessary and the ottobock maverick extreme with micro-
processing ankle/foot (obtained 04/24/2020) would still be under warranty and appropriate with approved new 
custom socket. There is no documentation to support that you have had functional change (downgrade) to K2 
level and L5972 (K2 foot) and L5968 (K2 ankle) are therefore not medically 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 prosthetics have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an addition to lower extremity, socket insert, below knee (L5655), an addition to lower 
extremity, below knee/above knee, custom fabricated from existing mold or prefabricated, socket insert, 
silicone gel, elastomeric or equal, for use with locking mechanism (L5673x2), an all-lower extremity 
prosthesis, foot, flexible keel (L5972) and an addition to lower limb prosthesis, multiaxial ankle with swing 
phase active dorsiflexion feature (L5968).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service (CPT code 87150) provided on March 
3, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that the claim should be paid. The Plan denied 
your request. The Plan says the service is not supported by the records. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
The medical records do not contain documentation to support coding criteria for CPT code 87150. The 
laboratory report includes documentation regarding the methodology (PCR) for the assay panel(s) performed 
but does not describe culture and typing by nucleic acid probe. There is one report submitted for review and no results are provided for CPT 87150. Therefore, we decided that the Plan does not have to pay for the laboratory 
service (CPT code 87150) provided on March 3, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on February 7, 
2022. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you should not have to pay this 
copayment. The Plan denied your request. The Plan says the copayment applied was correct. 
 
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 $135 
copayment for diagnostic radiology services received. You have been asked to pay the allowed amount of 
$81.97 which is less than the $135 copayment. 
 
You have been asked to pay a $81.97 copayment for an ultrasound. An ultrasound falls within the Inpatient 
Stay: Covered Services Received in a Hospital or SNF During a Non-Covered Inpatient Stay - Diagnostic 
Radiology Services Received benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an 
ultrasound provided on February 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an out-of-network visit, provided on April 6, 2022. 
 
You asked the Plan to pay for an out-of-network visit. You say that you have never had this issue with the Plan 
before and feel they should pay. The Plan denied your request. The Plan says the cost applied was correct. 
 
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 will be reimbursed a 
maximum of $3,000 for out-of-network (POS) services per calendar year for physician/practitioner services. 
You had already reached this amount at the time of the visit; therefore you have been asked to pay the full 
amount of $254. 
 
You have been asked to pay $254 for out-of-network (POS) services per calendar year. for an out-of-network 
visit. An out-of-network visit falls within the physician/practitioner 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 an out-of-network visit, provided on April 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for portable oxygen equipment provided on 
May 23, 2021. 
 
You asked the Plan to waive the coinsurance for the portable oxygen equipment. You say that you were not 
informed of any monthly costs for the equipment. The Plan denied your request. The Plan says the correct 
coinsurance was applied. 
 
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 20% coinsurance for durable medical equipment (DME) items, including oxygen equipment.  
 
Item Allowed Amount 20% Coinsurance 
Oxygen Concentrator $123.75 $24.75 
Portable Oxygen Machine $22.30 $4.46 
Total:  $29.21 
 
You have been asked to pay a total of $29.21, which is 20% of the allowed amount for the portable oxygen 
equipment. The portable oxygen equipment 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 portable oxygen 
equipment provided on May 23, 2021.