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

 
We decided that the Plan does not have to pay for prophylaxis (D1110), and a periodic oral evaluation (D0120) 
provided by an out-of-network provider on December 8, 2021. 
 
You asked the Plan to pay for dental services. You say that you would like the Plan to pay for this. The Plan 
denied your request. The Plan says services provided by an out-of-network provider are not covered 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. The Plan covers dental 
services when the services are provided by a participating provider. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of dental services have not been met. Therefore, we decided that the Plan does not have to pay for prophylaxis (D1110), and a periodic oral evaluation (D0120) provided by an out-of-network provider on December 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the SelectMDx testing (81479) provided on November 16, 
2021. 
 
You asked the Plan to pay for the SelectMDx testing. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, the SelectMDx testing, was requested solely for screening purposes. Medicare 
does not cover this test solely for screening purposes. Additionally, the documentation submitted does not 
include any clinical information. There is insufficient information to determine why this testing was ordered, 
how the results will affect the member's treatment or if Medicare criteria for coverage have been met. 
Therefore, we decided that the Plan does not have to pay for the SelectMDx testing (81479) provided on 
November 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay the in network rate for the 2D photographic images (D0350 x 4) 
provided on October 19, 2021. 
 
You asked the Plan to pay the in network rate for the 2D photographic images. You say that this claim was 
denied for using an out of network dentist. You also say that you selected this provider from the plan's website. 
The Plan denied your request. The Plan says 2D photographic images are not listed as covered services.  
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 2D photographic images are not 
among those covered under this benefit regardless of the providers network status. Therefore, we decided that 
the Plan does not have to pay the in network rate for the 2D photographic images (D0350 x 4) provided on 
October 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an endocrinology specialist office visit 
provided on October 6, 2021. We also decided that the Plan does not have to waive the coinsurance for a 
romosozumab injection provided on October 27, 2021. 
 
You asked the Plan to waive the copayment for a specialist office visit. You also asked the Plan to waive the 
coinsurance for an injection. You say that in the approval letter it never said it was going to cost about $427 or 
about $5,000 a year. The Plan denied your request. The Plan says you have been charged the correct cost 
sharing amount. 
 The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for in-network Part B drugs. The Plan contract also says that enrollees must pay a $35 copayment 
for an in-network specialist office visit. 
 
You have been asked to pay $392.45, which is 20% of the allowed amount for an injection ($1, 962.24 allowed 
amount x 20% coinsurance = $392.45). An injection falls within the Medicare Part B Prescription Drugs 
benefit category.  
 
You have also been asked to pay a $35 copayment for a specialist office visit. A specialist office visit falls 
within the Physician/Practitioner Services, Including Doctors Office Visits benefit category. You have been 
asked to pay a total of $427.45 ($392.45 coinsurance + $35 copayment = $427.45). 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 endocrinology specialist office visit provided on October 6, 2021. We also 
decided that the Plan does not have to waive the coinsurance for a romosozumab injection provided on October 
27, 2021. 
 
Your complaint about the approval letter not saying what the charge was going to be is not a valid appeal for 
medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does 
not permit us to make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0676). 
 
You asked the Plan to pay for a pneumatic compression device. You say that the items are medically necessary. 
The Plan denied your request. The Plan says the pneumatic compression device is not covered by Medicare to 
prevent deep vein thrombosis during and/or following surgery. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
 We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0676).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prophylaxis (D1110) provided by a participating provider on 
December 13, 2021. 
 
You asked the Plan to pay for prophylaxis. You say that this was a routine cleaning. The Plan denied your 
request. The Plan says the benefit limit for D1110 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 Plan's coverage rules apply in this case. The Plan covers prophylaxis 
when the services are medically necessary and reasonable.  
 
 We looked at the file and Medicare rules. Evidence was provided to show that D1110 was provided on April 
12, 2021, and August 2, 2021. Based on this information, we decided that the Plan's rules for coverage of 
prophylaxis have not been met. Therefore, we decided that the Plan does not have to pay for prophylaxis 
(D1110) provided by a participating provider on December 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diagnostic consultation provided by a dentist/physician 
other than the ordering dentist/physician (D9310) provided on December 11, 2021. 
 
You asked the Plan to pay for the diagnostic consultation. You say that you cannot afford this cost and you 
were unaware that this service would not be covered. The Plan denied your request. The Plan says this service 
is not covered by your dental benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
diagnostic consultation provided by a dentist/physician other than the ordering dentist/physician (D9310) 
provided on December 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150), and an 
extraction (D7140) to be provided by an oral surgeon. 
 
You asked the Plan to pre-approve a comprehensive oral evaluation and an extraction. You say that you need 
these services and would like the Plan to approve them. The Plan denied your request. The Plan says services 
must be provided by a general dentist. 
 
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 a 
comprehensive oral evaluation and an extraction when the services are provided by a generally dentist.  
 
We looked at the file and Medicare rules. D0150 and D7140 cannot be provided by an oral surgeon. Based on 
this information, we decided that the Plan's rules for coverage of a comprehensive oral evaluation and an 
extraction have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
comprehensive oral evaluation (D0150), and an extraction (D7140) to be provided by an oral surgeon.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ultralight wheelchair and accessories. 
 
You asked the Plan to pre-approve a wheelchair to include a transit system and bend push handle. You say that 
this wheelchair and accessories are medically necessary. The Plan denied your request. The Plan says while the 
wheelchair and Medicare approved accessories were approved, the transit system and bend push handle are not 
covered as they are not required for use in the home. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home. A transit system and bend push handle are not required for use in the 
home. Although these items may be helpful, neither Medicare nor the Plan covers equipment for use outside 
the home. Therefore, we decided that the Plan does not have to pre-approve an ultralight wheelchair and 
accessories.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy services from an OON provider. 
 
You asked the Plan to pre-approve physical therapy services. You say that the facility is too far from 
your home. The Plan denied your request. The Plan says the denial of authorization for this service is correct, 
because this provider is out-of-network with the Plan, and you can be treated at an in-network physical therapy 
facility. 
 
Medicare rules say that plans must make care accessible to enrollees. According to Medicare rules, care is 
considered accessible to an enrollee if contract providers are available within reasonable distance and travel 
time from the enrollee's home. The Plan says that enrollees must use contract providers.  
 
The provider is a non-contract provider. We were able to confirm that the Plan has contract providers located 
within reasonable distance and travel time from your home who can provide physical therapy services. Under 
Medicare rules, this means that contract providers are accessible to you. Therefore, we decided that the Plan 
does not have to pre-approve physical therapy services from an OON provider.
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 palliative 
(emergency) treatment of dental pain (D9110) provided on September 8, 2021. 
 
You asked the Plan to pay for the first intraoral periapical x-ray and palliative (emergency) treatment of dental 
pain. You say that this was an emergency appointment and you should only be charged $90. The Plan denied 
your request. The Plan says these services are not benefits under the dental 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 first 
intraoral periapical x-ray (D0220) and palliative (emergency) treatment of dental pain (D9110) provided on 
September 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for WATS 3D Histocytology (88361, 88312, 88305, 88104) 
provided July 29, 2021. 
 
You asked the Plan to pay for WATS 3D Histocytology. You say that please review and respond with coverage 
of your claim for the performance of WATS 3D tissue analysis which is now a standard of care when ordered 
according to ASGE guidelines and therefore deemed medically necessary for this enrollee. The Plan denied 
your request. The Plan says the documentation does not support medical necessity of the services. 
 
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 pay for WATS 3D Histocytology. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found in this case, the record indicates that the enrollee underwent upper endoscopy for a 
history of Barrett's esophagus in the setting of gastroesophageal reflux. The literature does not support the 
safety and efficacy of the requested service, as defined by Medicare rules, for the enrollee's clinical condition. 
The American Society of Gastrointestinal Endoscopy has given the requested service a conditional 
recommendation for the noted use with low quality of evidence, insufficient to establish the safety and efficacy 
of the requested service, as defined by Medicare rules, for the enrollee's clinical condition. The record provided 
does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested 
service. The elements of the coverage criteria are not satisfied. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of WATS 3D Histocytology have not been met. Therefore, we decided that the 
Plan does not have to pay for WATS 3D Histocytology (88361, 88312, 88305, 88104) provided July 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740). 
 
You asked the Plan to pre-approve the crown. The Plan denied your request. The Plan says this service is 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 pre-approve a 
crown (D2740).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are to be released from the hospital soon and 
need to be in rehabilitation. The Plan denied your request. The Plan says criteria for admission to the Acute 
Inpatient Rehabilitation setting have not been met. 
 
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 no rehabilitation nursing needs are identified or documented in the record. Our 
reviewer found that you do not need intensive therapies, consisting of at least 3 hours of therapy per day at least 
5 days per week with multidisciplinary approach to daily therapy in an IRF. Our physician reviewer also found 
that while you may benefit from physical therapy, and occupational therapy, your rehabilitation can be safely 
provided at a lower intensity and alternate setting such as in a skilled nursing facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established 
patient (D0150), panoramic radiographic image (D0330) and bitewings - two radiographic images (D0272) 
provided November 11, 2021. 
 
You asked the Plan to pay for the comprehensive oral exam, panoramic x-ray and bitewing x-rays. You say that 
you only planned to get a cleaning and you were unaware that you could only have one examination every 3 
years. The Plan denied your request. The Plan says you have exceeded the frequency limit for these services. 
 
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 
comprehensive oral exam, panoramic x-ray once every three plan years and bitewing x-rays once per plan year. 
We looked at the file and Medicare rules. The Plan provided documentation showing that a comprehensive 
exam, panoramic x-rays and bitewing x-rays were previously covered on July 19, 2021. Based on this 
information, we decided that the Plan's frequency limits for coverage of the comprehensive oral exam, 
panoramic x-ray and bitewing x-rays have been exceeded. Therefore, we decided that the Plan does not have to 
pay for the comprehensive oral evaluation - new or established patient (D0150), panoramic radiographic image 
(D0330) and bitewings - two radiographic images (D0272) provided November 11, 2021.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay for the comprehensive oral evaluation (D0150). We decided that the Plan 
does not have to pay for the complete series of intraoral x-rays (D0210).  You asked the Plan to pay for the comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210) provided on December 6, 2021. You say that you feel these charges are not justified because you were not told beforehand that this claim would be denied and you would be held responsible for this portion. 
The Plan says that these services are not covered expenses under your dental plan. 
 
We decided that the Plan has to pay for the comprehensive oral evaluation (D0150).  
 
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 
comprehensive oral evaluation (D0150) when the services are medically necessary and reasonable. 
 
We looked at the file and Medicare rules. The record shows that you received a comprehensive oral evaluation 
(D0150) which was denied by the Plan as not being a covered benefit. The 2021 Evidence of Coverage says 
that exams, including periodic oral exam and comprehensive oral evaluation, share a frequency limitation of 
one procedure code per calendar year. The record does not show that you received either a periodic oral exam 
or comprehensive oral evaluation prior to this date of service, which would have exhausted your exams benefit. 
You reasonably believed this service would be covered because comprehensive oral evaluation is listed as a 
covered service. Therefore, we decided that the Plan has to pay for the comprehensive oral evaluation (D0150).  
 
We also decided that the Plan does not have to pay for the complete series of intraoral x-rays (D0210). 
 
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 
complete series of intraoral x-rays (D0210). 
 
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 the problem focused limited oral evaluation (D0140) 
provided on August 17, 2021. 
 
You asked the Plan to pay for the problem focused limited oral evaluation. You say that it was verified three 
times prior to the service being rendered that the exam and dentists were both covered under the Plan. The Plan 
denied your request. The Plan says this service is not a covered expense under your dental plan. The Plan says 
that the enrollee did contact the Plan prior to this date of service to verify their benefits for extractions only. 
The Plan also says that the enrollee's provider contacted the Plan and was advised that the Plan is code specific, 
but declined to have a copy of the benefits faxed to them. 
 
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 
problem focused limited oral evaluation (D0140) provided on August 17, 2021.