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

 
We decided that the Plan does not have to pre-approve a complete denture - maxillary (D5110), and 
mandibular partial denture - cast metal framework with resin denture bases (including retentive/clasping 
materials, rests and teeth) (D5214). 
 
You asked the Plan to pre-approve the dental services. You say that you need the upper denture as you are 
unable to eat and is causing you pain. The Plan denied your request. The Plan says your benefit for the 
requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service February 13, 2020. 
Therefore, we decided that the Plan does not have to pre-approve a complete denture - maxillary (D5110), and 
mandibular partial denture - cast metal framework with resin denture bases (including retentive/clasping 
materials, rests and teeth) (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crown - porcelain/ceramic (D2740) and core buildup, 
including any pins when required (D2950), Tooth #31. 
 
You asked the Plan to pre-approve dental services. You say that the requested services are medically necessary 
for your health. The Plan denied your request. The Plan says they have not received any x-rays to support the 
dental treatment is medically necessary. This does not meet the plan requirements that require all treatment to 
be medically necessary. 
 
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 covers dental 
services when the services are medically necessary and reasonable.  
 
  We decided that the Plan's rules for coverage of dental services have not been met. There are no x-rays or 
medical records to prove the requested dental services are medically necessary. Therefore, we decided that the 
Plan does not have to pre-approve crown - porcelain/ceramic (D2740) and core buildup, including any pins 
when required (D2950), Tooth #31.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for the intraoperative neuromonitoring services provided on May 4, 2022. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says that the codes 
are not supported in the documentation. 
 
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. 
 
We looked at the file and the rules. The Plan cites an operative report and technical report in their denial. 
However, these documents were not provided by the Plan. 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 the intraoperative neuromonitoring services provided on May 4, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the occlusal adjustment (D9951) for tooth #1 provided on 
June 30, 2022. 
 
You asked the Plan to pay for the dental service. You say that the dental procedure was a simple procedure, and 
it should be covered by the Plan. The Plan denied your request. The Plan says the denial of payment for this 
service is correct, because the occlusal adjustment is not covered by the 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 pay for the 
occlusal adjustment (D9951) for tooth #1 provided on June 30, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) with 
concurrently acquired computed tomography (CT) (78815). 
 
You asked the Plan to pre-approve a PET/CT scan. The Plan denied your request. The Plan says since the 
enrollee has had three FDG PET/CT scans following their treatment, further follow-up scans are not covered by 
Medicare in the setting of surveillance, especially since post-treatment imaging has been negative 
 
The Plan follows Medicare rules. Medicare rules say that three FDG PET scans are nationally covered when 
used to guide subsequent management of anti-tumor treatment strategy after completion of initial anti-cancer 
therapy. 
 
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 PET/CT scan. Our reviewer says that 
an additional PET/CT scan is not reasonable and necessary for the enrollee. Our physician reviewer found the 
record indicates that the enrollee has metastatic recurrent laryngeal squamous cell carcinoma. The record 
indicates that the enrollee has completed treatment and has had three previous PET scans. Our reviewer found 
that the record does not include physical examination or radiographic findings that would indicate an additional 
scan would alter management at this time. The elements of the coverage criteria are not satisfied. Our physician 
reviewer also found that the requested service is not recommended. 
 
 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 PET/CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) with concurrently acquired computed tomography 
(CT) (78815).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on July 28, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for lab testing. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says the enrollees network primary care provider (PCP) or plan must give the enrollee 
approval in advance before they can use providers not in the plan's network. This is called giving you a 
"referral." 
 
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 lab testing provided on July 28, 2022, by an out-
of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a two-dimensional (2D) oral/facial photographic image 
(D0350) and a cone beam computed tomography (CT) capture and interpretation with field of view of both 
jaws (D0367) provided on July 12, 2022. 
 
You asked the Plan to pay for a two-dimensional (2D) oral/facial photographic image (D0350) and a cone 
beam computed tomography (CT) capture and interpretation with field of view of both jaws (D0367). You say 
that when you called the Plan, you were told that your dental benefits would cover one set of x-ray 
examinations and one dental cleaning a year. The Plan denied your request. The Plan says these services are 
not covered by your Plan. 
 Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a two-
dimensional (2D) oral/facial photographic image (D0350) and a cone beam computed tomography (CT) 
capture and interpretation with field of view of both jaws (D0367) provided on July 12, 2022.  
 
Your complaint about potentially being taken advantage of by the provider 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the placement of a semi-precision abutment provided by a 
participating provider on June 22, 2022. 
 
You asked the Plan to pay for the placement of a semi-precision abutment. You say that you went ang got this 
work done because you were told denture repairs were covered. The Plan denied your request. The Plan says 
the rendered dental work is 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 pay for the 
placement of a semi-precision abutment provided by a participating provider on June 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing (81210, 81235, 81245, 81272, 81275, 
81276, 81310, 81311 and 81315) provided on May 27, 2022. 
 
You asked the Plan to pay for laboratory testing. You say that this testing was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says there is insufficient information 
to show that this test was medically necessary and was requested by a provider who is treating the enrollee. 
 
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 laboratory testing have been met. 
Specifically, no progress notes or medical records from the ordering physician were submitted to support the 
medical necessity of this panel or to show that the ordering physician is treating this enrollee. Therefore, we 
decided that the Plan does not have to pay for laboratory testing (81210, 81235, 81245, 81272, 81275, 81276, 
81310, 81311 and 81315) provided on May 27, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay on July 26, 2022, to 
July 27, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that you want to appeal the 
amount being charged. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $850 
copayment per stay, after your $1,000 plan deductible, for inpatient services. Includes inpatient acute, inpatient 
rehabilitation, long-term care hospitals and other types of inpatient hospital services. Inpatient hospital care 
starts the day you are formally admitted to the hospital with a doctors order. The day before you are 
discharged is your last inpatient day. 
 
 
 
 You have been asked to pay a $850 copayment for inpatient hospital stay. This item/service falls within the 
Inpatient hospital care 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 inpatient 
hospital stay on July 26, 2022, to July 27, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room services on January 27, 
2022. 
 
You asked the Plan to waive the copayment for emergency room services. You say that you want to appeal the 
amount being charged. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 
copayment for emergency room visit. Emergency care refers to services that are furnished by a provider 
qualified to furnish emergency services, and needed to evaluate or stabilize an emergency medical condition. 
 
You have been asked to pay a $90 copayment for emergency room services. This item/service falls within the 
Emergency care 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 emergency room 
services on January 27, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mental health visits provided from July 8, 2022, to July 20, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for mental health visits. You say that you have always accepted the patients enrolled 
in the Plan and never had an issue. The Plan denied your request. The Plan says an authorization was not 
obtained prior to the services rendered. 
 
  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 mental health visits provided from July 8, 2022, to 
July 20, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on June 23, 2022. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the services were medically 
necessary. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network 
providers require prior authorization. 
 
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 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for subsequent nursing facility care provided on June 23, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are appealing the denial of an 
LTACH admission. The Plan denied your request. The Plan says you are receiving appropriate inpatient acute 
care and are currently unstable for transfer to an LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer 
says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found you appear to be more stable and improving and should only require short-term 
additional acute care services that can safely be provided at the current facility.  Transfer to the LTACH would 
not be clinically advantageous at this time and completion of treatment at the current facility is recommended.  
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection to be provided by an out-
of-network (OON) provider. 
 
You asked the Plan to pre-approve OON services. You say that nothing has helped relieve the enrollee's pain. 
The Plan denied your request. The Plan says the service is available by a provider in the 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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve an 
epidural steroid injection to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung 
cancer screening (71271). 
 
You asked the Plan to pre-approve the requested LDCT scan. You say that this service is medically necessary 
for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of 
the requested service. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung 
cancer screening for enrollees who meet all the criteria described in the Medicare rules section of this letter.  
 
 We reviewed the case file and Medicare rules. Based on this information, we find that the enrollee does not 
meet Medicare criteria for coverage of this service. Specifically, the rules say that Medicare covers one annual 
LDCT scan for lung cancer screening for enrollees who are between 55 and 77 years of age. Therefore, we 
decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung 
cancer screening (71271).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pulp cap - indirect tooth #'s 12 and 13 (excluding final 
restoration) (D3120), and localized delivery of antimicrobial agents via a controlled release vehicle into 
diseased crevicular tissue, per tooth #'s 10, 12, and 13 (D4381). 
 
You asked the Plan to pre-approve the pulp cap - indirect tooth #'s 12 and 13 (excluding final restoration) 
(D3120), and localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular 
tissue, per tooth #'s 10, 12, and 13 (D4381). The Plan denied your request. The Plan says these services are not 
covered under the benefit package. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.  
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
pulp cap - indirect tooth #'s 12 and 13 (excluding final restoration) (D3120), and localized delivery of 
antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth #'s 10, 12, and 13 
(D4381).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab work provided on August 11, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for lab work. You say that this should be covered as it was medically necessary. The 
Plan denied your request. The Plan says there was no preauthorization by a primary care provider (this is 
different than a referral) for an out-of-network (OON) provider or facility, and this was not an emergency. 
Therefore, the decision is upheld. 
 
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 lab work provided on August 11, 2022, by an out-
of-network (OON) provider.