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

 
We decided that the Plan does not have to pay for the immediate upper denture (D5130), unspecified 
removable prosthodontic procedure (D5899 x 2), immediate lower denture (D5140) provided on February 1, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were told you needed to get all of your 
teeth removed. You say that you could have had 2 teeth removed per quarter. You say that you were advised 
not to do it this way. The Plan denied your request. The Plan says the $600 quarterly allowance has 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the $600 quarterly allowance has been 
exhausted. The record shows that the Plan paid $600 for extractions and sedation services that you received on 
the date of service in this case. Therefore, we decided that the Plan does not have to pay for the immediate 
upper denture (D5130), unspecified removable prosthodontic procedure (D5899 x 2), immediate lower denture 
(D5140) provided on February 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost for PDT and Medicare Part B drugs provided on 
January 3, 2022. 
 
You asked the Plan to waive the cost for PDT and Medicare Part B drugs. You say that you had the same 
services done recently and only had to pay $35. The Plan denied your request. The Plan says the cost share was 
applied 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 $75 
copayment for diagnostic procedures and tests for the PDT and 20% coinsurance for Medicare Part B drugs. 
 
You have been asked to pay a total of $231.99 for the PDT and Medicare Part B drugs.  
 
Service Allowed Amount Standard Cost Member Liability 
Photodynamic Therapy (PDT ) $252.91 $75 $75 
Medicare Part B Drugs $784.96 20%  $156.99 
TOTAL:   $231.99 
 
 
The photodynamic therapy (PDT ) falls under the Outpatient diagnostic tests and therapeutic services 
and supplies benefit category. The Part B drugs fall within the Medicare Part B prescription drugs 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 cost for the PDT and Medicare Part B drugs provided on 
January 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve physical therapy services. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says from the records they received, no medical need is shown 
as to why the enrollee cannot get physical therapy from a provider in the Plan network. The Plan also says there 
are contracted healthcare professionals that are available. 
 
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 
physical therapy services to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the urgent care visit provided on December 
13, 2021. 
 
You asked the Plan to waive the copayment for an urgent care visit. You say that your provider asked you to go 
to urgent care since they do not take walk-ins so you should not have to pay. The Plan denied your request. The 
Plan says the copayment was applied 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 $15 
copayment per visit for Medicare-covered urgently needed services during the visit.  
 
You have been asked to pay $15 for the urgent care visit. An urgent care visit falls within the Urgently needed 
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 the urgent care visit 
provided on December 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140), periapical x-ray 
(D0220), and root canal (D3330) provided on October 18, 2021, by the out of network provider. 
 
You asked the Plan to pay for the dental services. You say that you called on October 14, 2021, and October 
29, 2021 about the out of network provider. You say that the plan representative did not let you know that you 
needed a prior authorization on file to be reimburse for the out of network claim. The Plan denied your request. 
The Plan says dental services must be received by a participating provider. 
 
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, dental services received out of network 
are not among those covered under this benefit. The record shows that dental services must be received by a 
participating provider. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation 
(D0140), periapical x-ray (D0220), and root canal (D3330) provided on October 18, 2021, by the out of 
network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an out-of-network provider on 
January 25, 2022. 
 
You asked the Plan to pay for dental services. You say that you do not understand why you had out-of-network 
coverage last year, but not this year. The Plan denied your request. The Plan says dental services provided out-
of-network 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 Plans coverage rules apply in this case. The Plan covers covered 
dental services when the services are provided by participating providers.  
 
We looked at 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 
dental services provided by an out-of-network provider on January 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (CPT code 83789) provided on June 
7, 2021. 
 
You asked the Plan to pay for the laboratory services. 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. 
 
We find that CPT code 83789 is not supported in the medical record. Specifically, CPT Code 83789-59 (1 
Unit) remains not supported. This code is included in Healthcare Common Procedure Coding System (HCPCS) 
code G0480; therefore, it cannot be separately reimbursed. The medical records received do not support that 
the procedure or service was distinct or independent from other services performed; this means the use of the 
59 modifier and billed units cannot be supported. Of note, the medical records provided indicate that the urine 
specimen was collected for drug testing. When specimen validity testing is conducted as part of drug testing, it 
cannot be billed separately. Based on this information, we decided that Medicare rules for coverage of the 
laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the 
laboratory services (CPT code 83789) provided on June 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an out-of-network provider on 
January 26, 2022. 
 
You asked the Plan to pay for dental services. You say that you believe that the Plan should pay for this. The 
Plan denied your request. The Plan says services provided out-of-network are not covered. 
 
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 provided in-network. 
 
We looked at 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 
dental services provided by an out-of-network provider on January 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home health visit provided on December 29, 2021, by an 
OON provider. 
 
You asked the Plan to pay for the home health visit. You say that the facility is responsible to get the 
authorization and it was medically necessary to treat the enrollee. The Plan denied your request. The Plan says 
the rendering provider is an OON provider and there was no referral from an in-network provider or an 
approved authorization. Also, the service rendered was not urgent or emergent. 
 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 a home health visit provided on December 29, 
2021, by an OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on December 29, 2021, by 
an OON provider. 
 
You asked the Plan to pay for the laboratory services. You say that you would like to appeal the denied claim. 
The Plan denied your request. The Plan says the rendering and referring providers are both OON providers and 
there was no approved authorization. Also, the service rendered was not urgent or emergent. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the laboratory services provided on December 29, 
2021, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral exam (D0140) and extraction (D7210) 
provided on November 30, 2021, and December 10, 2021. 
 
You asked the Plan to pay for the dental services. You say that you were told you could see any provider and 
you would be reimbursed for these services. The Plan denied your request. The Plan says the provider in this 
case does not accept Medicare payment. You are required to use a provider who accepts Medicare patients in 
the United States and has not opted out of Medicare. The Plan also says that you were told in a call on October 
29, 2021, that you could not use an opt out provider, and the provider submitted a signed copy of a private 
contract you signed acknowledging you would be fully responsible for payment of 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 dental 
services when the services are performed by a licensed dental provider who accepts Medicare patients in the 
United States and has not opted out of Original Medicare.  
 
We looked at the file and the Plan's rules. The provider in this case does not accept Medicare patients and has 
opted out of Original Medicare. Based on this information, we decided that the Plan's rules for coverage of the 
dental services have not been met. Therefore, we decided that the Plan does not have to pay for the limited oral 
exam (D0140) and extraction (D7210) provided on November 30, 2021, and December 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral exam (D0120) and cleaning (D1110) 
provided on July 26, 2021. 
 
You asked the Plan to pay for the dental services. You say that you are covered for two exams per year and did 
not exceed your frequency limitations. The Plan denied your request. The Plan says you have exhausted your 
$325 annual allowance for dental services, and you are responsible for the remaining cost. 
 
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 pays a maximum of 
$325 for supplemental dental care every year. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, items or services that exceed the $325 
annual allowance are not covered under this benefit. The documentation shows that the Plan made partial 
payment for these services at the time of service, as they are covered, however, you exceeded your $325 
allowance on the date in question and are responsible for the excess charges. Therefore, we decided that the 
Plan does not have to pay for the periodic oral exam (D0120) and cleaning (D1110) provided on July 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Root canal, bicuspid (excluding restoration) (D3320) 
provided December 29, 2021. 
 
You asked the Plan to pay for the dental service. You say that you have coverage for a root canal, which you 
have previously received and there is no mention of a time limit of a benefit, only the lifetime of the enrollee. 
The Plan denied your request. The Plan says the annual maximum benefit has 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 health Plan contract says 
that the annual maximum is $1000. The records show that this benefit was met before the processing of this 
service. 
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 Root 
canal, bicuspid (excluding restoration) (D3320) provided December 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mandibular partial denture (dental code D5214). 
 
You asked the Plan to pre-approve mandibular partial denture. You say that you cannot wait one more year as 
your current dentures are broken and do not fit. The Plan denied your request. The Plan says the denial of 
authorization for this service is correct, because you previously received partial dentures on October 1, 2018 so 
5 years have not passed. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
mandibular partial denture (dental code D5214).
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 the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has 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 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 
enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for an 
intensive 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 pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 the medical record does not indicate that the enrollee requires services that she is not 
currently receiving but that would be available at the LTACH facility. The elements of the coverage rules 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral exam (D0140), intraoral x-ray (D0220) and 
unspecified preventative procedure (D1999) provided on November 11, 2021. 
 
You asked the Plan to pay for the dental services. You say that these services were necessary. The Plan denied 
your request. The Plan says these services are not covered by the Plan's 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 
limited oral exam (D0140), intraoral x-ray (D0220) and unspecified preventative procedure (D1999) provided 
on November 11, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that inpatient care is medically 
necessary following elective surgery. The Plan denied your request. The Plan says there is no medically 
necessity for inpatient admission. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this 
case. Our physician reviewer found that the enrollee is undergoing a planned lumbar laminectomy. She is 
medically stable and has been provided medical clearance to undergo this elective procedure. The planned 
procedure listed under CPT codes 63047 and 63048 are not listed on the Centers for Medicare and Medicaid 
Services Inpatient Only List. The procedure is currently approved as an ambulatory procedure. There is no 
documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay. The 
review has determined that the record does not show that at the time of inpatient admission the admitting 
physician reasonably expected that the patient's necessary hospital care (including earlier emergency 
department and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.