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

 
We decided that the Plan does not have to waive the copayment for a periodic oral evaluation (D0120), and 
prophylaxis (D1110) provided by a participating provider on January 4, 2022. 
 
You asked the Plan to waive the copayment for a periodic oral evaluation and prophylaxis. You say that you 
have never had to pay for this before. The Plan denied your request. The Plan says the correct copayments have 
been 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 $15 
copayment for dental services/in-network.  
 
You have been asked to pay a $15 copayment for a periodic oral evaluation and prophylaxis. The total amount 
you are being asked to pay is $30 ($15 (D0120) + $15 (D1110) = $30). A periodic oral evaluation and 
prophylaxis falls within the dental services/in-network 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 a periodic oral evaluation (D0120), and prophylaxis (D1110) provided by a participating 
provider on January 4, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an electrocardiogram (EKG) provided on 
February 21, 2022. 
 
You asked the Plan to waive the copayment for the EKG. You say that you have this service done each time 
you see your doctor and it was always covered. 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 a $25 
copayment for non-radiological diagnostic services, such as EKG's.  
 
You have been asked to pay $14.35, which is less than the $25 copayment for the EKG. The file shows that the 
Plan has indicated any previous claims involving EKGs without a copayment were processed incorrectly. 
However, the Plan has also indicated that they will not seek reimbursement for these services. The EKG falls 
within the Outpatient Diagnostic Tests and Therapeutic Services and 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 copayment for an electrocardiogram (EKG) provided on February 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bitewings - two radiographic images (D0272), 
prophylaxis - adult (D1110), periodic oral evaluation - established patient (D0120) provided March 17, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the bitewing x-rays, dental cleaning and periodic oral exam. You say that you 
were told the cleaning would be covered. The Plan denied your request. The Plan says these services are not 
covered when provided OON. Additionally, the Plan says that they reviewed phone logs and did not find any 
calls about coverage made prior to receiving the 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 bitewing 
x-rays, dental cleaning and periodic oral exam when they are provided in-network. 
 
We looked at the file and Medicare rules. These services were provided OON. Based on this information, we 
decided that the Plan's rules for coverage of the bitewing x-rays, dental cleaning and periodic oral exam have 
not been met. Therefore, we decided that the Plan does not have to pay for the bitewings - two radiographic 
images (D0272), prophylaxis - adult (D1110), periodic oral evaluation - established patient (D0120) provided 
March 17, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 2 implant placements (D6010), 2 custom abutments 
(D6057), 2 abutment supported crowns (D6059), and 2 bone replacement grafts for ridge preservation (D7953). 
 
You asked the Plan to pre-approve the dental services. You say that you were denied for implants that were 
requested by your dentist. You say that your dentures are bothering you. You say that you are unable to eat and 
are losing weight. You also say that your dentures will not stay in your mouth. The Plan denied your request. 
The Plan says the services 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested implants and 
related services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pre-approve 2 implant placements (D6010), 2 custom abutments (D6057), 2 abutment supported crowns 
(D6059), and 2 bone replacement grafts for ridge preservation (D7953).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on October 25, 
2021. 
 
You asked the Plan to pay for . You say that this should be paid for. The Plan denied your request. The Plan 
says the documentation does not support payment for CPT codes as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of the denied codes are: 
 
70544-26-59 - Magnetic resonance angiography, head; without contrast material(s) 
70553-26-77 - Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast 
material, followed by contrast material(s) and further sequences 
70549-26 - Magnetic resonance angiography, neck; without contrast material(s), followed by contrast 
material(s) and further sequences 
 
We asked our coder 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 . Our reviewer says that the services at issue in this case were 
not supported by the medical records. Our reviewer found after a careful review of medical 
records, documentation was not found for radiology services. The documentation includes laboratory services. Therefore these procedures cannot be reviewed or covered. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of  have not been met. Therefore, we decided that the Plan does not have to pay for 
imaging services provided to the enrollee on October 25, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Taltz. 
 
You asked the Plan to pre-approve Taltz. You say that you would like the Plan to reconsider their denial. The 
Plan denied your request. The Plan says Taltz is not covered under the enrollee's Medicare Part B benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Taltz.  
 
Benefits for Taltz may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair expandable controller upgrade and 
harness for upgrade to expandable controller. 
 
You asked the Plan to pre-approve a power wheelchair expandable controller upgrade and harness for upgrade 
to expandable controller. You say that you would like the plan to reconsider their denial. The Plan denied your 
request. The Plan says the enrollee does not meet criteria for the requested items.  
The Plan must follow Medicare rules. Medicare rules say that expandable controllers and harnesses are only 
covered for certain indications. 
 
We looked at the file and Medicare rules. Review of the file shows that no power options are being requested 
and approved for the requested power wheelchair. As there are not three actuators for the wheelchair, the 
request for the expandable controller and harness are not allowed unless a specialty interface is used. No 
specialty controller has been requested or approved. Based on this information, we decided that Medicare rules 
for coverage of a power wheelchair expandable controller upgrade and harness for upgrade to expandable 
controller have not been met. Therefore, we decided that the Plan does not have to pre-approve a power 
wheelchair expandable controller upgrade and harness for upgrade to expandable controller.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 2 retainer crowns (D6750), and a pontic (D6240). 
 
You asked the Plan to pre-approve the fixed bridge. You say that the enrollee needs these services. The Plan 
denied your request. The Plan says the claim was processed correctly. 
 
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 2 
retainer crowns (D6750), and a pontic (D6240).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dental implant (D6010) and temporary upper denture 
(D5820). 
 
You asked the Plan to pre-approve a dental implant and temporary denture. You say that these services are 
necessary. The Plan denied your request. The Plan says these services are 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 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 
dental implant (D6010) and temporary upper denture (D5820).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the bone marrow aspirate (CPT code 20939). 
 
You asked the Plan to pre-approve the bone marrow aspirate. You say that the service is medically necessary. 
The Plan denied your request. The Plan says the clinical value and effectiveness of bone marrow aspirate in the 
setting of spinal fusion surgery have not been demonstrated in the peer-reviewed literature. 
 
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 the bone marrow aspirate. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found bone marrow aspirate remains experimental. More research is needed. 
 
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 bone marrow aspirate have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the bone marrow aspirate (CPT code 20939).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the application of caries arresting medicament (D1354) 
provided by a participating provider. 
 
You asked the Plan to pre-approve the application of caries arresting medicament. You say that you would like 
the Plan to approve these services. The Plan denied your request. The Plan says the requested service is not a 
covered dental 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 the 
application of caries arresting medicament (D1354) provided by a participating provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve functional electrical stimulation (FES).
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that FES is covered 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the FES device is only covered for use in patients with a history of a spinal cord injury. The records show that you do not have a history of a spinal cord injury. Your history is notable for a prior stroke. The Medicare criteria for coverage are not met and the services are therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve functional electrical stimulation (FES).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve viscosupplementation services (20610).

You asked the Plan to pre-approve viscosupplementation services. You say that repeat injections are medically necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met.

The Plan must follow Medicare rules. Medicare rules say that repeat series of injections are subject to the criteria listed in the Medicare rules section.

We looked at the file and Medicare rules. In this case, there is no documentation of the results of the prior series of injections. Based on this information, we decided that Medicare rules for coverage of viscosupplementation services have not been met. Therefore, we decided that the Plan does not have to pre-approve viscosupplementation services (20610).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve mastectomy bra and breast prosthesis to be provided by 
an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve mastectomy bra and breast prosthesis. You say that you would like to appeal 
the denial of the claim. The Plan denied your request. The Plan says the provider is out-of-network and it was 
determined these services can be received 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 
mastectomy bra and breast prosthesis to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a cardiac computed tomography (CT) scan. 
 
You asked the Plan to pre-approve CT scan. You say that this is clearly clinically indicated and would help 
determine if the enrollee should begin statin medication therapy. The Plan denied your request. The Plan says 
that this is not a covered service. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
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 CT scan. Our reviewer says that the 
enrollee meets the Medicare criteria for the requested CT scan. Our physician reviewer found the 
documentation describes the enrollee with a low-density lipoprotein (LDL) of 114 and a calculated 
atherosclerotic cardiovascular disease (ASCVD) risk score around 11% to 13%. The most recent guidelines 
suggest that patients with a calculated ASCVD risk score between 7.5% to 20% are appropriate for CT scan 
calcium scoring for assistance with risk stratification to decide if statin therapy would be helpful if they are not 
already on statin therapy. This is considered 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 CT scan have been met. Therefore, we decided that the Plan has to pre-approve 
a cardiac computed tomography (CT) scan.  
 
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 pre-approve a complete upper denture (D5110) and a complete lower 
denture (D5120). 
 
You asked the Plan to pre-approve the dental items. You say that you have paralysis in your mouth. You also 
say that you need dentures to be done. The Plan denied your request. The Plan says complete dentures 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested complete dentures are 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
complete upper denture (D5110) and a complete lower denture (D5120).
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 service is medically necessary. The 
Plan denied your request. The Plan says the service is not medically necessary. 
 
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 do not require services at the LTACH that are not available at the acute care 
hospital where you are currently receiving care. 
 
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. Specifically, medically necessary 
services are being obtained at the enrollee's current level of care. This means admission into an LTACH is not 
medically necessary. Therefore, we decided that the Plan does not have to pre-approve long term acute care 
hospital (LTACH) services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 7 additional physical therapy visits provided by a 
participating provider. 
 
You asked the Plan to pre-approve physical therapy. You say that you would like the Plan to approve 10 
additional sessions. The Plan denied your request. The Plan says 3 sessions have been approved, but the 
additional 7 sessions are not medically necessary.  
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
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 physical therapy. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found documentation does not show that 7 additional physical therapy 
sessions are no not needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of physical therapy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve 7 additional physical therapy visits provided by a participating provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate (20939). 
 
You asked the Plan to pre-approve bone marrow aspirate. You say that this is medically necessary for the 
enrollee's condition. The Plan denied your request. The Plan says the requested procedure is considered 
experimental/investigational. 
 
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 bone marrow aspirate. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the requested bone marrow aspirate is experimental. More research is needed before 
coverage can be approved. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bone marrow aspirate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone marrow aspirate (20939).