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

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on March 22, 
2022. 
 
You asked the Plan to pay for the dental service. You say that this should be covered. The Plan denied your 
request. The Plan says your benefit for the limited oral evaluation 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 limited oral evaluation was exhausted on date of service February 19, 2022. 
Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on 
March 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve application of desensitizing resin (D9911) for seven 
teeth. 
 
You asked the Plan to pre-approve application of desensitizing resin. You say that this service is necessary, and 
you cannot afford to pay for it. 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 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 
application of desensitizing resin (D9911) for seven teeth.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller, harness upgrade, electronic 
connection between the wheelchair controller and two or more power seating system motors, and detachable 
harness. 
 
You asked the Plan to pre-approve an expandable controller, harness upgrade, electronic connection between 
the wheelchair controller and two or more power seating system motors, and detachable harness. You say that 
you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested 
items are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that power wheelchair accessories are only covered 
for certain indications.  
 
We looked at the file and Medicare rules. Review of the file shows that the enrollee has three out of five 
strength in the upper limbs. The enrollee's upper limb strength and function are adequate for the enrollee to be 
able to control the power options using their own switches which are included in the allowance of the approved 
options. The approved power options come with their own switches. The request for the arm rests are 
unbundled from the approved power tilt and recline system. This means these cannot be separately requested. 
Based on this information, we decided that Medicare rules for coverage of an expandable controller, harness 
upgrade, electronic connection between the wheelchair controller and two or more power seating system 
motors, and detachable harness have not been met. Therefore, we decided that the Plan does not have to pre-
approve an expandable controller, harness upgrade, electronic connection between the wheelchair controller 
and two or more power seating system motors, and detachable harness.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gingival irrigation (D4921). 
 
You asked the Plan to pre-approve gingival irrigation. You say that this service is necessary and appropriate. 
The Plan denied your request. The Plan says this service is 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 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 
gingival irrigation (D4921).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient stay provided from March 15, 
2022, to March 19, 2022. 
 
You asked the Plan to waive the copayment for an inpatient stay. You say that you cannot afford this 
copayment. The Plan denied your request. The Plan says the copayment applied was correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $275 per 
day for days 1 to 7 for inpatient hospital care. You were hospitalized for 4 days ($275 x 4 days = $1100). 
 
You have been asked to pay $1100 for an inpatient stay. An inpatient stay 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 an inpatient stay provided from 
March 15, 2022, to March 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a drug test provided on January 26, 2022, by an OON 
provider. 
 
You asked the Plan to pay for a drug test. You say that it is our position that services performed by us have met 
the medical necessity criteria as indicated. The Plan denied your request. The Plan says the out-of-network 
services were not authorized. 
 
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 drug test provided on January 26, 2022, by an 
OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a filling (D2330) provided on February 3, 2022. 
 
You asked the Plan to pay for a filling. You say that you do not understand why the Plan will not cover this 
service. The Plan denied your request. The Plan says the service at issue 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 a filling 
(D2330) provided on February 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a tertiary level of care. 
 
You asked the Plan to pre-approve a tertiary level of care. You say that the enrollee is being followed by an 
oncologist in the community who has not started any systemic therapy. You say that the enrollee had a bleed 
within his hepatocellular carcinoma (HCC), although embolization is indicated, these cases always have 
spillage of tumor in the surrounding tissue and automatically become stage 5. However, nothing was done by 
an outside oncologist. You say that the requested doctor at the tertiary facility has extensive experience treating 
these patients. The Plan denied your request. The Plan says the enrollee's condition is stable and the service 
requested can be rendered in a community level setting. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a tertiary level of care. Our reviewer 
says that a tertiary level of care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found follow-up care can be done in the community at a non-tertiary level of care. An 
oncologist can do serial Alpha Fetoprotein (AFP) and recommend and treat failure after the ablation with 
chemotherapy/immunotherapy or Tyrosine Kinase Inhibitors (TKI.)  
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 tertiary level of care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a tertiary level of care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible and copayment for skin lesion removal and a 
specialist office visit provided on March 29, 2022. 
 
You asked the Plan to waive the deductible and copayment for the lesion removal and specialist visit. You say 
that you were never charged this amount before and feel it may be incorrect. The Plan denied your request. The 
Plan says the correct deductible and copayment were applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is $750 deductible which applies to certain items and services. 
 
Your contract with the Plan also clearly says that you must pay a $35 copayment for each specialist visit. 
 
The lesion destruction falls within the Outpatient Surgery, Including Services Provided at Hospital Outpatient 
Facilities and Ambulatory Surgical Centers benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is $750 deductible which applies to certain items and services. This cost 
sharing is a contractual obligation that had not been met at the time the lesion removal was performed on March 29, 2022. You have also been asked to pay a $35 copayment for the specialist visit, which is not subject 
to the deductible. The specialist visit falls within the Physician/Practitioner Services, Including Doctor's Office 
Visits 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 deductible and copayment for skin lesion 
removal and a specialist office visit provided on March 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 19, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed based 
on the medical documentation. The Plan denied your request. The Plan says this claim has not been billed as 
required by Medicare coding regulations. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the laboratory services provided on January 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on April 
11, 2022. 
 
You asked the Plan to pay for the dental services. You say that you do not understand why a dental 
examination is not covered. 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 April 5, 2021. Therefore, 
we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on April 
11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the evaluation and management services provided on January 
10, 2022. 
 
You asked the Plan to pay for the services provided. You say that this service has only been billed once. The 
Plan denied your request. The Plan says the service is not billed separately. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that the services at issue were provided during the global surgery period. The services were not billed 
with a modifier to indicate the service was unrelated to the surgery. Based on this information, we decided that 
Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan 
does not have to pay for the evaluation and management services provided on January 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 9 additional hours of medical nutrition therapy. 
 
You asked the Plan to pre-approve medical nutrition therapy. You say that you think these visits would be 
helpful for the enrollee's health. The Plan denied your request. The Plan says the denial of authorization for 
additional medical nutrition therapy is correct, because the Plan already approved 3 hours of medical nutrition 
therapy which is the maximum benefit for the first year that the beneficiary received medical nutritional 
therapy according to Medicare rules. 
 
The Plan must follow Medicare rules. Medicare rules say that the maximum benefit for basic coverage of 
medical nutrition therapy in the first year is 3 hours of administration.  
 
We looked at the file and Medicare rules. The Plan has already approved 3 hours of medical nutrition therapy 
administration, which is the maximum covered benefit for the first year. Based on this information, we decided 
that Medicare rules for coverage of medical nutrition therapy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve 9 additional hours of medical nutrition therapy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance (D4910) provided on March 31, 
2022. 
 
You asked the Plan to pay for periodontal maintenance. You say that periodontal maintenance is another term 
for normal cleaning that is down twice a year. The Plan denied your request. The Plan says your reimbursement 
allowance has been exhausted. 
 
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 have a $1,500 
reimbursement allowance per year for non-Medicare covered comprehensive dental services. 
 
The record shows periodontal maintenance is considered a comprehensive dental service. The record also 
shows that your reimbursement allowance for comprehensive dental services has been exhausted. You have 
been asked to pay $180 for periodontal maintenance. Periodontal maintenance falls within the Dental Services 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to pay for periodontal maintenance (D4910) provided on 
March 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scalings and root planings (D4341) and a 
mandibular partial denture (D5214). 
 
You asked the Plan to pre-approve the scalings and planings and mandibular partial denture. The Plan denied 
your request. The Plan says these 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 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 
periodontal scalings and root planings (D4341) and a mandibular partial denture (D5214).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit, x-ray and electrical stimulation provided by a 
chiropractor on January 24, 2022, and January 26, 2022. 
 
You asked the Plan to pay for the office visit, x-ray, and electrical stimulation. You say that you have low back 
pain and have been on disability since 2017. The Plan denied your request. The Plan says all services other than 
manual manipulation of the spine for treatment of subluxation of the spine are excluded when ordered or 
performed by a Doctor of Chiropractic. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for an office visit, x-ray and electrical stimulation provided by a chiropractor on 
January 24, 2022, and January 26, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health skilled nursing services. 
 
You asked the Plan to pre-approve home health skilled nursing services. You say that you recommend the 
enrollee receive twice weekly skilled nursing care to continue to treat their chronic venous stasis dermatitis. 
The Plan denied your request. The Plan says the enrollee does not have a skilled nursing need. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services.  
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 home health skilled nursing services. 
Our reviewer says that the requested home health services are not medically necessary. Our physician reviewer 
found the documentation does not support that the enrollee requires additional skilled nursing services to 
provide treatment that is medically necessary. The enrollee does not require additional skilled nursing services 
to effectively provide treatment, care, and/or services in order to improve the enrollees condition, perform a 
maintenance program to maintain the enrollees condition and/or prevent deterioration. Our reviewer also 
found that the enrollee has been medically stable without any recent exacerbations of chronic medical problems 
or hospitalizations. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health skilled nursing services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve home health skilled nursing services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for PT services provided by a chiropractor from February 9, 
2022, to March 29, 2022. 
 
You asked the Plan to pay for the PT services. You say that your previous insurance has covered this therapy. 
The Plan denied your request. The Plan says chiropractic manipulative treatment is the only chiropractic 
service that is covered. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for physical therapy (PT) services provided by a chiropractor from February 9, 
2022, to March 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown (D2740) and core buildup, including any pins 
when required (D2950) provided on October 20, 2021, and November 19, 2021. 
 
You asked the Plan to pay for the crown and core buildup. You say that you feel the Plan should pay for these 
services because you were not told until after the fact that these services were not covered under your plan. The 
Plan denied your request. The Plan says these services are not covered benefits under your dental 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 crown 
(D2740) and core buildup, including any pins when required (D2950) provided on October 20, 2021, and 
November 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility care provided on January 21, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for skilled nursing facility care. You say that you treated the patient in good faith of 
reimbursement since their care was priority at the time of service. The Plan denied your request. The Plan says 
services from non-participating providers are not covered under the Plan unless they are authorized before the 
services are provided. 
 
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 skilled nursing facility care provided on January 
21, 2022, by an out-of-network (OON) provider.