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

 
We decided that the Plan does not have to pre-approve a bone replacement graft for ridge preservation 
(D7953). 
 
You asked the Plan to pre-approve a bone replacement graft. You say that you require the bone transfer to 
complete the partial procedure. The Plan denied your request. The Plan says this service is not covered on 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 pre-approve a 
bone replacement graft for ridge preservation (D7953).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral - periapical first radiographic image (D0220), 
and intraoral - periapical each additional radiographic image (D0230) provided on December 29, 2021. 
 
You asked the Plan to pay for the dental services. You say that you paid out-of-pocket and would like to be 
reimbursed. 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 December 29, 2021. 
Therefore, we decided that the Plan does not have to pay for an intraoral - periapical first radiographic image 
(D0220), and intraoral - periapical each additional radiographic image (D0230) provided on December 29, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for protective restoration (D2940), and limited oral evaluation - 
problem focused (D0140) September 19, 2022. 
 
You asked the Plan to pay for the protective restoration (D2940), and limited oral evaluation - problem focused 
(D0140). You say that you are appealing this because it is covered next year. 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 pay for protective 
restoration (D2940), and limited oral evaluation - problem focused (D0140) September 19, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room and inpatient hospital 
services provided on August 16, 2022, to August 18, 2022. 
 
You asked the Plan to waive the copayment for emergency room and inpatient hospital services. You say that 
you are disputing the share cost. 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 $210 
copayment per day for days 1 to 6 for inpatient hospital care and $90 copayment for emergency care. 
 
You have been asked to pay $210 copayment per day for days 1 to 6 for inpatient hospital services and $90 copayment for emergency room. These items/services fall within the inpatient hospital care and emergency 
care benefit categories. 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 and inpatient 
hospital services provided on August 16, 2022, to August 18, 2022.
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. The Plan denied your request. The Plan says there is 
no documentation that the enrollee will benefit from and improve with LTACH admission. The enrollee's care 
may be safely provided in the current inpatient hospital. 
 
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 enrollee does not require services at the LTACH that are not available at the acute 
care hospital where the enrollee is currently receiving care. The Plan has approved ongoing care in the current 
acute care setting.  
 
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 panoramic x-ray (D0330) provided on August 15, 2022. 
 
You asked the Plan to pay for the panoramic x-ray. 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 24, 2022. 
Therefore, we decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on August 
15, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve the non-implanted continuous glucose monitor (CGM) sensors 
(A4238). 
 
You asked the Plan to pre-approve the CGM sensors. You say that the items are medically necessary. The Plan 
denied your request. The Plan says that the member has already been provided these supplies. 
 
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. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not provided any documentation indicating the member has already 
been provided these supplies. Therefore, we decided that the Plan has to pre-approve the non-implanted 
continuous glucose monitor (CGM) sensors (A4238).  
 
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 hearing aids (V5261) purchased on April 21, 2022, from 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the hearing aids. You say that this claim should be paid under the direct member 
reimbursement provision. You also say that although the services were rendered by an OON provider, your 
benefits should remain the same as in-network beneficiaries. The Plan denied your request. The Plan says you 
have not set up a hearing profile and there was no provider assigned. The Plan also says you received these 
hearing aids from an OON provider. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when you use the Plan's approved hearing aid vendor for your hearing aid benefits.  
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for 
the hearing aids (V5261) purchased on April 21, 2022, from an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a free soft tissue graft procedure of the first tooth (D4277) 
and a free soft tissue graft procedure of each additional contiguous tooth (D4278) provided on September 1, 
2022. 
 
You asked the Plan to pay for a free soft tissue graft procedure of the first tooth (D4277) and a free soft tissue 
graft procedure of each additional contiguous tooth (D4278). You say that not knowing that the rider excludes 
this procedure, you would like to know why this was not covered. The Plan denied your request. The Plan says 
grafting procedures are excluded from the 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 pay for a free soft 
tissue graft procedure of the first tooth (D4277) and a free soft tissue graft procedure of each additional 
contiguous tooth (D4278) provided on September 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for provider services provided from November 30, 2021, to 
December 15, 2021, by an OON provider. 
 
You asked the Plan to pay for provider services. You say that you did not know preauthorization was necessary 
The Plan denied your request. The Plan says you must receive your care from a network provider. 
 
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 provider services provided from November 30, 
2021, to December 15, 2021, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unlisted procedure, urinary system (53899) provided on 
December 27, 2021. 
 
You asked the Plan to pay for the surgical service. You say that the service should be covered. The Plan denied 
your request. The Plan says there is a more appropriate procedure code to describe the service that was billed in 
this case. 
 
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 code 53899 is unlisted procedure, urinary system. 
 
We find that CPT code 53899 is not supported in the medical record. Specifically, there are more appropriate 
codes to describe the services that were rendered. Based on this information, we decided that Medicare rules 
for coverage of the surgical service have not been met. Therefore, we decided that the Plan does not have to 
pay for the unlisted procedure, urinary system (53899) provided on December 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the complete upper and lower dentures (D5110, D5120). 
 
You asked the Plan to pre-approve the dental services. You say that your purse was stolen, and your dentures 
were inside. You say you need new dentures. The Plan denied your request. The Plan says your benefit for the 
requested dentures 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 dentures was exhausted on date of service October 13, 2020. Therefore, we decided 
that the Plan does not have to pre-approve the complete upper and lower dentures (D5110, D5120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation - new or established patient 
(D0150) provided on August 4, 2022. 
 
You asked the Plan to pay for the dental services. You say that the enrollee changed dentists in 2022 due to the 
fact that she did not like the dentist she went to in 2021. 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 May 28, 2021. Therefore, 
we decided that the Plan does not have to pay for a comprehensive oral evaluation - new or established patient 
(D0150) provided on August 4, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services. 
 
You asked the Plan to pay for the ambulance services. You say that you thought you had the copayment 
corrected but received a repeat bill. The Plan denied your request. The Plan says these services are not a 
covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on July 24, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of intravenous immune globulin (IVIG). 
 
You asked the Plan to pre-approve IVIG. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no current symptom to warrant IVIG without a trial of immunosuppressive 
medication. 
 
The Plan follows Medicare rules. Medicare rules state that IVIG may be covered for treatment of myasthenia 
gravis under certain conditions. 
 
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 IVIG. Our reviewer says that the 
enrollee does not meet the Medicare criteria for IVIG. Our physician reviewer found the record indicates the 
enrollee has a diagnosis of myasthenia gravis with acute exacerbation. The records do not document that the 
enrollee is either refractory to corticosteroids over a 6 week period, has been unable to successfully taper 
corticosteroids below moderately high doses, or has developed severe side-effects due to steroid therapy, and 
has also failed at least one immunosuppressive agent.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IVIG have not been met. Therefore, we decided that the Plan does not have to 
pre-approve use of intravenous immune globulin (IVIG).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and prophylaxis 
(D1110) provided on September 8, 2022. 
 
You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that maintaining excellent 
oral health has been a priority, and necessity for you due to your history. You also say that at minimum, two 
cleanings and preventive care per year is necessary to prevent another infection. The Plan denied your request. 
The Plan says your benefits for the requested serviced have 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 benefits for the requested services were exhausted on date of service February 16, 2022. Therefore, 
we decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and prophylaxis 
(D1110) provided on September 8, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from April 3, 2022, to 
April 20, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from April 3, 2022, to April 
20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for anesthesia services provided on August 19, 
2022. 
 
You asked the Plan to waive the deductible for anesthesia services. You say that you disagree with the charge 
for the anesthesiology assistant and feel it should all be included in one charge. 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. Your 
contract with the Plan says that there is a $750 deductible which applies to anesthesia.  
 
The item or service you asked the Plan to waive the deductible for falls within the anesthesia benefit category. 
The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible which 
applies to anesthesia. This cost sharing is a contractual obligation that had not been met at the time anesthesia 
services was received on August 19, 2022. Therefore, we decided that the Plan does not have to waive the 
deductible for anesthesia services provided on August 19, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on February 22, 2022, to 
February 26, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that these 
services were reported appropriately and are supported as billed. The Plan denied your request. The Plan says 
the DRG submitted on this claim is not supported by the medical records provided. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with unspecified severe protein-calorie malnutrition 
(E43). We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules 
to determine if the Plan was correct in denying the request to pay for the inpatient hospital services at the DRG 
originally billed. Our reviewer says that this diagnosis is not supported in the medical record. Our physician 
reviewer found that the enrollee with chronic hepatitis C and liver cirrhosis who presented with right upper 
quadrant pain, nausea, vomiting, and poor intake of food for 1-2 days. She was diagnosed with a urinary tract 
infection (UTI) and sepsis, given antibiotics and fluids. Following initial treatment in the emergency 
department, she was hemodynamically stable. The enrollees albumin level was 1.7 and she was noted to gain 
weight during the admission. Physical findings did not exhibit signs of muscle wasting or underweight status. 
Also, low albumin is common in those with liver cirrhosis and is not related to protein-deficiency malnutrition. 
Therefore, severe protein-calorie malnutrition is not supported in the documentation.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on February 22, 2022, to February 26, 2022, at the Diagnosis Related 
Group (DRG) originally billed.