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

 
We decided that the Plan does not have to pre-approve therapeutic parenteral drug (D9612), initial 15 minutes 
of anesthesia (D9222), and additional 15 minutes of anesthesia (D9223 x 2). 
 
You asked the Plan to pre-approve the therapeutic parenteral drug. You say that you need these services. The 
Plan denied your request. The Plan says therapeutic parenteral drug is not listed as a covered service. 
 
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 therapeutic parenteral 
drug is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-
approve therapeutic parenteral drug (D9612), initial 15 minutes of anesthesia (D9222), and additional 15 
minutes of anesthesia (D9223 x 2).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an out-of-network consultation. 
 
You asked the Plan to pre-approve an out-of-network consultation. You say that you were already seen by this 
provider a year ago and would like to see him again since he knows your condition. You say that the network 
provider is too far away, and you can get to the out-of-network provider quicker in an emergency. The Plan 
denied your request. The Plan says contracted providers 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 
an out-of-network consultation.
Appeal type: DME/ Orthotics
Decision: Unfavorable


We decided that the Plan does not have to waive the coinsurance for a wheelchair and additional wheelchair equipment provided on November 16, 2021.
You asked the Plan to waive the coinsurance for a wheelchair and additional wheelchair equipment. You say that the wheelchair was assembled incorrectly and only upon your assistance was that mistake corrected. You also want someone to explain the total cost of $11, 408.58. 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 20%
coinsurance for in-network durable medical equipment.
You have been asked to pay a total of $1,723.54 for a wheelchair and additional wheelchair equipment received on November 16, 2021.
Code Allowed Amount Coinsurance
K0005NU $2,152.10 $430.42 E2206NU $80.46 $16.09 E0973NU $127.80 $25.56 E0971NU $69.82 $13.96 E2607EU $226.61 $45.32 E2613NU $329.85 $65.97 E0986NU $5,319.27 $1,063.85 K0108NU $113.85 $22.77 K0108NU $198.00 $39.60 Total $8,617.76 $1,723.54
A wheelchair and additional wheelchair equipment fall within the Durable Medical Equipment (DME) and Related 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 coinsurance for a wheelchair and additional wheelchair equipment provided on November 16, 2021
Your complaint about the wheelchair not being assembled correctly is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve psychological testing (90791, 96130, 96131, 96136, 
96137). 
 
You asked the Plan to pre-approve psychological testing. You say that the medical records provided support the 
necessity of the requested services. The Plan denied your request. The Plan says psychological testing before 
weight loss surgery is not not medically necessary. 
 
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 psychological testing. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found based on review the records provided this enrollee does not meet the criteria for 
authorization of psychological testing based on LCD L34646 claiming that psychological testing is medically 
appropriate if information provided indicates a mental illness or signs of a mental illness where psychological 
testing is indicated to assist with the diagnosis and/or treatment. This enrollee does not meet the criteria for 
authorization of psychological testing based on the LCD as he has no psychiatric/psychological diagnosis and 
is believed that this could be accomplished by outpatient treatment with a physician. 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of psychological testing have not been met. Therefore, we decided that the Plan 
does not have to pre-approve psychological testing (90791, 96130, 96131, 96136, 96137).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and complete lower 
denture (D5120). 
 
You asked the Plan to pre-approve dentures. You say that your current dentures are unusable and need to be 
replaced. The Plan denied your request. The Plan says you previously received a set of complete dentures in 
February 2018 which were covered by the Plan. Complete dentures may only be covered once every five plan 
years for each jaw. 
 
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 can cover one 
complete upper denture (D5110) every five plan years and one complete lower denture (D5120) every five plan 
years. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the dentures are requested in a 
frequency that is not covered under this benefit. Documentation shows that you received a complete upper 
denture and complete lower denture in 2018. Therefore, we decided that the Plan does not have to pre-approve 
a complete upper denture (D5110) and complete lower denture (D5120).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the Medicare Part B drug injection 
provided on October 7, 2021. 
 
You asked the Plan to waive the coinsurance for the Medicare Part B drug injection. You say that these charges 
should be waived. The Plan denied your request. The Plan says the coinsurance amount charged for the 
Medicare Part B injection is 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 20% 
coinsurance of the total cost for Medicare Part B drugs.  
 
You have been asked to pay $23.86, which is 20% of the Plan's allowed amount ($119.28), for the Medicare 
Part B drug injection. Medicare Part B drug injections 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 coinsurance for the Medicare Part B drug 
injection provided on October 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incisional biopsy of oral tissue (D7286). 
 
You asked the Plan to pre-approve the dental service. You say that the biopsy is medically necessary. The Plan 
denied your request. The Plan says incisional biopsy of oral tissue is not listed as a covered dental service. 
 
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 incisional biopsy of oral 
tissue is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-
approve incisional biopsy of oral tissue (D7286).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150) and surgical 
extraction (D7210). 
 
You asked the Plan to pre-approve the dental services. You say that your dentist referred you to an oral surgeon 
for the services. The Plan denied your request. The Plan says dental services to be performed by an oral 
surgeon 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 oral evaluation and 
surgical extraction to be performed by an oral surgeon are not among those covered under this benefit. 
Therefore, we decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150) and 
surgical extraction (D7210).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a porcelain fused to high noble metal crown (D2750) for 
tooth #21. 
 
You asked the Plan to pre-approve the crown. You say that this crown is medically necessary. The Plan denied 
your request. The Plan says you received two crowns on January 11, 2022. Your dental benefit covers a 
maximum of two caps or crowns per year. Therefore, the request for a third crown exceeds the frequency 
limitations of your 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. The Plan can cover two caps 
or crowns per year. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the crown is requested in a frequency 
that is not covered under this benefit. Documentation shows you previously had two crowns this year which 
were covered by the Plan. Therefore, we decided that the Plan does not have to pre-approve a porcelain fused 
to high noble metal crown (D2750) for tooth #21.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone replacement graft (D7953). 
 
You asked the Plan to pre-approve a bone replacement graft. You say that this service is medically necessary. 
The Plan denied your request. The Plan says this service is not covered by your dental benefit under any 
condition. 
 
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 (D7953).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core build up (D2950) for teeth # 3 and 19. 
 
You asked the Plan to pre-approve the dental services. You say that you are genuinely concerned that if your 
teeth are not fixed soon, you could end up with endocarditis or some other kind of bad infection. The Plan 
denied your request. The Plan says core build up is not listed as a covered service. 
 
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 core build up are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve core 
build up (D2950) for teeth # 3 and 19.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous intraoperative neurophysiology monitoring 
(G0453), a central motor evoked potential study (transcranial motor stimulation); in upper and lower limbs 
(95939), a short-latency somatosensory evoked potential study (95938), a neuromuscular junction test (95937), 
a needle electromyography (95861, 95865, 95868, 95937),  provided on February 9, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for a continuous intraoperative neurophysiology monitoring (G0453), a central 
motor evoked potential study (transcranial motor stimulation); in upper and lower limbs (95939), a short-
latency somatosensory evoked potential study (95938), a neuromuscular junction test (95937), a needle 
electromyography. You say that this claim should be processed under the in-network umbrella of the surgeon 
and the hospital for its services rendered. The Plan denied your request. The Plan says these services were out-
of-network services. 
 
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 continuous intraoperative neurophysiology 
monitoring (G0453), a central motor evoked potential study (transcranial motor stimulation); in upper and 
lower limbs (95939), a short-latency somatosensory evoked potential study (95938), a neuromuscular junction 
test (95937), a needle electromyography (95861, 95865, 95868, 95937),  provided on February 9, 2021, by an 
out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Litespeed Plastic Wheels, Primo Express solid tires, 
and Uni-Lock Wheel Lock. 
 
You asked the Plan to pre-approve the wheels, tires and wheel lock. You say that you would like 
reconsideration because the requested equipment is medically necessary. The Plan denied your request. The 
Plan says if an option or accessory that is included in another code is billed separately, the claim line will be 
denied as not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that each power wheelchair code is required to 
include a complete set of tires and casters. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the wheels, tires and wheel lock have not been met. Specifically, the requested equipment is 
included in the approved ultralight wheelchair. Therefore, we decided that the Plan does not have to pre-
approve the Litespeed Plastic Wheels, Primo Express solid tires, and Uni-Lock Wheel Lock.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial upper denture (D5225). 
 
You asked the Plan to pre-approve the denture. You say that this service is necessary. The Plan denied your 
request. The Plan says dentures (prosthodontics) 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 
partial upper denture (D5225).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for your inpatient hospital stay provided on 
April 7, 2021 to April 9, 2021 
 
You asked the Plan to waive the copayment for your inpatient hospital stay. You say that the copayment should 
be waived because it was COVID related. The Plan denied your request. The Plan says the copayment amount 
charged is 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 a $325 
copayment for each day for days 1-5 each time you are admitted for Medicare-covered hospital care.   
 
You have been asked to pay a $650 copayment for an inpatient hospital stay lasting two days ($325x2). An 
inpatient hospital 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 your inpatient hospital stay provided on April 7, 2021 to April 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a implant (D60100, prefabricated abutment (D6056), 
and a crown (D6065). 
 
You asked the Plan to pre-approve the routine dental care. You say that the services are medically necessary. 
The Plan denied your request. The Plan says these are not covered services. 
 
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 
implant (D60100, prefabricated abutment (D6056), and a crown (D6065).
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 this is medically necessary. The Plan denied your 
request. The Plan says care can be had at an alternate level, like skilled nursing. 
 
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. The enrollee was admitted for gangrene and osteomeylitis and had a below the knee amputation. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While the medical record supports a need for physical and/or occupational 
therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be 
provided in a different level of care. 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung 
cancer screening. 
 
You asked the Plan to pre-approve the requested LDCT scan. You say that this is medically necessary. The 
Plan denied your request. The Plan says the criteria is not met. 
 The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung 
cancer screening for enrollees who meet all the criteria described in the Medicare rules section of this letter.  
 
We reviewed the file and the Medicare rules. We find that the enrollee is 51 years old. The age range for this 
request is 55-77 years old.. Therefore, we decided that the Plan does not have to pre-approve a low dose 
computed tomography (LDCT) scan for lung cancer screening.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve drugs or medicaments dispensed in the office for home 
use (D9630). 
 
You asked the Plan to pre-approve drugs dispensed in the office for home use. You say that this service is 
necessary as the enrollee is experiencing pain and anxiety. 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 
drugs or medicaments dispensed in the office for home use (D9630).