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

 
We decided that the Plan does not have to pay for the prefabricated post and core in addition to crown, core 
buildup, including any pins when required, inhalation of nitrous oxide, or pay more for the crown provided on 
March 22, 2022. 
 
You asked the Plan to pay for the prefabricated post and core, core buildup, inhalation of nitrous oxide, and to 
pay more for the crown. You say that you would like help paying this bill. The Plan denied your request. The 
Plan says you have met your annual maximum 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 Plan offers a $0 copay up to the 
$1,000 allowance for all covered dental services. The contract says you pay 100 percent of charges beyond the 
$1,000 allowance or if you exceed a service limit. The record shows that you met the annual maximum benefit 
on March 22, 2022, and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan 
does not have to pay for the prefabricated post and core in addition to crown, core buildup, including any pins 
when required, inhalation of nitrous oxide, or pay more for the crown provided on March 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services provided on January 4, 2021, and January 
6, 2021. 
 
You asked the Plan to pay for the anesthesia services. You did not provide an argument with your appeal 
request. The Plan denied your request. The Plan says you did not timely file your claim. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. The record shows that a claim for the 
anesthesia services was not filed until January 7, 2022. This means that more than one calendar year from the 
date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay 
for anesthesia services provided on January 4, 2021, and January 6, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on February 17, 2022. 
 
You asked the Plan to pay for the services provided. You say that drug testing is needed to monitor possible 
opioid abuse. The Plan denied your request. The Plan says this code is not separately reimbursed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 We looked at the file and Medicare rules. We find that the testing described by billed code 83789 is considered 
specimen validity testing which is not separately payable. Based on this information, we decided that Medicare 
rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay 
for the lab testing services provided on February 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endodontic therapy of molar (D3330) tooth #19 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the dental services. You say that an x-ray showed that your tooth was dead, 
so you were advised to see this provider for a root canal. The Plan denied your request. The Plan says dental 
services from an out-of-network provider are not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
You are requesting dental services from an out-of-network provider. Though the Plan offers a dental benefit in 
excess of Medicare coverage, the requested items or services are not covered under this benefit when received 
from an out-of-network provider. Therefore, we decided that the Plan does not have to pre-approve endodontic 
therapy of molar (D3330) tooth #19 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the radiation therapy provided from March 
11, 2022, to March 31, 2022. 
 
You asked the Plan to waive the cost share for the radiation therapy. You say that you do not agree with the 
copay and would like the Plan to revise the claim. 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 20% 
coinsurance for radiation therapy.  
 
 
 You have been asked to pay $500 which is the Maximum out of Pocket (MOOP) for radiation therapy. 
Radiation therapy 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 cost share for the radiation therapy provided from March 11, 
2022, to March 31, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that you have several health issues, neuropathy in 
feet, arthritis all over body which severely hurts when standing a long period of time The Plan denied your 
request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on April 1, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for the lab services. You say that the member thought they had the same coverage as 
Original Medicare. The Plan denied your request. The Plan says unauthorized, non-plan care is not covered. 
 
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. 
 
Your organization 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 lab services provided on April 1, 2022, by an out-of-network 
(OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aranesp. 
 
You asked the Plan to pre-approve Aranesp. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested drug does not meet step therapy criteria. 
 
 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Aranesp. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has a diagnosis of anemia in the setting of stage 4 chronic kidney disease. The 
documentation does not support that the enrollee has tried and failed Retacrit or Procrit therapy for two 
consecutive months. The documentation does not support that Retacrit or Procrit would likely be less effective 
or would likely have adverse effects for the enrollee. Therefore, the enrollee does not meet criteria for the 
requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Aranesp have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Aranesp.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an annual wellness visit provided on September 16, 2021. 
 
You asked the Plan to pay for an annual wellness visit. The Plan denied your request. The Plan says the 
provider needs to bill traditional Medicare. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
 
 
 
 
 
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for an annual wellness visit provided on September 16, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on 
January 29, 2022. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you were sent home from 
the emergency room unwell, so a second ambulance was needed. 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 $275 
copayment for ambulance services.  
 
 
 
 
 
 
 You have been asked to pay a $275 copayment for ambulance services. Ambulance services fall within the 
Ambulance Services benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ambulance 
services provided on January 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for moderate sedation services (procedure code 99152) provided 
to the enrollee on January 21, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) code 99152 (1 Unit) remains not supported. 
 
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 99152 is "Moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older." 
 
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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that there is no documentation to support the presence of an independent trained observer to assist in the monitoring of the patient's level of 
consciousness and physiological status during the procedure. The documentation provided does not support the 
billing of CPT code 99152. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for moderate sedation services (procedure code 99152) provided to the enrollee on January 21, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the four periodontal scalings and root planings (D4342 x4), 
four gingival irrigations (D4921 x4), and three drugs or medicaments dispensed in the office for home use 
(D9630 x3) provided on February 11, 2021. 
 
You asked the Plan to pay for the scalings and planings, gingival irrigations, and drugs or medicaments. You 
say that prior to going to the dentist you spoke with someone about the work that was recommended, and you 
were told your insurance would cover the work up to $1,000. You also say that you cannot afford to pay for 
these services. The Plan denied your request. The Plan says these services are not covered. The Plan also says 
you did not contact the Plan prior to the date of service to verify benefits and provider eligibility.  
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 four 
periodontal scalings and root planings (D4342 x4), four gingival irrigations (D4921 x4), and three drugs or 
medicaments dispensed in the office for home use (D9630 x3) provided on February 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and 
pulp vitality tests (D0460) provided on March 15, 2022. 
 
You asked the Plan to pay for the problem focused limited oral evaluation and pulp vitality tests. You say that 
you would like these services to be covered. 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 pay for the 
problem focused limited oral evaluation (D0140) and pulp vitality tests (D0460) provided on March 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids (V5298) purchased on 
January 12, 2022. 
 
You asked the Plan to issue reimbursement for these items. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says the items at issue are not payable 
as they were rendered by an out-of-network 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 they are rendered by an in-network provider.  
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically, the items in this case were purchased from an out-of-
network provider. The Plan contract says that hearing aids purchased outside of the network provider are not 
covered. Therefore, we decided that the Plan does not have to issue reimbursement for the hearing aids 
(V5298) purchased on January 12, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve replacement of breast implants. 
 
You asked the Plan to pre-approve the surgical procedure. You say that the new placement should be 
considered reconstructive and medically necessary. The Plan denied your request. The Plan says the 
replacement of the failed implants is considered cosmetic. 
 
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 surgical procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found in this case, the record indicates that the enrollee had breast implants for cosmetic 
reasons. The record indicates that the implants are ruptured and removal has been approved. The record does 
not indicate that the enrollee has cancer or that the replacement is to repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease. The record 
does not indicate functional impairment. The requested procedure is considered cosmetic under Medicare rules. 
 
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 surgical procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve replacement of breast implants.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97010 billed for date of service March 4, 2022. 
 
You asked the Plan to pay for procedure code 97010. You say that these services were pre-approved and should 
be paid. The Plan denied your request. The Plan says they have agreed to pay for some of the therapy services; 
however, procedure code 97010 is considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
 We find that CPT code 97010 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 97010 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of procedure code 97010 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 97010 billed for date of service March 4, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service February 18, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
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, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service February 18, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (81455) provided on March 3, 2022 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the services should be covered as you 
disagree with the charges. The Plan denied your request. The Plan says the services denied correctly as they 
were non-emergent and prior authorization was not obtained. 
 
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 laboratory services (81455) provided on March 3, 
2022 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve the home ventilator (CPT code E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that the home ventilator is necessary. The Plan 
denied your request. The Plan says that the request for a home mechanical ventilator set in intelligent volume 
assured pressure support (iVAPS) mode with Auto-EPAP (AE) that could be delivered by bilevel positive 
airway pressure (BiPAP) is not covered. 
 
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 forward any medical records to verify if you meet the Medicare 
criteria for the home ventilator. Therefore, we decided that the Plan has to pre-approve the home ventilator 
(CPT code E0466).  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Addition, endoskeletal system, below knee, flexible 
protective outer surface covering system (L5962). 
 
You asked the Plan to pre-approve the extra protective cover. You say that the enrollee's current foot is out of 
warranty and it has been 5 years since this foot has been changed. The Plan denied your request. The Plan says 
this item is 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 looked at this the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the extra protective cover have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Addition, endoskeletal system, below knee, flexible protective outer surface covering system (L5962).