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

 
We decided that the Plan does not have to pay for dental services provided by an opt-out provider on 
September 9, 2021. 
 
You asked the Plan to pay for dental services. You say that you would like this claim reconsidered for payment. 
The Plan denied your request. The Plan says the rendering dentist has opted out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for dental 
services provided by an opt-out provider on September 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for Chiropractic services provided from 
December 7, 2021 through December 30, 2021. 
 
You asked the Plan to waive the copayments for Chiropractic services. You say that you would like to appeal 
the cost share. The Plan denied your request. The Plan says the additional charges have been applied correctly. 
The Plan only covers manual manipulation of the spine to correct subluxation. 
 
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 
copayment for each Medicare-covered visit for Chiropractic services. For claims 21363E075P00, 
21350E08Q400, 21364E037500, and 22004E05N200, the copayments are $80.  With the additional services 
provided that werent considered manual manipulation of the spine, there is an additional $21.43 per visit.  The 
total cost share is $165.72. You have been asked to pay a $20 copayment for each Medicare-covered visit for Chiropractic services. 
Chiropractic services falls within the Chiropractic 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 copayments for Chiropractic services provided from December 7, 2021 through December 30, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core build up (D2950 x 4), porcelain crowns (D2740 x 
4), prefabricated post and core in addition to a crown (D2954), unspecified restorative procedure (D2999 x 5), 
gingivectomy (D4211 x 5), and occlusal adjustment (D9951). 
 
You asked the Plan to pre-approve the dental services. You say that you need at least 3 crowns as soon as 
possible. You say that you cannot afford to pay for them. You say that other insurances cover 3 crowns per 
year. You also say that you feel your teeth are diminishing due to cancer treatments that you had in 2019. The 
Plan denied your request. The Plan says 1 crown is covered per calendar year. The Plan says that the frequency 
limit has been exceeded. The Plan also says that core build up, post and core in addition to a crown, unspecified 
restorative procedure, gingivectomy, and occlusal adjustment are not listed as covered services. 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage and 1 crown is covered per calendar 
year, the frequency limit has been exceeded. The record shows that the Plan paid for a crown that you received 
on February 28, 2022. Additionally, the requested core build up, post and core in addition to a crown, 
unspecified restorative procedure, gingivectomy, and occlusal adjustment are not among those covered under 
this benefit. Therefore, we decided that the Plan does not have to pre-approve core build up (D2950 x 4), 
porcelain crowns (D2740 x 4), prefabricated post and core in addition to a crown (D2954), unspecified 
restorative procedure (D2999 x 5), gingivectomy (D4211 x 5), and occlusal adjustment (D9951).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental cleaning (D1110) provided on November 29, 2021. 
 
You asked the Plan to pay for the cleaning. You say that it is necessary for you to have three cleanings per 
year, and this service should be covered. The Plan denied your request. The Plan says you had previous dental 
cleanings provided on March 30, 2021, and August 9, 2021. Your benefit covers a maximum of two cleanings 
per year; therefore, the cleaning provided on the date in question exceeded 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 Plan's coverage rules apply in this case. The Plan covers a maximum 
of two dental cleanings per calendar year. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the documentation shows that the 
cleaning is requested in a frequency that is not covered under this benefit. Therefore, we decided that the Plan 
does not have to pay for the dental cleaning (D1110) provided on November 29, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on August 10, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like reconsideration because 
there is no contract language indicating that these services are included in the dialysis payment. The Plan 
denied your request. The Plan says payment for these services is included in the dialysis payment. 
 
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 August 10, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on April 5, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.  
 
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and 
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on April 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an immediate lower partial denture (D5224). 
 
You asked the Plan to pre-approve the dental item. You say that you never received the dentures in 2018. You 
say that you only have 4 molars. You say that your ability to eat has been affected. You also say that your self-
esteem has been affected. The Plan denied your request. The Plan says immediate lower partial denture is not 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 immediate lower partial 
denture is not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pre-approve an immediate lower partial denture (D5224).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2751) for tooth # 7. 
 
You asked the Plan to pre-approve the dental service. You say that you hardly have any teeth. You say that you 
have about 4 missing teeth. You also say that it is hard for you to chew on the left side. The Plan denied your 
request. The Plan says the claim denied correctly. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage and 1 crown is covered per tooth every 
5 60 months, the frequency limit has been reached. The record shows that you received a crown for tooth # 7 
only 4 months prior. Therefore, we decided that the Plan does not have to pre-approve a crown (D2751) for 
tooth # 7.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture services provided from October 5, 2021, to 
October 29, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the service 
must be provided by a legally qualified physician. 
 The Plan must follow Medicare rules. The rules say that acupuncture services only covered under certain 
medical indications.  
  
We looked at the file and Medicare rules. The records do not show that the services at issue were provided by 
or under the supervision of a qualified physician. Based on this information, we decided that the rules for 
coverage of the acupuncture services have not been met. Therefore, we decided that the Plan does not have to 
pay for the acupuncture services provided from October 5, 2021, to October 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids (V5261) provided on October 19, 2021. 
 
You asked the Plan to pay for the hearing aids. You say that you have seen this audiologist for many years and 
trust their services and recommendations. The Plan denied your request. The Plan says hearing aids are only 
covered when they are purchased through the specified hearing vendor. 
 
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 received from the specified vendor network.  
 
We looked at the file and the Plan's rules. The provider in this case is not part of the Plans specified hearing 
vendor network. 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) 
provided on October 19, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve TriVisc. 
 
You asked the Plan to pre-approve TriVisc. You say that this is medically necessary. The Plan denied your 
request. The Plan says step therapy requirements have not been met. 
 
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 TriVisc. Our reviewer says that the 
requirements for coverage of TriVisc have not been met. Our physician reviewer found he Plan requires a trial 
of Orthovisc or Synvisc before they will approve the requested drug. The patient has not tried and failed the 
required drugs. Based on the medical records provided, there is no indication that the required drugs would 
likely be less effective or have adverse effects for the patient. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of TriVisc have not been met. Therefore, we decided that the Plan does not have to 
pre-approve TriVisc.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Hospital services provided on February 8, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for Hospital services. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says prior authorization is required for an out-of-network 
visit. 
 
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 Hospital services provided on February 8, 2021 by 
an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that you are weak and need skilled nursing care. You 
say that you are unable to take care of yourself. The Plan denied your request. The Plan says the enrollee does 
not meet the requirements for coverage. The Plan says that the services needed can safely be received at a 
different setting. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee has stabilized medically and 
is ready for discharge from the hospital. The enrollee does not require skilled nursing and/or skilled therapy 
services on a daily basis. She is medically stable and can receive further rehabilitation services at a lower level 
of care. Although further rehabilitation services would be appropriate to improve function, as a practical 
matter, the intermittent skilled services can be provided at a lower level of care than a skilled nursing facility. 
The enrollee does not have any parental medication, complex wound care or nutrition given via a feeding tube. 
She is medically stable without any acute exacerbations of chronic medical problems. Her physical function is 
at or near her baseline and she can receive services at a lower level of care. Admission to a SNF for inpatient 
skilled rehabilitation services is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on May 11, 2021. 
 
You asked the Plan to pay for the lab services. You say that there is no agreement that the codes are included in 
the dialysis rate. The Plan denied your request. The Plan says the tests are bundled into the dialysis services. 
 
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 lab services provided on May 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an out-of-network provider on 
June 19, 2021. 
 
You asked the Plan to pay for dental services. You say that you would like the Plan to pay for this. The Plan 
denied your request. The Plan says services provided by out-of-network providers are not covered 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. The Plan covers dental 
services when the services are provided in-network.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of dental services have not been met. Therefore, we decided that the Plan does not 
have to pay for dental services provided by an out-of-network provider on June 19, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on June 21, 2021. 
 
You asked the Plan to pay for the lab services. You say that there is no agreement that the codes are included in 
the dialysis rate. The Plan denied your request. The Plan says the testing is bundled into dialysis services. 
 
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 lab services provided on June 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services provided on October 28, 2021. 
 
You asked the Plan to pay for the services. You say that ultrasound guidance is payable separately. The Plan 
denied your request. The Plan says no separate payment is made. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
We find that CPT code 99100 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99100 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 anesthesia 
services provided on October 28, 2021.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve positron emission tomography (PET) scan services. 
 
You asked the Plan to pre-approve a PET scan. You say that the requested PET is needed to assess the 
likelihood that the questionable calvarial foci represents metastatic prostate cancer and also to rule out occult 
metastatic disease. You say that the requested PET will guide treatment planning and staging of the enrollee's 
prostate cancer. The Plan denied your request. The Plan says that the requested PET is not supported for the 
first staging of prostate cancer. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a PET scan. Our reviewer says that the 
criteria for coverage have been met. Our physician reviewer found the enrollee has newly diagnosed prostate 
cancer. Ga 68 PSMA-11 injection is a radioactive diagnostic agent indicated for positron emission tomography 
(PET) of prostate specific membrane antigen (PSMA) positive lesions in men with prostate cancer. It is 
medically appropriate for patients with suspected metastasis who are candidates for initial definitive therapy. 
 
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 PET scan have been met. Therefore, we decided that the Plan has to pre-
approve positron emission tomography (PET) scan services.  
 
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 dental cleaning (D1110), exam (D0120) and x-rays 
(D0220, D0230, D0274) provided on November 9, 2021. 
 
You asked the Plan to pay for the dental services. You say that your benefits were confirmed prior to services. 
The Plan denied your request. The Plan says the provider in this case is not part of the specified dental vendor 
network, and therefore services received from this provider are not covered. The Plan also states that there is no 
record of contact from you regarding your dental benefits or network. 
 
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 requires 
supplemental dental care to be received from a provider in the specified vendor network. 
Though the Plan offers a dental benefit in excess of Medicare coverage, out-of-network items or services are 
not covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental cleaning 
(D1110), exam (D0120) and x-rays (D0220, D0230, D0274) provided on November 9, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81240, 81241, 81291, 81220, 81227, 
81355, 81230, and 81335) provided on August 2, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT code 81479. Therefore, we decided that the Plan does not have 
to pay for the laboratory services (81240, 81241, 81291, 81220, 81227, 81355, 81230, and 81335) provided on 
August 2, 2021.