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

 
We decided that the Plan does not have to pay for dental services provided to the enrollee on June 23, 2022. 
 
You asked the Plan to pay for the dental services. You say that the provider's office told you they were 
participating. The Plan denied your request. The Plan says the dental services were received from an out-of-
network provider and 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. 
 
The record shows you received the requested 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 pay for dental services provided to the enrollee on June 23, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Injectafer 1000mg (J1439) medication. 
 
You asked the Plan to pre-approve this medication. You say that this medication is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee does not meet step therapy criteria for 
coverage of the requested medication. 
 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 this medication. Our reviewer says that 
the enrollee does not meet step therapy criteria for coverage of this medication. Our physician reviewer found 
that the Plan requires a trial of the drug Infed (iron dextran) and Venofer before they will approve the requested 
drug. In this case, the enrollee has not tried and failed the required drug(s). There is no documentation provided 
indicating that the Plans required drug(s) would likely be less effective and/or likely have adverse effects for 
the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Injectafer 1000mg (J1439) medication.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive periodontal evaluation (D0180) provided 
on June 15, 2022. 
 
You asked the Plan to pay for an evaluation. You say that you disagree with the denial of dental services. The 
Plan denied your request. The Plan says a comprehensive periodontal evaluation (D0180) is not covered by 
your dental 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. 
 
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 
comprehensive periodontal evaluation (D0180) provided on June 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a gingival flap procedure (D4241) and core build up (D2950) 
provided on June 27, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says the dental services were received from an out-of-network provider 
and 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. 
 
The record shows you received the requested 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 pay for a gingival flap procedure (D4241) and core build up (D2950) provided on June 27, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug services rendered on February 18, 2022. 
 
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 are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that intra-operative services are included in the global 
surgical package. 
 
We looked at the file and Medicare rules. Procedure code J3490 was billed on the same day as a minor surgical 
procedure. Payment for these services is included in the global surgical package. Therefore, we decided that the 
Plan does not have to pay for the drug services rendered on February 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an upper limb orthosis (E3999). 
 
You asked the Plan to pre-approve an upper limb orthosis. You say that the requested device is medically 
necessary. The Plan denied your request. The Plan says the use of the upper limb orthotic is unproven and not 
medically necessary due to insufficient evidence of safety and/or efficacy. 
 
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 an upper limb orthosis. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the device does not meet Medicare criteria of the program integrity manual as this 
request is not in keeping with medical practice standards and it is far from clear the device is able to meet the 
enrollee's needs. The device and others have primarily been tested in hemiplegia and have shown most success 
when the injury is less than a year old. Even when there has been success, the results are variable, and it is 
difficult to determine who will benefit. Hence the IIB rating in the vendor's reference from the American Heart 
association for stroke. Our reviewer is unable to find a randomized trial for cervical spinal cord injury which 
supports the vendors position. The benefits of the device are unknown for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an upper limb orthosis have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an upper limb orthosis (E3999).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cone beam imaging (D0364) provided on June 2, 2022. 
 
You asked the Plan to pay for imaging. You say that you disagree with the denial of dental services. The Plan 
denied your request. The Plan says cone beam imaging (D0364) is not covered by your dental 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. 
 
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 cone 
beam imaging (D0364) provided on June 2, 2022.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for x-rays provided on April 26, 2022.

You asked the Plan to waive the copayment for x-rays. You say that you have not had to pay a copayment for x-rays before. 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 a $15 copayment for x-rays. 

You have been asked to pay $15 per x-ray. You received two x-rays, therefore the total you owe is $30. This item/service falls within the for x-rays 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 x-rays provided on April 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the removal of lateral exostosis on tooth #26 (D7471) 
provided on May 16, 2022. 
 
You asked the Plan to pay for the removal of later exostosis. You say that you were told these services were 
covered. The Plan denied your request. The Plan says the removal of lateral exostosis (D7471) is not covered 
by your dental 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. 
 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 
removal of lateral exostosis on tooth #26 (D7471) provided on May 16, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan with 
concurrently acquired computed tomography (CT) (78815). 
 
You asked the Plan to pre-approve a PET/CT scan. The Plan denied your request. The Plan says the 
documentation provided shows no new subjective or objective clinical information since the January 2022 visit 
indicating why an additional PET/CT would be medically necessary or preferable over standard advanced 
imaging for surveillance purposes. 
 
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/CT scan. Our reviewer says that 
a PET/CT scan is not reasonable and necessary. Our physician reviewer found the enrollee's most recent 
encounter was July 29, 2022, where the physical exam revealed no evidence of mass or sign of recurrence. 
Three serial PET/CT scans have been negative.  The Centers for Medicare & Medicaid Services (CMS) rules 
allow for up to 3 PET/CT scans as follow-up for cancer unless there is a specific reason explained by the 
requesting physician as the indication for more than the allowed 3 PET/CT scans. Our reviewer found that no 
such explanation has been provided by the clinician requesting the fourth scan.  Our physician reviewer also 
found that the medical necessity of the requested PET/CT has not been established in the submitted records. 
 
 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/CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan with concurrently acquired computed 
tomography (CT) (78815).
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 limited oral evaluation - problem focused (D0140) provided on June 4, 2022. 
 
You asked the Plan to pay for an intraoral - periapical first radiographic image (D0220), and limited oral 
evaluation - problem focused (D0140). You say that you went in for an emergency visit due to a root canal 
breaking and that the EOB is confusing. 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 an 
intraoral - periapical first radiographic image (D0220), and limited oral evaluation - problem focused (D0140) 
provided on June 4, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires intensive inpatient rehabilitation 
with daily physician management, 24-hour specialized rehab nursing and intensive therapies to optimize 
mobility and strengthening. The Plan denied your request. The Plan says the enrollee does not meet the criteria 
for admission to an IRF. 
 
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 that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. 
 
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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93010 billed for date of service December 
15, 2021. 
 
You asked the Plan to pay for procedure code 93010. You say that these services should be paid. The Plan 
denied your request. The Plan says payment for code 93010 is bundled into payment for code 12002. 
 
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 93010 
is a column II code to column I code 12002. 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 93010 billed for date of service December 15, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), prophylaxis (D1110), 
bitewing x-rays (D0274), an adjunctive pre-diagnostic test (D0431), and fluoride varnish (D1206) provided on 
March 9, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says a periodic oral evaluation (D0120), prophylaxis (D1110), bitewing 
x-rays (D0274) were received from an out-of-network provider and are not covered by your supplemental 
benefits. The Plan also says that an adjunctive pre-diagnostic test (D0431) and fluoride varnish (D1206) are not 
covered by your dental 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 record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, a periodic oral evaluation (D0120), prophylaxis 
(D1110), bitewing x-rays (D0274) are not covered under this benefit when received from an out-of-network 
provider. An adjunctive pre-diagnostic test (D0431) and fluoride varnish (D1206) are not covered under this 
benefit. Therefore, we decided that the Plan does not have to pay for a periodic oral evaluation (D0120), 
prophylaxis (D1110), bitewing x-rays (D0274), an adjunctive pre-diagnostic test (D0431), and fluoride varnish 
(D1206) provided on March 9, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services billed with code A0425-UA billed for 
dates of service October 5, 2021, to January 2, 2022. 
 
You asked the Plan to pay for code A0425-UA. You say that these ambulance services were medically 
necessary and should be paid. The Plan denied your request. The Plan says you did not bill code A0425 
correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that the UA modifier is non-covered for Medicare 
services.  You billed code A0425 with a UA modifier, which is why this particular code cannot be paid as 
billed. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code A0425-UA have not been met. Therefore, we decided that the Plan does not have to pay for 
ambulance services billed with code A0425-UA billed for dates of service October 5, 2021, to January 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services billed for date of service June 8, 2022, with 
the following codes: D0367 (Cone Beam - Both Jaws), D0431 (Adjunctive Pre-Diagnostic Test That Aids In 
Detection Of Mucosal Abnormalities), and D0603 (Caries Risk Assessment And Documentation, With A 
Finding of High Risk). 
 
You asked the Plan to pay for codes D0367, D0431, and D0603. You say that these services should be covered 
because you have money left to use. The Plan denied your request. The Plan says these services are not covered 
under your dental 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. 
 
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 dental 
services billed for date of service June 8, 2022, with the following codes: D0367 (Cone Beam - Both Jaws), 
D0431 (Adjunctive Pre-Diagnostic Test That Aids In Detection Of Mucosal Abnormalities), and D0603 
(Caries Risk Assessment And Documentation, With A Finding of High Risk).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a CT scan of the abdomen provided on 
April 20, 2022. 
 
You asked the Plan to waive the copayment for a CT scan of the abdomen. You say that you went where you 
were told and where the appointment was made. 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 $195 
copayment for all other diagnostic and nuclear medicine radiological services.  
 You have been asked to pay a $195 copayment for a CT scan of the abdomen. This item/service falls within the 
other diagnostic and nuclear medicine radiological 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 a CT scan of the abdomen provided on April 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for a periodic oral evaluation (D0120), 
prophylaxis (D1110), and bitewing x-rays (D0274) provided on June 23, 2022. 
  
 
You asked the Plan to waive the copayments for the dental services. You say that you were unaware that you 
had a copayment. 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 a $15 
copayment for each covered routine dental service.  
 
You have been asked to pay $15 copayment for each dental service received on June 23, 2022. You have been 
asked to pay a total of $45 ($15 copayment x 3 services = $45). These items/services fall within the dental 
services benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayments for a periodic oral evaluation 
(D0120), prophylaxis (D1110), and bitewing x-rays (D0274) provided on June 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an adjustable bed and an adjustable lift chair purchased on 
April 26, 2022, from a provider not certified with Medicare. 
 
You asked the Plan to pay for an adjustable bed and an adjustable lift chair. You say that you would like this 
claim reprocessed and approved for payment. The Plan denied your request. The Plan says payment cannot be 
made to a provider not certified with Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for an adjustable bed and an adjustable lift 
chair purchased on April 26, 2022, from a provider not certified with Medicare.