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

 
We decided that the Plan does not have to pay for the surgical extraction (D7210), diagnostic consultation 
(D9310) and inhalation of nitrous oxide (D9230) provided on December 20, 2021. 
 
You asked the Plan to pay for the dental services. You say that this was an in-network provider, and you did 
not know these services would not be covered. The Plan denied your request. The Plan says these services were 
provided by a dental specialist. Services must be performed by a participating general dentist in order to be 
eligible for coverage. In addition, a diagnostic consultation and inhalation of nitrous oxide are not covered 
services under 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 Plan's coverage rules apply in this case. Though the Plan 
offers a dental benefit in excess of Medicare coverage, items or services received from dental 
specialists are not covered under this benefit. In addition, diagnostic consultations and inhalation of nitrous 
oxide are not listed as covered services under this benefit. Therefore, we decided that the Plan does not have to 
pay for the surgical extraction (D7210), diagnostic consultation (D9310) and inhalation of nitrous oxide 
(D9230) provided on December 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary or rest home visit for the evaluation and 
management of an established patient (99337) rendered by the out-of-network (OON) provider on October 11, 
2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. 
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the domiciliary or rest home visit for the evaluation and management of an established 
patient (99337) rendered by the out-of-network (OON) provider on October 11, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home infusion therapy services (S9501) provided from 
December 23, 2021, to December 29, 2021. 
 
You asked the Plan to pay for home infusion therapy. You say that these services were billed appropriately. 
The Plan denied your request. The Plan says this code is not valid for Medicare purposes. 
 
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 S9501 has a Status Indicator of I on the Physician Fee Schedule. This means that CPT 
code S9501 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for 
coverage of home infusion therapy have not been met. Therefore, we decided that the Plan does not have to pay 
for home infusion therapy services (S9501) provided from December 23, 2021, to December 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core build up (D2950 x 2), retainer crowns (D6740 x 5), 
and pontics (D6245 x 2) provided on February 2, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are hoping to be reimbursed for the money 
you spent. You also say that this is not right, and you are not happy. 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the core build up, retainer crowns, and 
pontics are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the core build up (D2950 x 2), retainer crowns (D6740 x 5), and pontics (D6245 x 2) provided on February 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composite (D2391) provided on January 12, 2022. 
 
You asked the Plan to pay for the resin-based composite. You say that the dentist put in a permanent filling 
because the temporary filling was falling out. The Plan denied your request. The Plan says the service provided 
is not a covered benefit under your dental plan. 
 
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 items or services are not 
among those covered under this benefit. The record shows that you are enrolled in the Plan's dental preferred 
(PPO) plan. The resin-based composite (D2391) was provided on tooth #4, which is a 
posterior tooth. According to the 2022 Evidence of Coverage, your dental benefit does not include coverage for 
resin-based composites for posterior teeth. Therefore, we decided that the Plan does not have to pay for the 
resin-based composite (D2391) provided on January 12, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Orencia. 
 
You asked the Plan to pre-approve Orencia. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has 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 Orencia. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the record does not indicate that the 
enrollee has a contraindication to, or would have an adverse effect from the plan's preferred step one 
alternative. The elements of the coverage criteria are not satisfied. The requested service cannot be 
recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Orencia have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Orencia.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc-One. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has pain related to right 
knee osteoarthritis. She has not tried and failed the Plan's required drugs, Orthovisc and Supartz FX. The 
records do not show that the required drugs would be contraindicated or less effective; therefore, the Synvisc-
One is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Synvisc-One.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implant /abutment supported removable denture for 
edentulous arch  maxillary (D6110) and semi-precision attachments  placement (D6192). 
 
You asked the Plan to pre-approve an implant /abutment supported removable denture for edentulous upper 
arch and semi-precision attachments - placement. You say that it is medically necessary for you to have this 
type of denture. The Plan denied your request. The Plan says these services are not covered under your 
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 pre-approve 
implant /abutment supported removable denture for edentulous arch  maxillary (D6110) and semi-precision 
attachments  placement (D6192).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan of the abdomen and 
pelvis (74176) provided on December 5, 2021. 
 
You asked the Plan to pay for the CT scan of the abdomen and pelvis. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says this claim is a duplicate to 
what has already been paid. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Medicare rules say that claims or claim lines 
that have been determined to be exact duplicates of another claim or claim line are denied. 
 In this case, the CPT Code Manual definition of code 74176 is computed tomography, abdomen and pelvis; 
without contrast material. 
 
We looked at the file and Medicare rules. In this case, the medical documentation does not indicate that an 
additional unit of 74176 was performed beyond what has already been paid.  Based on this information, we 
decided that Medicare rules for coverage of the CT scan of the abdomen and pelvis have not been met. 
Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan of the 
abdomen and pelvis (74176) provided on December 5, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to approve continued inpatient psychiatric services from June 2, 2022 
onward. 
 
You asked the Plan to approve these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee was 
admitted to the hospital on April 30, 2022 with unspecified Bipolar disorder and major neurocognitive disorder 
most likely due to Alzheimer's disease. Based on the submitted records, it is not expected that she will improve 
in a reasonable period of time beyond the dates in question, as she does not have suicidal or homicidal ideation 
or auditory or visual hallucinations. She is compliant with treatment and is not showing any acute threats to 
safety. It does not appear that active treatment is taking place. The services are not reasonably expected to 
improve her condition or for the purpose of diagnosis beyond the dates in question. The continued services are 
not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to approve continued inpatient psychiatric services from June 2, 2022 onward.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health aide services. 
 
You asked the Plan to pre-approve home health aide services. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
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 home health aide services. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found based on the medical 
records provided there is no documentation that the home health aide services meet Medicare criteria for 
reasonable and necessary to the treatment of your illness or injury by the skilled professional staff. Records do 
not document that you require or are receiving skilled nursing or therapy services at this time. As you are not 
receiving any skilled services, home health aide services do not meet Medicare criteria for coverage. The 
services being requested are custodial in this case. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health aide services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve home health aide services.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Prolia. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says that the services are not medically necessary because the step therapy requirement 
is not met. 
 
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 states that Prolia is not medically necessary at this time because the 
enrollee has not tried and failed their required drugs; however, the Plan has not provided any medical records. 
Without medical records, a determination based on medical necessity cannot be supported. Therefore, we 
decided that the Plan has to pre-approve Prolia.  
 
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: Favorable

 
We decided that the Plan has to waive the coinsurance for the CGM supplies provided from January 11, 2021, 
to December 13, 2021. 
 
You asked the Plan to waive the coinsurance for CGM supplies. You say that you were told you would have no 
copayment for the supplies. The Plan denied your request. The Plan says that the coinsurance was applied 
correctly. 
 
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 provide information showing the allowed amounts for the 
CGM supplies after they decided to cover the claims. Without knowing the allowed amounts, the coinsurance 
cannot be properly determined. Therefore, we decided that the Plan has to waive the coinsurance for the CGM 
supplies provided from January 11, 2021, to December 13, 2021.  
 
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: 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 the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 your medical and rehabilitation needs does not require an acute 
hospital inpatient rehabilitation stay with an interdisciplinary approach to rehabilitation care. Documentation does not support the medical necessity for admission to 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay the remaining charges for the cleaning (D1110), periodic oral 
exam (D0120), x-rays (D0210) and fluoride application (D1206) provided on September 30, 2021, by an out-
of-network provider. 
 
You asked the Plan to pay the remaining charges for the dental services. You say that you did not realize the 
provider's network status had changed, and you would like the Plan to cover these services as in-network this 
one time. The Plan denied your request. The Plan says this claim was processed in accordance with your 
contract. 
 
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. Your contract with the Plan 
clearly states that if you choose to see an out-of-network dentist, you might be billed for any amount greater 
than what the Plan pays, even for services listed as a $0 copayment. The Plan's contract lists routine periodic 
exams (D0120), cleanings (D1110), full mouth x-rays (D0210) and fluoride (D1206) with $0 copayments. 
 
The provider billed the Plan a total of $327 for the services in question. The Plan's total allowed amount for 
these services is $159. This is the amount that an in-network provider would accept as full payment for these 
services; however, out-of-network providers do not have this agreement with the Plan and are allowed to bill 
you the charges that exceed the Plan's payment. The Plan paid the full allowed amount, as these services are 
listed with a $0 copayment, and cost sharing is generally calculated from the allowed costs for services. You 
have been asked to pay $168 for the services provided on September 30, 2021 ($327 - $159 = $168). 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 pay the remaining charges for the cleaning (D1110), periodic oral exam (D0120), x-
rays (D0210) and fluoride application (D1206) provided on September 30, 2021, by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) 
provided February 21, 2022. 
 
You asked the Plan to pay for the limited oral exam. You say that you only use your insurance for dental claims 
and getting your teeth pulled. The Plan denied your request. The Plan says you have exceeded the frequency 
limit for this 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. The Plan covers the limited 
oral exam once every 12 months.  
 
We looked at the file and Medicare rules. The Plan provided documentation showing that a limited oral exam 
was previously covered on August 24, 2021. Based on this information, we decided that the Plan's frequency 
limit for coverage of the limited oral exam has been exceeded. Therefore, we decided that the Plan does not 
have to pay for the limited oral evaluation - problem focused (D0140) provided February 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene panel testing provided on January 5, 2022. 
 
You asked the Plan to pay for the testing services. You say that the testing detects mutations in genes and gene 
rearrangements. The Plan denied your request. The Plan says the testing is not a Medicare benefit. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We looked at the file and the rules. We find that the FoundationOne gene panel includes testing for the FANCC 
gene. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we 
decided that the Plan does not have to pay for the gene panel testing provided on January 5, 2022.