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

 
We decided that the Plan does not have to pre-approve therapeutic parenteral drugs (D9612) and the removal of 
torus palatinus (D7472) provided by an out-of-network provider. 
 
You asked the Plan to pre-approve therapeutic parenteral drugs and the removal of torus palatinus. You say that 
you need these services done in order to get your dentures. The Plan denied your request. The Plan says the 
requested services 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. 
 
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 
therapeutic parenteral drugs (D9612) and the removal of torus palatinus (D7472) provided by an out-of-
network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oral exam. 
 
You asked the Plan to pre-approve the requested services. You say that you have bone loss. The Plan denied 
your request. The Plan says services performed by a periodontist 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.  
 
We looked at the file, and Medicare rules. The services you requested will not be performed by a general 
dentist. Covered dental services are only covered when performed by a participating general dentist. Based on 
this information, we decided that the Plan's rules for coverage of the requested services have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an oral exam.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from October 6, 2021, to 
November 1, 2021. 
 
You asked the Plan to pay for the services provided. You say that this is the final claim. The Plan denied your 
request. The Plan says the claim denied correctly. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We looked at the file and the rules. The case file does not show that a request for anticipated payment (RAP) 
was submitted within 5 calendar days as required. Based on this information, we decided that Medicare rules 
for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to 
pay for the home health services provided from October 6, 2021, to November 1, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied 
your request. The Plan says that the 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 that the enrollee's functional status does not require intensive rehabilitation to 
recover. The enrollee can maintain or improve with repetitive exercise and support from non-skilled personnel. 
 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 IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental x-rays on May 24, 2022. 
 
You asked the Plan to pay for dental x-rays. You say that the services provided were medically necessary. The 
Plan denied your request. The Plan says the service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for dental x-
rays on May 24, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve after cataract laser surgery (66821) to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve after cataract laser surgery (66821). You say that this provider has been this 
patient's long time ophthalmologist. You also say that the enrollee does not see any other provider per 
continuity of care. The Plan denied your request. The Plan says there are multiple participating providers 
available who can see the member and schedule the procedure at participating facilities. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
  The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
after cataract laser surgery (66821) to be provided by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care after 
October 22, 2022. 
 
You asked the Plan to pre-approve SNF care after October 22, 2022. You say that the continued admission to a 
SNF is medically necessary. The Plan denied your request. The Plan says the continued admission to a SNF is 
not medically necessary.  
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 care after October 22, 2022. Our 
reviewer says that the requested SNF care is not considered medically reasonable and necessary based on 
Medicare guidelines. Our physician reviewer found the evaluating therapists recommend memory care unit. 
From a practical standpoint there is no documentation to show that patient requires continued daily skilled 
services thus SNF criteria not met. 
 
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 care after October 22, 2022, have not been met. Therefore, we decided that 
the Plan does not have to pre-approve continued skilled nursing facility (SNF) care after October 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an incisional biopsy of oral tissue (D7286) provided by 
a participating provider. 
 
You asked the Plan to pre-approve an incisional biopsy of oral tissue. You say that you need to have this tumor 
removed. The Plan denied your request. The Plan says the requested dental service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an 
incisional biopsy of oral tissue (D7286) provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a filling for a crown (D2952), nerve treatment (D3310), 
and gum and root cleaning (D4341) for tooth #10. 
 
You asked the Plan to pre-approve the dental services. You say that the enrollee needs these dental services 
completed. The Plan denied your request. The Plan says your benefit for the requested items or services has 
already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested items or services was exhausted on dates of service of November 9, 2021, 
November 11, 2021, and June 9, 2022. Therefore, we decided that the Plan does not have to pre-approve a 
filling for a crown (D2952), nerve treatment (D3310), and gum and root cleaning (D4341) for tooth #10.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 12034 billed for date of service April 25, 
2022. 
 
You asked the Plan to pay for procedure code 12034. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says payment for code 12034 is bundled into 
payment for code 62256. 
 
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 12034 
is a column II code to column I code 62256. 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 12034 billed for date of service April 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an occlusal orthotic device provided by a participating 
provider. 
 
You asked the Plan to pre-approve an occlusal orthotic device. You say that you need this guard for your TMJ. 
The Plan denied your request. The Plan says the requested dental product is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an 
occlusal orthotic device provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the collection and application of autologous blood 
concentrate product (D7921) provided on September 22, 2021. 
 
You asked the Plan to pay for the dental services. You say that you thought you were covered for up to $1,000 
per year for dental problems. The Plan denied your request. The Plan says this service 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 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 
collection and application of autologous blood concentrate product (D7921) provided on September 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for endodontic therapy (D3320) and does not have to pay 
for cone beam imaging (D0380) and the treatment of a root canal obstruction (D3331) provided on March 24, 
2022. 
 
You asked the Plan to pay more for the dental services. You say that you disagree with the processing of this 
claim for dental services. The Plan denied your request. The Plan says you are responsible for any charged 
amount above the Plans cost-sharing amount when your services are received from an out-of-network 
provider. The Plan also says that cone beam imaging (D0380) and the treatment of a root canal obstruction 
(D3331) 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. 
 
 You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment for endodontic therapy (D3320). This cost sharing is a contractual obligation you agreed to pay when 
you enrolled in the Plan.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, cone beam imaging (D0380) and the 
treatment of a root canal obstruction (D3331) are not among those covered under this benefit.  Therefore, we 
decided that the Plan does not have to pay more for endodontic therapy (D3320) and does not have to pay for 
cone beam imaging (D0380) and the treatment of a root canal obstruction (D3331) provided on March 24, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve extractions (D7140) and an immediate maxillary 
denture (D5140) provided by an out-of-network provider. 
 
You asked the Plan to pre-approve extractions and an immediate maxillary denture. You say that these services 
are needed as part of a dental emergency. The Plan denied your request. The Plan says the requested dental 
services 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. 
 
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 
extractions (D7140) and an immediate maxillary denture (D5140) provided by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) with supplies and 
receiver (K0553, K0554) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a CGM with supplies and receiver. You say that the enrollee needs this 
glucose monitor. The Plan denied your request. The Plan says there are in-network providers who are available 
to fulfill your request. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a continuous glucose monitor (CGM) with supplies and receiver (K0553, K0554) to be provided by an out-of-
network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a rhythm electrocardiogram (ECG) (procedure code 93042) 
provided to the enrollee on September 16, 2021. 
 
You asked the Plan to pay for the ECG. You say that this should be paid for. The Plan denied your request. The 
Plan says Current Procedural Terminology (CPT) code 93042-59 (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 93042 is "Rhythm ECG, 1-3 leads; interpretation and 
report only." 
 
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 ECG. Our reviewer says that the services at issue in this 
case were not supported by the medical records. Our reviewer found that at issue is whether CPT 93042, with 
1-3 lead rhythm strip, is a separate and distinct procedure compared with 93010, which reflects interpretation 
and report of at least 12 leads. The records do not support this as a separate and distinct procedure, but instead 
would be included in 93010. 
 
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 ECG have not been met. Therefore, we decided that the Plan does not have 
to pay for a rhythm electrocardiogram (ECG) (procedure code 93042) provided to the enrollee on September 
16, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that additional routine 
transportation services are necessary. The Plan denied your request. The Plan says additional routine 
transportation would exceed the Plan's coverage benefit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 60 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services (D2954, D2752, D2954, D2752) provided on 
January 24, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. 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 (D2954, D2752, D2954, D2752) provided on January 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an occlusal guard (D9944) provided on April 19, 2022. 
 
You asked the Plan to pay for the occlusal guard. 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 do not fall 
within 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 an 
occlusal guard (D9944) provided on April 19, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have waive the copayments for surgical services provided from December 6, 
2021, to December 14, 2021. 
 
You asked the Plan waive the copayments for surgical services. You say that you should not be responsible to 
pay this. 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 $250 
copayment for surgery or other services provided to you at a Tier 2 outpatient hospital, including but not 
limited to hospital or other facility charges and physician or surgical charges.  
 
 
 
 You have been asked to pay $689.30 copayment for surgical services.  
 
Date of Service Service Plan Allowance Cost Per Contract Your Responsibility 
December 6, 2021 Debridement 
Procedure 
$364.62 $250 $250 
December 8, 2021 Cast Application $254.27 $250 $250 
December 14, 2021 Wound Care $189.30 $250 $189.30 
Total    $689.30 
 
 
These items/services fall within the outpatient surgery and other medical services provided at hospital 
outpatient facilities and ambulatory surgical centers 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 waive the 
copayments for surgical services provided from December 6, 2021, to December 14, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the lumbar injection for myelography 
provided on March 10, 2022. 
 
You asked the Plan to waive the copayment for the lumbar injection for myelography. You say that you should 
not be responsible to pay this. 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 $100 
copayment for outpatient hospital surgery.  
 
You have been asked to pay $100 for the lumbar injection for myelography. This item/service falls within the 
outpatient hospital surgery 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 lumbar 
injection for myelography provided on March 10, 2022.