Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pre-approve ten additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve ten additional PT visits. You say that the requested services are medically 
necessary. The Plan denied your request. The Plan says that the services at issue are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
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 an additional ten PT visit. Our reviewer 
says that the services are medically necessary. Our physician reviewer found that while your progress has 
slowed in terms of improved range of motion and motor strength, you have made gradual improvement in your 
ability to ambulate longer distances. You still have functional deficits with mobility. Therefore, additional 
therapy and the skills of a physical therapist would be appropriate to continue to meet these goals and transition 
to a home exercise program to ensure independence and minimize fall risk. 
 
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 additional ten PT visit have been met. Therefore, we decided that the Plan 
has to pre-approve ten additional physical therapy (PT) visits.  
   
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 a limited oral evaluation (D0140) and a panoramic x-ray 
(D0330) provided on April 12, 2022. 
 
You asked the Plan to pay for the dental services. You say that  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 a limited oral evaluation was exhausted on date of service January 26, 2022. The record 
also shows your benefit for a panoramic x-ray was exhausted on date of service November 18, 2020. Therefore, 
we decided that the Plan does not have to pay for a limited oral evaluation (D0140) and a panoramic x-ray 
(D0330) provided on April 12, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are requesting LTACH services for 
the enrollee. The Plan denied your request. The Plan says rules for LTACH care have not been met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where the 
enrollee is currently receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the disposable drug delivery system (A4305) provided April 
22, 2021 to April 30, 2021. 
 You asked the Plan to pay for the disposable drug delivery system. You say that you are asking that this claim 
be reviewed and reprocess for payment. The Plan denied your request. The Plan says service not covered by 
Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the disposable drug delivery system have not been met. Therefore, we decided that the Plan does 
not have to pay for the disposable drug delivery system (A4305) provided April 22, 2021 to April 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral - periapical first radiographic image (D0220), 
limited oral evaluation (D0140), and intraoral - periapical each additional radiographic image (D0230) 
provided on July 13, 2021. 
 
You asked the Plan to pay for the dental services. You say that you are not paying a penny for these services 
after the dentist failed to numb you. 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 intraoral - periapical first radiographic image (D0220), limited oral evaluation (D0140), and intraoral 
- periapical each additional radiographic image (D0230) provided on July 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150),  panoramic 
radiographic image (D0330), and intraoral - periapical each additional radiographic image (D0230) provided 
on May 16, 2022. 
 
You asked the Plan to pay for the dental services. You say that the dentist should have told you the services 
wouldnt be covered. The Plan denied your request. The Plan says your benefit for the requested items or 
services have 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 comprehensive oral evaluation (D0150) and panoramic radiographic 
image (D0330)  were exhausted on date of service May 27, 2021. The record also shows your benefit for the 
intraoral -periapical radiographic image (D0230) was exhausted on this appealed claim. At the same visit you 
received intraoral-periapical first radiographic image (D0220) which shares the same frequency as D0230. This 
means only one frequency per calendar year is allowed.  
 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150),  
panoramic radiographic image (D0330), and intraoral - periapical each additional radiographic image (D0230) 
provided on May 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for the extraction (D7210) and bone 
replacement graft (D7953) provided on May 2, 2022, by the out-of-network provider. 
 
You asked the Plan to pay an additional amount for the dental services. You say that the main dentist in this 
office just brought in a new dentist. You say that he is on the in-network provider list but the new dentist is not. 
You also say that you did not know this. The Plan denied your request. The Plan says the provider in this case 
is out-of-network. The Plan also says that the cost share was applied 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 dental services received out-of-
network are covered, there is a 20% coinsurance that applies to each service. This is a contractual obligation 
you agreed to when you enrolled in the Plans dental coverage. Additionally, the plan confirmed that both 
dentists at this office are out-of-network.  Therefore, we decided that the Plan does not have to pay an additional amount for the extraction (D7210) and 
bone replacement graft (D7953) provided on May 2, 2022, by the out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the transcutaneous electrical nerve stimulation (TENS) 
device, four or more leads, for multiple nerve stimulation (E0730) electrical stimulator supplies, 2 lead, per 
month (A4595). 
 
You asked the Plan to pre-approve the TENS devices and supplies. You say that the Tens unit is needed to help 
with the pain. The Plan denied your request. The Plan says the enrollee's clinical information provided does not 
meet medical necessity criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the TENS devices and supplies. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the NCD for TENS specifically excludes TENS for low back pain. Therefore, the request is considered not medically reasonable or 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 the TENS devices and supplies have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the transcutaneous electrical nerve stimulation (TENS) device, four or 
more leads, for multiple nerve stimulation (E0730) electrical stimulator supplies, 2 lead, per month (A4595).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve eight (8) additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve the additional PT visits. You say that additional physical therapy visits are 
medically necessary as the enrollee continues to present with continued limitations and is at risk for falls. The 
Plan denied your request. The Plan says additional physical therapy visits are not medically necessary and it is 
the 4th request for the left hip. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
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 the PT visits. Our reviewer says that 
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that eight additional physical therapy visits is not medically necessary. 
Our physician reviewer also found that clinical documentation states that the enrollee has some weakness of the 
lower limbs with low fall risk and although the diagnosis is "hip pain, pain control is not listed as one of the 
therapy goals. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the PT visits have not been met. Therefore, we decided that the Plan does not 
have to pre-approve eight (8) additional physical therapy (PT) visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bitewings - four radiographic images (D0274), periodontal 
maintenance (D4910), and periodic oral evaluation (D0120) provided on January 19, 2022. 
 
You asked the Plan to pay for the dental services. You say that the Plan should check their credentialing 
department. 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 bitewings - four radiographic images (D0274), periodontal maintenance (D4910), and periodic oral 
evaluation (D0120) provided on January 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral-periapical first radiographic image (D0220), the 
bitewing x-rays-four radiographic images (D0274), and the dental cleaning (D1110) provided on April 18, 
2022. 
 
You asked the Plan to pay for the dental services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. 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 that you received the dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the services provided 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 
the intraoral-periapical first radiographic image (D0220), the bitewing x-rays-four radiographic images 
(D0274), and the dental cleaning (D1110) provided on April 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) and a periapical x-ray 
(D0220) provided on May 11, 2022. 
 
You asked the Plan to pay for an evaluation and an x-ray. You say that you disagree with the denial of dental 
services. The Plan denied your request. The Plan says your dental allowance has 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. 
 
The record shows your dental allowance has been exhausted. 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 when 
your dental allowance has been exhausted. Therefore, we decided that the Plan does not have to pay for a 
limited oral evaluation (D0140) and a periapical x-ray (D0220) provided on May 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140) and the panoramic 
radiographic image (D0330) provided on March 17, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says your benefit for the services provided 
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 services provided was exhausted on date of service February 2, 2022. Specifically, 
you previously received a comprehensive oral examination and a panoramic x-ray on February 2, 2022, which 
was paid for by the Plan. The dental benefit allows for one oral examination every six months and one 
panoramic radiographic image every 60 months. Therefore, the allowable benefit for these services has been 
exhausted.  Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) and the 
panoramic radiographic image (D0330) provided on March 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on April 19, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you were told that the provider is in network. 
Therefore, you say you were unaware that the services required a referral. The Plan denied your request. The 
Plan says the rendering provider is out-of-network and there is no referring provider for the services received. 
Furthermore, the Plan says the services provided to the enrollee were not urgent or emergent. In lieu of a prior 
approval, the office visit cannot be covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 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 an office visit provided on April 19, 2022, by an 
out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on March 19, 
2022. 
 
You asked the Plan to pay for an evaluation. The Plan denied your request. The Plan says a limited oral 
evaluation (D0140) 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 limited 
oral evaluation (D0140) provided on March 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on March 3, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the rendering physician is a 
hospitalist physician with the group and depends upon the hospital staff to verify eligibility and to obtain the 
proper authorization from the patient's insurance company. The Plan denied your request. The Plan says 
services from non-participating providers are not covered unless preauthorized. 
 
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 subsequent nursing facility care provided on 
March 3, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anti-reflective coating, polarized lenses, oversized lenses, 
and to pay more for the frames provided on April 22, 2022. 
 
You asked the Plan to pay for the anti-reflective coating, polarized lenses, oversized lenses, or pay more for the 
frames. You say that you have a condition known as dry eye which makes clear vision difficult. You also say 
that you ordered the upgraded lenses to help you with your vision. The Plan denied your request. The Plan says 
the allowed amount was paid by the Plan for the frames and one set of lenses. The Plan also says that the anti-
reflective coating, polarized lenses, oversized lenses are not covered benefits. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers up to $100 for frames every year, but additional upgrades are not covered.  
We looked at the file and the Plan's rules. The record shows that your frames allowance was exhausted on this 
date of service, and you received upgraded lenses which are not covered under your benefits. Based on this 
information, we decided that the Plan's rules for coverage of the anti-reflective coating, polarized lenses, 
oversized lenses, or pay more for the frames have not been met. Therefore, we decided that the Plan does not 
have to pay for the anti-reflective coating, polarized lenses, oversized lenses, and to pay more for the frames 
provided on April 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on October 12, 2021. 
 
You asked the Plan to pay for lab test. You say that the Plan is required to provide coverage for this testing. 
The Plan denied your request. The Plan says the denial of payment for this test is correct, because code U0004 
has a Procedure-to-Procedure (PTP) edit of 0 with code U0003 so is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code U0004 
is a column II code to column I code U0003 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for lab testing provided on October 12, 2021.