Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on November 10, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that you are appealing the claim payment denial. The Plan 
denied your request. The Plan says the services were provided out-of-network and were not approved in 
advanced. 
 
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 office visit at issue in this appeal. The Plan did not pre-approve the 
office visit at issue. We found no exception that would require the Plan to pay for the office visit. Therefore, we 
decided that the Plan does not have to pay for office visit provided on November 10, 2021, by an out-of-
network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the orthosis billed for services provided on August 3, 2021. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the billed supply 
code cannot be verified. The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a proof of delivery for the shoulder/elbow/wrist/hand orthosis at issue in this case. 
The record shows that the Plan made several attempts to obtain the necessary documentation without success. 
Therefore, we decided that the Plan does not have to pay for the orthosis billed for services provided on August 
3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ophthalmic biometry services (92136) provided on 
November 3, 2021. 
 
You asked the Plan to pay for ophthalmic biometry services. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says documentation required 
for payment was not received. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of ophthalmic biometry services (92136) 
provided on November 3, 2021. have been met. [ADJUDICATOR - ENTER INCOMPLETE, MISSING, OR 
INVALID DATA ELEMENTS]. Therefore, we decided that the Plan does not have to pay for ophthalmic 
biometry services (92136) provided on November 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve procedures to separate teeth with rubber dams (D3910) 
for teeth #22, #28 and #29. 
 
You asked the Plan to pre-approve rubber dams. You say that this service should be covered by your dental 
benefit, as it is necessary. The Plan denied your request. The Plan says this service is not covered by 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 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 
procedures to separate teeth with rubber dams (D3910) for teeth #22, #28 and #29.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an appointment with an out-of-network (OON) 
prosthodontist. 
 
You asked the Plan to pre-approve the dental services. You say that your dentist referred you to this provider 
because you have Bruxism, and this OON dentist can help you with this. The Plan denied your request. The 
Plan says dental services from an out-of-network provider 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. 
 
You are requesting 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 pre-approve an 
appointment with an out-of-network (OON) prosthodontist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the surgical placement of an implant body  
(D6010 x 10), prefabricated abutmentsincludes modification and placement (D6056 x 10), the dental 
implant/abutment supported interim fixed denture for the lower arch (D6118), and the dental implant/abutment 
supported interim fixed denture for the upper arch (D6119). 
 
You asked the Plan to pre-approve these dental items. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says these items are not covered under your contractual 
policy. 
 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 are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the surgical 
placement of an implant body (D6010 x 10), prefabricated abutmentsincludes modification and placement 
(D6056 x 10), the dental implant/abutment supported interim fixed denture for the lower arch (D6118), and the 
dental implant/abutment supported interim fixed denture for the upper arch (D6119).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on April 15, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on April 15, 2022, by an 
out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on December 2, 2020, to 
December 30, 2020. 
 
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. Medicare rules say that the value code D5 is billed for the last Kt/V 
reading taken during the billing period. 
 
We looked at the file and Medicare rules. The file shows that the claim was not billed with the required D5 
value code. 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 pay for the laboratory services rendered on 
December 2, 2020, to December 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown on tooth #13 (D2740). 
 
You asked the Plan to pre-approve a crown. You say that there is a gap between tooth #12 and 13 which causes 
food to get stuck. The Plan denied your request. The Plan says a crown is not covered for cosmetic reasons or 
for closing gaps. 
 
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 for closing gaps. Therefore, we decided that the Plan does not have to 
pre-approve a crown on tooth #13 (D2740).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the upper spinal 
canal without contrast. 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plans 
denial. The Plan denied your request. The Plan says the requested service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 this service. Our reviewer says that this 
service is not medically necessary. Our physician reviewer found that based on the medical records provided, 
there is no documentation that indicates the MRI at issue in this case meets Medicare criteria for being 
medically reasonable and necessary. The most recent provided records document that the enrollees pain was 
essentially resolved with "no new weakness, numbness, tingling or other symptoms of concern. It has also 
been documented that an MRI will not be ordered as the enrollee is feeling better. No additional, more up to 
date records are provided indicating a change in status to meet Medicare criteria for an MRI. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve magnetic resonance imaging (MRI) of the upper spinal canal without contrast.
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 March 21, 2022. 
 
You asked the Plan to pay for the dental services. You say that this service is covered under your plan. The 
Plan denied your request. The Plan says your benefit for the requested item or service 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 item or service was exhausted on date of service February 23, 2022. 
Therefore, we decided that the Plan does not have to pay for the limited oral evaluation - problem focused 
(D0140) provided March 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a core build up (D2950) provided on March 25, 2022. 
 
You asked the Plan to pay for a core build up. You say that you did not see that core build ups were not 
covered. The Plan denied your request. The Plan says the service at issue 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 a core 
build up (D2950) provided on March 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220), two additional 
intraoral periapical x-rays (D0230 x2), preventive procedure (D1999), and to pay more for the periodic oral 
evaluation (D0120), and prophylaxis (D1110) provided on April 20, 2022 by an out-of-network (OON) 
provider. 
 
  You asked the Plan to pay for the intraoral periapical x-rays, preventive procedure, or pay more for the periodic 
oral evaluation, and prophylaxis. You say that it was your understanding that you got one cleaning, one exam, 
and one x-ray yearly. The Plan denied your request. The Plan says the intraoral periapical x-rays and preventive 
procedure are not covered expenses under your dental plan. The Plan also says that these services were 
performed by an OON provider, and you are responsible for any difference between the Maximum Allowable 
Fee and the amount the provider bills you for the services. 
 
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, first intraoral periapical x-ray (D0220), 
additional intraoral periapical x-ray (D0230), and preventive procedure (D1999) are not among those covered 
under this benefit. The contract says that you are responsible for a 50 percent coinsurance for the periodic oral 
evaluation (D0120) and prophylaxis (D1110), plus the difference between the billed amount and allowed 
amount because these services were received OON. Therefore, we decided that the Plan does not have to pay 
for the first intraoral periapical x-ray (D0220), two additional intraoral periapical x-rays (D0230 x2), 
preventive procedure (D1999), and to pay more for the periodic oral evaluation (D0120), and prophylaxis 
(D1110) provided on April 20, 2022 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional nasogastric tubes and gastrostomy tubes. 
 
You asked the Plan to pre-approve additional nasogastric tubes and gastrostomy tubes. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says the requested items are not a 
covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that more than three nasogastric tubes and one 
gastrostomy/jejunostomy tube every three months is not reasonable and necessary. 
 
We looked at the file and Medicare rules. Review of the file shows that the number of supplies exceeds the 
benefit limit. Based on this information, we decided that Medicare rules for coverage of additional nasogastric 
tubes and gastrostomy tubes have not been met. Therefore, we decided that the Plan does not have to pre-
approve additional nasogastric tubes and gastrostomy tubes.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Synvisc-One injection (J7325) in the right knee. 
 
You asked the Plan to pre-approve Synvisc-One. You say that the injection is being requested for use in the 
patellofemoral joint. You say that this part of the knee was not part the enrollee's previous knee replacement. 
You also say that the enrollee is in significant amount of pain and would like to receive an injection to resolve 
this. The Plan denied your request. The Plan says the requested use of this drug is not approved for the clinical 
situation in this case. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Synvisc-One. Our reviewer says that 
the requested drug, Synvisc-One, is not medically necessary. Our physician reviewer found the Food and Drug 
Administration (FDA) has not stated that the requested drug is indicated for the enrollee's condition. The 
Medicare approved drug compendia do not contain a supportive citation for the use of the requested drug in the 
enrollee's clinical situation. Therefore, the reviewer found that the requested drug is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Synvisc-One have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Synvisc-One injection (J7325) in the right knee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator (E1392). 
 
You asked the Plan to pre-approve a portable oxygen concentrator. You say that due to the enrollee's multiple 
medical issues and frequency traveling, it would be more beneficial for her to use a portable oxygen 
concentrator. The Plan denied your request. The Plan says the portable tanks and oxygen sparing devices 
provided by the network provider are equivalent weight and duration as requested device. Frequent traveling is 
not a Medicare LCD indication requiring the Plan to cover the requested device. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that the enrollee has 2 D tanks and backpack portability. The 2 D tanks serves the same purpose 
as the portable oxygen concentrator. Therefore, we decided that the Plan does not have to pre-approve a 
portable oxygen concentrator (E1392).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pulp vitality tests (D0460) provided on October 11, 2021. 
 
You asked the Plan to pay for the dental service. You say that you disagree with the denial of payment in the 
amount of $40.33. The Plan denied your request. The Plan says pulp vitality test is not listed as a covered 
service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the pulp 
vitality tests (D0460) provided on October 11, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on December 1, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says this is not a 
covered screening test. 
 The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this 
testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab 
services provided on December 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete upper denture (D5110) and a complete lower 
denture (D5120) received on April 4, 2022. 
 
You asked the Plan to pay for the dental services. You say that you need replacements for your dentures. The 
Plan denied your request. The Plan says your benefit for the requested item or service 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 item or service was exhausted on date of service January 3, 2019. 
Therefore, we decided that the Plan does not have to pay for a complete upper denture (D5110) and a complete 
lower denture (D5120) received on April 4, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care (99308) provided on 
January 18, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the subsequent nursing facility care. You say that services were provided in good 
faith of reimbursement. The Plan denied your request. The Plan says this service is not covered when provided 
OON 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 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 the subsequent nursing facility care (99308) 
provided on January 18, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a porcelain ceramic crown (D2740). 
 
You asked the Plan to pre-approve a porcelain ceramic crown. You say that the services requested are 
medically necessary. The Plan denied your request. The Plan says the enrollee has not met the criteria for 
coverage for a porcelain ceramic crown (D2740) 
 
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 a 
porcelain ceramic crown (D2740).