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

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), 
additional intraoral periapical x-ray (D0230), and resin-based composite (D2331) provided on January 26, 
2021. 
 
You asked the Plan to pay for the problem focused limited oral evaluation, additional intraoral periapical x-ray, 
and resin-based composite. You say that you would like to appeal these services. The Plan denied your request. 
The Plan says problem focused limited oral evaluation is not covered. The Plan says that your benefits for the 
additional intraoral periapical x-ray and resin-based composite have been satisfied and the frequency 
limitations have been exceeded. The Plan also says that you did not contact the Plan prior to this date of service 
to verify benefits and provider eligibility. 
 
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, problem focused limited oral 
evaluation (D0140) is not among those covered under this benefit. The contract says that intraoral x-rays are 
limited to one procedure code per calendar year, and restorations (fillings) are limited to two procedure codes 
per calendar year. The record shows that you received a first intraoral periapical x-ray (D0220) and three resin-
based composites, two of which were covered by the Plan, on January 26, 2021 and your intraoral x-rays and 
restorations benefits have been exhausted. Therefore, we decided that the Plan does not have to pay for the 
problem focused limited oral evaluation (D0140), additional intraoral periapical x-ray (D0230), and resin-based 
composite (D2331) provided on January 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), panoramic x-ray 
(D0330), and four additional intraoral periapical x-rays (D0230 x4) provided on October 11, 2021. 
 
You asked the Plan to pay for the comprehensive oral evaluation, panoramic x-ray, and additional intraoral 
periapical x-rays. You say that you would like to appeal these services. The Plan denied your request. The Plan 
says your benefits for these services have been satisfied and the frequency limitations have been exceeded. 
 
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, comprehensive oral evaluation 
(D0150) is limited to one procedure code every three years. The record shows that you received a 
comprehensive oral evaluation (D0150) on June 2, 2020 and your comprehensive oral evaluation (D0150) 
benefit has been exhausted. The Plan contract says that full mouth or panoramic x-rays are limited to one 
procedure code every five years. The record shows that you received a panoramic x-ray (D0330) on June 9, 
2020 and your full mouth or panoramic x-rays benefit has been exhausted. The contract also says that intraoral 
x-rays are limited to one procedure code per calendar year. The record shows that you received a first intraoral 
periapical x-ray (D0220) on October 11, 2021 and your intraoral x-rays benefit has been exhausted. Therefore, 
we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), panoramic x-ray 
(D0330), and four additional intraoral periapical x-rays (D0230 x4) provided on October 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the simple extractions (D7140) provided on September 20, 
2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the simple extractions. You say that you were told that the Plan would pay half 
of the bill for extractions if the dentist was not in the Plan's network. The Plan denied your request. The Plan 
says this service is not covered when provided by an OON provider. The Plan also says that you were correctly 
advised that you were allowed two extractions per calendar year, and they would be covered at 50% provided 
in-network, and you would pay out of pocket if the service was rendered OON. 
 
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, you are responsible for 100% of the 
cost for dental services rendered by an OON provider. Therefore, we decided that the Plan does not have to pay 
for the simple extractions (D7140) provided on September 20, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scaling and root planing - four or more teeth 
per quadrant (D4341). 
 
You asked the Plan to pre-approve the periodontal scaling and root planing. You say that this deep cleaning is 
necessary to prevent major issues later. The Plan denied your request. The Plan says you will exceed 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 
periodontal scaling and root planing once every 3 calendar years.  
 
We looked at the file and Medicare rules. The Plan provided documentation showing that periodontal scaling 
and root planing for each quadrant was previously covered on January 28, 2021, and February 4, 2021. Based 
on this information, we decided that the Plan's frequency limit for coverage of the periodontal scaling and root 
planing would be exceeded with the requested service. Therefore, we decided that the Plan does not have to 
pre-approve periodontal scaling and root planing - four or more teeth per quadrant (D4341).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implants (D6010) for teeth # 13, 14, and 18. 
 
You asked the Plan to pre-approve the dental services. You say that you need these implants so you can chew 
your food. The Plan denied your request. The Plan says implants and all related services 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested implants are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve implants 
(D6010) for teeth # 13, 14, and 18.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cytopathology services provided on October 1, 2021.
You asked the Plan to pay for the services provided. You say that this is a payable code. The Plan denied your request. The Plan says screening testing is not a Medicare benefit.
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. We looked the file and the rules. The records do not show that the testing will impact clinical management. The testing services appear to have been requested for screening purposes. Medicare does not cover this test for screening purposes. Therefore, we decided that the Plan does not have to pay for the cytopathology services provided on October 1, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Retacrit for the enrollee.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says the use of this drug for a diagnosis of essential thrombocytopenia is not a FDA-approved indication.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 the injection. Our reviewer says that the requested drug is not medically reasonable or necessary.
Our physician reviewer found the enrollee does not have a covered FDA-approved indication or an off-label indication for this drug. Retacrit would not be considered medically reasonable, necessary, safe, or effective for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the injection have not been met. Therefore, we decided that the Plan does not have to pre-approve Retacrit for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that he LTACH is medically necessary. The Plan denied your request. The Plan says LTACH is not medically necessary, and the enrollee's needs can be met in the current inpatient hospital
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 record indicates that the enrollee is improving but still requires acute care services. The enrollee continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that he is not currently receiving but that would be available at the LTACH facility. 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 long term acute care hospital (LTACH) services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from 
December 1, 2020, to December 30, 2020.  
You asked the Plan to pay for home health services. You say that this should be paid for. The Plan denied your 
request. The Plan says the final payment was adjusted on the final bill. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, the initial 
Request for Anticipated Payments (RAP) claim was not received within 5 calendar days from the start of care.. 
Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee 
from December 1, 2020, to December 30, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance service, advanced life 
support, emergency transport, level 1 (A0427) and ground mileage (A0425) provided September 15, 2021. 
 
You asked the Plan to waive the copayment for the emergency ambulance service. You say that you don't 
understand why the Plan isn't covering more of the cost. The Plan denied your request. The Plan says the 
copayment was applied 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 $325 
copayment per trip for Medicare-covered ambulance services. 
 
You have been asked to pay a $325 copayment for the emergency ambulance service. The emergency 
ambulance service falls within the Ambulance services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation 
you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive 
the copayment for the ambulance service, advanced life support, emergency transport, level 1 (A0427) and 
ground mileage (A0425) provided September 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the tube to drain bladder (A4352), 
provided on February 16, 2021. 
 
You asked the Plan to waive the coinsurance for the tube to drain bladder. You say that the cost share was 
wrong. The Plan denied your request. The Plan says the cost share was applied 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 20% 
coinsurance for durable medical equipment (DME) and related supplies..  
 
You have been asked to pay a 20% coinsurance for the tube to drain bladder. the tube to drain bladder falls 
within the durable medical equipment (DME) and related supplies. 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 coinsurance for the tube to drain bladder (A4352), provided on February 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an occlusal adjustment (D9952). 
 
You asked the Plan to pre-approve occlusal adjustment. You say that this service is necessary. The Plan denied 
your request. The Plan says this service is not covered by the Plan's 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 an 
occlusal adjustment (D9952).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pneumatic compression devices (E0675, E0673) provided on 
July 8, 2021. 
 
You asked the Plan to pay for pneumatic compression devices. You say that the items at issue were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment for pneumatic 
compression devices have not been met. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism is a preventive service. The rules also say that a PCD coded 
as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for pneumatic compression devices (E0675, E0673) provided on July 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on August 24, 2021. 
 
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 covered.  
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 test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening 
purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan 
does not have to pay for the laboratory services rendered on August 24, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy services provided from 
August 26, 2021, to October 29, 2021. 
 
You asked the Plan to waive the copayment for the physical therapy services. You say that the services should 
be covered as your husband has a different plan and doesn't pay anything and you feel the copayment is illegal. 
The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services provided. 
 
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 $40 
copayment for Outpatient rehabilitation services.  
 
 
 
 
 You have been asked to pay a $360 copayment for nine physical therapy visits. Physical therapy services fall 
within the Outpatient rehabilitation services benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for physical therapy services provided from August 26, 2021, to October 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abutment supported removable denture (D6111) provided 
on August 5, 2021. 
 
You asked the Plan to pay for the dental service. You say that you need this service. The Plan denied your 
request. The Plan says abutment supported removable denture 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 abutment supported removable 
denture is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay 
for the abutment supported removable denture (D6111) provided on August 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (88305, 88342) provided on November 19, 2021, by an out-of-network provider.
You asked the Plan to pay for laboratory services. You say that you did not need a referral for the services at
issue because the dermatologist is an in-network specialist. The Plan denied your request. The Plan says rules
for payment for out-of-network care have not been met.
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.
We confirmed via the Plan website that 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 laboratory services (88305, 88342) provided on November 19, 2021, by an out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Spineology OptiMesh (OptiLif) Expandable Cage 
System (CPT code 22842), for the enrollee. 
 
You asked the Plan to pre-approve the system. You say that the service is necessary. The Plan denied your 
request. The Plan says the clinical value and effectiveness of Spineology OptiMesh (OptiLif) Expandable Cage 
System in the setting of multi-level lumbar spine disease with prior fusion have not been demonstrated in the 
peer-reviewed literature. The Plan states more research is needed to show safety and efficacy. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the system. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the OptiLif expandable cage is experimental. More research is needed when used in multilevel 
ddd cases. 
 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 system have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Spineology OptiMesh (OptiLif) Expandable Cage System (CPT code 22842), for the 
enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation services.
You asked the Plan to pre-approve the requested services. You say that cooled radiofrequency ablation is the currently accepted method. The Plan denied your request. The Plan says the service is non-covered.
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. Cooled radiofrequency ablation is considered not reasonable and necessary. 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 pre-approve radiofrequency ablation services.