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

 
We decided that the Plan does not have to pay for the endodontic therapy, on molar tooth #3 provided on 
August 15, 2022. 
 
You asked the Plan to pay for the dental services. You say that this service should be covered under your 
medical plan instead of your dental plan. 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 
endodontic therapy, on molar tooth #3 provided on August 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown (D2740 x 2) and core buildup, including any pins 
when required (D2950 x 2) for tooth #'s 29 and 31 provided on February 18, 2022. 
 
You asked the Plan to pay for the dental services. You say that you cannot pay the full amount for these 
services because you are on a fixed income. The Plan denied your request. The Plan says these services are not 
covered by the Plan's 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 the crown 
(D2740 x 2) and core buildup, including any pins when required (D2950 x 2) for tooth #'s 29 and 31 provided 
on February 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a custom fabricated abutment (D6057) provided on July 28, 
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 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 a custom 
fabricated abutment (D6057) provided on July 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150) and the 
extractions of tooth #2, 15, 19, and 30 (D7210) with an oral surgeon. 
 
You asked the Plan to pre-approve an evaluation and extractions. You say that there is no dentist willing to do 
the extractions that you need. The Plan denied your request. The Plan says the requested services are not 
covered when performed by an oral surgeon. 
 
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 when performed by an oral surgeon. Therefore, we decided that the 
Plan does not have to pre-approve a comprehensive oral evaluation (D0150) and the extractions of tooth #2, 15, 
19, and 30 (D7210) with an oral surgeon.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an immediate denture - maxillary tooth #'s 01 and 16 
(D5130), and mandibular partial denture - flexible base tooth #17 (including retentive/clasping materials, rests, 
and teeth) (D5226). 
 
You asked the Plan to pre-approve the immediate denture - maxillary tooth #'s 01 and 16 (D5130), and 
mandibular partial denture - flexible base tooth #17 (including retentive/clasping materials, rests, and teeth) 
(D5226). The Plan denied your request. The Plan says these services are not covered under the benefit package. 
 
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 
immediate denture - maxillary tooth #'s 01 and 16 (D5130), and mandibular partial denture - flexible base tooth 
#17 (including retentive/clasping materials, rests, and teeth) (D5226).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for prophylaxis - adult (D1110) and periodic oral 
evaluation - established patient (D0120) provided on May 13, 2021, to November 18, 2021. 
 
You asked the Plan to reimburse for dental services. You say that you are requesting reimbursement because 
the Plan will reimburse up to $1,000. The Plan denied your request. The Plan says we cannot reimburse you 
because you received services from a provider who chose to not receive Medicare funds. This means they're on 
the Medicare opt-out list. For this benefit, you can see any licensed provider, in the US, which isn't on the opt-
out list. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to reimburse for 
prophylaxis - adult (D1110) and periodic oral evaluation - established patient (D0120) provided on May 13, 
2021, to November 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the compression stockings identified with code A6549 that 
were issued on September 9, 2021. 
 You asked the Plan to pay for these items. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says these items are not a covered benefit by the Plan or 
by Medicare. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although these items may be appropriate, they do not fall into a covered benefit category and cannot be paid 
for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the compression 
stockings identified with code A6549 that were issued on September 9, 2021.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to waive the copayment for emergency care provided from May 7, 2022, to May 
11, 2022. 
 
You asked the Plan to waive the copayment for emergency care. You say that your copayment should be 
waived because you were admitted to the hospital within 24 hours. The Plan denied your request. The Plan says 
that the cost sharing was applied correctly. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not forward medical records for review. Without medical records, 
we are unable to determine if you were admitted to the hospital. It is the burden of the Health Plan to 
substantiate their decision with evidence. In this case, the Plan has not submitted sufficient evidence to 
substantiate their decision so we must find in your favor. Therefore, we decided that the Plan has to waive the 
copayment for emergency care provided from May 7, 2022, to May 11, 2022.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided on July 7, 2022. 
 
You asked the Plan to pay for the self-administered drugs. The Plan denied your request. The Plan says these 
medications do not qualify for reimbursement under your Part A and Part B benefits. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
provided on July 7, 2022.  
 
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair and accessories (K0861, E2311, 
E2377, E2313, E2361, E1012, E1028x2, E1007, K0108, E2620, E0955, E2607). 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that you need a scooter to 
become more independent, especially in public. You would benefit greatly from having one. The Plan denied 
your request. The Plan says you do not have a medical need for multiple power options included with the 
power wheelchair. The electronic connection, expandable controller and harness cannot be covered as it is not 
medically necessary to control the 3 requested power options through the joystick. The power elevating leg 
rests are not medically needed. Since the PWC base is not covered, then related accessories are denied. The 
transit option does not serve a medical purpose and cannot be covered. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 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 a power wheelchair and accessories. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found you have 
Parkinson's disease. You walk with a cane and have requested a power wheelchair because you have an 
unsteady gait. There is no evidence that you cannot manage your mobility associated ADLs with a manual 
wheelchair. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a power wheelchair and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a power wheelchair and accessories (K0861, E2311, E2377, E2313, 
E2361, E1012, E1028x2, E1007, K0108, E2620, E0955, E2607).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive hearing test provided on August 4, 2022, by 
an OON provider. 
 
You asked the Plan to pay for the comprehensive hearing test. You say that you were in-between primary care 
providers at the time of your appointment. You also say that since you were between primary care physicians 
you were not able to obtain a referral. The Plan denied your request. The Plan says the out-of-network services 
were not authorized. 
 
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 a comprehensive hearing test provided on August 
4, 2022, by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the service is medically necessary. 
The Plan denied your request. The Plan says the service is not medically necessary and considered 
experimental and investigational. 
 
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 Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found documentation was/is lacking regarding reasonably detailed and/or evidenced 
findings supportive of the spinal vertebral bodies as being the overwhelming primary generators of the 
enrollees chronic persistent pain. Documentation does not support actual formal surgical ablation of pre-
designated basivertebral nerves as being medically necessary and/or reasonable at this time. There is no 
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception.  
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided from June 20, 2022, to 
June 22, 2022. 
 
You asked the Plan to pay for the self-administered drugs. You say that you agree with the $90 emergency 
room copay you are responsible for. You also say that you believe the other copays should be covered by the 
Plan. The Plan denied your request. The Plan says the self-administered drugs may be payable under Medicare 
Part D but are not payable under Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
provided from June 20, 2022, to June 22, 2022.  
 Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 17110 billed for date of service May 25, 
2022. 
 You asked the Plan to pay for procedure code 17110. You say that the services at issue have been billed 
correctly. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 17110 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 17110 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 17110 billed for date of service May 25, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided on April 6, 2022, by an OON 
provider. 
 
You asked the Plan to pay for the physician services. You say that the services were rendered in good faith and 
medically necessary. The Plan denied your request. The Plan says the out-of-network services were not 
authorized. 
 
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 physician services provided on April 6, 2022, by 
an OON provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 45385 billed for date of service June 1, 2022. 
 
You asked the Plan to pay for the billed service. You say that this is not included in any other service. The Plan 
denied your request. The Plan says the service is included within the global surgery package. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
The file shows that code 27043, which has a 90-day global surgery period, was provided on March 21, 2022. 
We find that CPT code 45385 was not billed with a valid modifier to indicate the service at issue was not 
related to the previous procedure. Based on this information, we decided that Medicare rules for coverage have 
not been met. Therefore, we decided that the Plan does not have to pay for procedure code 45385 billed for 
date of service June 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for durable medical equipment (DME) and a 
specialist office visit provided on July 5, 2022. 
 
You asked the Plan to waive the copayment for DME and a specialist office visit. You say that you feel the cost 
is too high. 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 20% 
coinsurance for Durable Medical Equipment (DME) and a $25 copayment for and Physician/Practitioner 
services/specialist.  
 
You have been asked to pay a 20% coinsurance for DME and a $25 copayment for a specialist office visit. The 
total allowed amount for the DME is $945.92 ($945.92 x 20% = $189.14). The total amount you are being 
asked to pay is $214.18 ($189.14 + $25 = $214.18). 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 
durable medical equipment (DME) and a specialist office visit provided on July 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for catheter placement for coronary angiography provided on 
June 6, 2022. 
 
You asked the Plan to pay for catheter placement. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says this code is missing the -26 modifier to reflect the professional 
component of the service. 
 
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 93454 is catheter placement in coronary artery for 
coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision 
and interpretation. This code has a professional/technical flag of 1, meaning this code has both a professional 
and technical component. Modifier -26 is used to represent the professional component, while modifier -TC is 
used to represent the technical component of the service. 
 
We find that CPT code 93454 is not supported in the medical record. Specifically, you are requesting payment 
for the professional component of this service but did not include modifier -26. Based on this information, we decided that Medicare rules for coverage of catheter placement have not been met. Therefore, we decided that 
the Plan does not have to pay for catheter placement for coronary angiography provided on June 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an out-of-network cardiologist provided on 
July 13, 2022. 
 
You asked the Plan to reduce the copayment for an out-of-network cardiologist. You say that you called the 
Plan ahead of time to make sure this provider was in-network. You should not have to pay extra. 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 $60 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $60 copayment for an out-of-network cardiologist. This item/service falls within 
the physician/practitioner services, including doctors office visits 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 reduce the copayment for an out-of-network cardiologist provided on July 13, 2022.