Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient services provided from November 6, 2020, 
through November 10, 2020, at DRG 441. 
 
You asked the Plan to pay for the inpatient services at DRG 441. You say that the discharge summary clearly 
documents acute/subacute liver failure as a relevant condition therefore K72.00 was coded as an additional 
condition. You say that both codes are needed to capture the enrollee's diagnoses and DRG 441 was 
appropriately billed. The Plan denied your request. The Plan says the removal of secondary diagnosis code 
K72.00 was appropriate. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services with secondary diagnosis code K72.00, defined as acute and 
subacute hepatic failure without coma. 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 pay for the 
inpatient services at DRG 441. Our reviewer says that the documentation does not support the secondary 
diagnosis code of K72.00. Our physician reviewer found that initially the diagnosis of hepatic failure was not 
specific and a placeholder for a final diagnosis, which ended up being autoimmune hepatitis. The criteria for 
hepatic failure includes having clear signs of encephalopathy which was not documented in the notes.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for the inpatient services provided from November 6, 2020, through November 10, 2020, at DRG 441.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the Tempus xT gene panel testing services provided on August 11, 
2021. 
 
You asked the Plan to pay for the Tempus xT gene panel testing services. You say that you would like this 
claim reprocessed based on the medical documentation. The Plan denied your request. The Plan says that the 
requested testing was not medically reasonable and necessary. 
 
The Plan follows Medicare rules. Medicare rules say that genetic testing services are subject to the criteria 
listed in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the Tempus xT gene panel testing services. 
Our reviewer says that the requested testing was medically reasonable and necessary. Our physician reviewer 
found that the panel encourages molecular testing of glioblastoma because if a driver mutation is detected, it 
may be reasonable to treat with a targeted therapy on a compassionate use basis and/or the patient may have 
more treatment options in the context of a clinical trial. Molecular testing also has a valuable role in improving 
diagnostic accuracy and prognostic stratification that may inform treatment selection. The requested testing 
was medically reasonable and necessary in this case. 
 
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 Tempus xT gene panel testing services have been met. Therefore, we 
decided that the Plan has to pay for the Tempus xT gene panel testing services provided on August 11, 2021.  
 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 pre-approve a complete maxillary denture (D5110). 
 
You asked the Plan to pre-approve the complete maxillary denture. You say that the immediate denture is 
fabricated and delivered when the remaining teeth are extracted, and the complete denture is placed when the 
gums heal after a couple of months. The Plan denied your request. The Plan says this denture would exceed the 
maximum benefit limitation of one denture per arch every 60 months. 
 
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, maxillary dentures are limited to one 
per 60 Month(s). The record shows that the enrollee has been approved to receive an immediate maxillary 
denture (D5130) and the enrollee's maxillary denture benefit has been exhausted. Therefore, we decided that 
the Plan does not have to pre-approve a complete maxillary denture (D5110).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture (D5213). 
 
You asked the Plan to pre-approve the maxillary partial denture. You say that you need this denture so you can 
eat correctly. The Plan denied your request. The Plan says this service is not covered under your 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 a 
maxillary partial denture (D5213).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on February 24, 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 of the denied claim. The Plan denied your request. The Plan says the provider is out-of-network and it was determined these services were not urgent or emergent.

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 February 24, 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 dental implants provided by a participating provider. 
 
You asked the Plan to pre-approve dental implants. You say that you are in pain and need these services. The 
Plan denied your request. The Plan says dental implants are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
dental implants provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an immediate mandibular partial denture (D5228). 
 
You asked the Plan to pre-approve the immediate mandibular partial denture. You say that you have had a 
partial since 2018. You also say that you are only going to have a couple of teeth and need the partial. The Plan 
denied your request. The Plan says your supplemental dental benefits allow you to obtain one partial or full 
denture every 5 years. The Plan also says that you will not be eligible for a mandibular partial denture until 
August 17, 2023. 
 
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, partial or full dentures are limited to 1 
per 5 years. The record shows that you received a mandibular partial denture on August 17, 2018 and your 
mandibular denture benefit has been exhausted. Therefore, we decided that the Plan does not have to pre-
approve an immediate mandibular partial denture (D5228).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve therapeutic parenteral drugs (D9612). 
 
You asked the Plan to pre-approve the therapeutic parenteral drugs. The Plan denied your request. The Plan 
says this service is not covered under your 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 
therapeutic parenteral drugs (D9612).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve deep gum and root cleaning (D4341) provided by a 
participating provider. 
 
You asked the Plan to pre-approve deep gum and root cleaning. You say that if the cleaning was done right the 
first time, you would not have to have this done again. The Plan denied your request. The Plan says the benefit 
limit for D4341 has already been met and 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 Plan covers one deep gum 
and root cleaning every 36 months. 
 
We looked at the file and Medicare rules. D4341 has already been met and exhausted. Based on this 
information, we decided that the Plan's rules for coverage of deep gum and root cleaning have not been met. 
Therefore, we decided that the Plan does not have to pre-approve deep gum and root cleaning (D4341) 
provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abutment supported porcelain fused metal crown on tooth 
#6 (D6061) provided by an out-of-network provider on April 15, 2021. 
 You asked the Plan to pay for the abutment supported porcelain fused to metal crown on tooth #6 (D6061). 
You say that you would like to be reimbursed for the claim. You say the only dentist who could help you was 
out-of-network. The Plan denied your request. The Plan says the service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the abutment supported porcelain fused 
to metal crown on tooth #6 (D6061) is not among those covered under this benefit. Therefore, we decided that 
the Plan does not have to pay for the abutment supported porcelain fused metal crown on tooth #6 (D6061) 
provided by an out-of-network provider on April 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit provided on February 17, 2022.

You asked the Plan to waive the copayment for the office visit. You say that you only saw an NP who did a finger prick test. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.

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 $35 copayment for each specialist visit. 

You have been asked to pay a $35 copayment for the office visit. Please note that the copayment applies to the provider's office type, which is a specialist in this case. The office visit falls within the Physician/Practitioner Services, Including Doctor's 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 waive the copayment for a specialist office visit provided on February 17, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan. 
 
You asked the Plan to pre-approve PET scan. You say that it is medically necessary for the enrollee to undergo 
this scan for evaluation of malignancy and possible metastatic disease. The Plan denied your request. The Plan 
says the denial of authorization for this service is correct, because there are not enough studies to support the 
use of this scan. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans 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 PET scan. Our reviewer says that the 
enrollee does not meet the Medicare criteria for a PET scan. Our physician reviewer found the enrollee has 
chronic kidney disease and a large left renal clear cell carcinoma. Abdominal staging has been completed with 
magnetic resonance imaging (MRI). Chest imaging can be done without contrast and a bone scan. The value of 
PET in renal clear cell carcinoma remains to be determined, but currently PET alone is not a tool that is 
standardly used to diagnose kidney cancer. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PET scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a positron emission tomography (PET) scan.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical placement of implant body: endosteal implants 
(D6010). 
 
You asked the Plan to pay for endosteal implants. You say that you need these implants so you can bite down 
on your food. The Plan denied your request. The Plan says this service is not covered under your 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 surgical 
placement of implant body: endosteal implants (D6010).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial lower denture (D5214). 
 
You asked the Plan to pre-approve a partial denture. You say that this denture is necessary. The Plan denied 
your request. The Plan says you previously received a partial lower denture, cast metal framework with resin 
denture base on January 31, 2019. This item is only covered once in a five-year period. 
 
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 one lower 
partial denture, cast metal framework with resin denture base (D5214) every five plan years. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the documentation supports that this 
denture is requested in a frequency that is not covered under this benefit. Therefore, we decided that the Plan 
does not have to pre-approve a partial lower denture (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve abutment supported cast metal crowns (D6063) and 
implant supported porcelain/ceramic crowns (D6065). 
 
You asked the Plan to pre-approve the abutment supported cast metal crowns and implant supported 
porcelain/ceramic crowns. You say that you really need these crowns. You also say that you already have the 
implants but need to take care of them because you have been having a lot of issues eating and chewing. The 
Plan denied your request. The Plan says these services are not covered under your benefit 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 pre-approve 
abutment supported cast metal crowns (D6063) and implant supported porcelain/ceramic crowns (D6065).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete mandibular denture (D5120). 
 
You asked the Plan to pre-approve the complete mandibular denture. You say that you lost your lower denture 
and need a new one covered before 2023. The Plan denied your request. The Plan says this service exceeds the 
maximum count allowed per period. 
 
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, complete mandibular denture (D5120) 
is limited to one procedure every five plan years. The record shows that you received a complete mandibular 
denture (D5120) on August 14, 2018 and your complete mandibular denture (D5120) benefit has been 
exhausted. Therefore, we decided that the Plan does not have to pre-approve a complete mandibular denture 
(D5120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a surgical placement of implant body: endosteal implant 
(D6010). 
 
You asked the Plan to pre-approve the endosteal implant. You say that you are in need of implants which is the 
only way your teeth will hold in your mouth. The Plan denied your request. The Plan says this service is not 
covered under your 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 a 
surgical placement of implant body: endosteal implant (D6010).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dry pressure mattress. 
 You asked the Plan to pre-approve a dry pressure mattress. You say that you cannot independently make 
changes in body position significant enough to alleviate pressure in your arms and upper body. The Plan denied 
your request. The Plan says you do not meet criteria for the requested item. 
 
The Plan must follow Medicare rules. Medicare rules say that a dry pressure mattress is only covered for 
certain indications.  
 
We looked at the file and Medicare rules. The documentation does not support that you are completely 
immobile, have limited mobility or a stage pressure ulcer on the trunk or pelvis AND at least one condition of 
A-D listed below: 
A. Impaired nutritional status 
B. Fecal or urinary incontinence 
C. Altered sensory perception 
D. Compromised circulatory status 
 
Based on this information, we decided that Medicare rules for coverage of a dry pressure mattress have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a dry pressure mattress.
Appeal type: Supplemental Benefit
Decision: Unfavorable

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

 
We decided that the Plan does not have to pre-approve surgical extractions (D7210) for tooth #2 and tooth #5. 
 
You asked the Plan to pre-approve surgical extractions. You say that these services are necessary. The Plan 
denied your request. The Plan says surgical extractions are 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 
surgical extractions (D7210) for tooth #2 and tooth #5.