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

 
We decided that the Plan does not have to pay for dental services provided on September 7, 2022, to September 
23, 2022. 
 
You asked the Plan to pay for the dental services. You say that you did not know you needed to go within 
network. The Plan denied your request. The Plan says the dental services were received from an out-of-network 
provider and are not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for dental services provided on September 7, 2022, to September 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on August 30, 2022, provided by an 
out-of-network provider. 
 
You asked the Plan to pay for the dental services. You say that you disagree with this denial. The Plan denied 
your request. The Plan says the dental services were received from an out-of-network provider and are not 
covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for dental services provided on August 30, 2022, provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit provided on September 23, 
2022. 
 
You asked the Plan to waive the copayment for the office visit. You say that this visit was just a blood pressure 
check. 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 $10 
copayment for each covered visit or consultation in an outpatient location with your primary care provider or 
other primary care provider.   
 
You have been asked to pay a $10 copayment for the office visit. 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 waive the copayment for the office visit provided on September 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the facet joint injection provided on September 7, 2022. 
 
You asked the Plan to pay for the facet joint injection. You say that the facet joint injection was medically 
necessary. The Plan denied your request. The Plan says the requested facet joint injection does not meet the 
Medicare LCD coverage criteria. 
 
The Plan follows Medicare rules.  
 
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 facet joint injection. Our reviewer says 
that the facet joint injection was not medically necessary. Our physician reviewer found that the number of 
levels blocked exceeds the utilization criteria of the Medicare LCD. Only the first 2 levels bilaterally are 
considered medically reasonable and necessary. Additional levels are considered not medically reasonable and 
necessary. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the facet joint injection have not been met. Therefore, we decided that the Plan 
does not have to pay for the facet joint injection provided on September 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the all-metal crown (D2791) for teeth #3 and #4. 
 
You asked the Plan to pre-approve the all-metal crown (D2791) for teeth #3 and #4. You say that it is too hard 
to eat food and you are afraid your teeth will be inflamed. The Plan denied your request. The Plan says the 
teeth do not meet the clinical requirements for the crown 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. The Plan covers the all-metal 
crown (D2791) for teeth #3 and #4 when the services are medically necessary and reasonable.   
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 all-metal crown (D2791) for teeth 
#3 and #4. Our reviewer says that the service is not medically necessary. Our physician reviewer found that the 
documentation indicates that teeth #'s 3 and 4 have severe periodontal issues which must be resolved prior to 
crown placement due to a poor prognosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the all-metal crown (D2791) for teeth #3 and #4 have not been met. Therefore, 
we decided that the Plan does not have to pre-approve the all-metal crown (D2791) for teeth #3 and #4.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a resin-based composite (D2392) for teeth 
#2 and #3 on February 3, 2022. 
 
You asked the Plan to waive the copayment for a resin-based composite. You say that you should only be 
charged one $20 copayment. 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 
copayment for dental services/in-network/restorative 
service.  
 
You have been asked to pay a $20 copayment for each resin-based composite. The total amount you are being 
asked to pay is $40 ($20 copayment x 2 restorative services = $40). This item/service falls within the dental 
services/in-network/restorative service 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 resin-based composite (D2392) for teeth #2 and #3 on February 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal scaling and root planing, and gingival irrigation 
services (D4341, D4921) provided on September 12, 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 
periodontal scaling and root planing, and gingival irrigation services (D4341, D4921) provided on September 
12, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Bilateral Microphlebectomy (37765 and 37766). 
 
You asked the Plan to pre-approve a Bilateral Microphlebectomy. You say that the services are medically 
necessary. The Plan denied your request. The Plan says the services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that conservative therapy and inability to tolerate 
compressive bandages or stockings and the reason for such intolerance must be documented in the medical 
record for treatment of varicose veins to be considered 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 a Bilateral Microphlebectomy. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found There is no documentation of weight loss attempts, daily exercise, or periodic leg elevation. The review has determined 
that a 6 week trial of conservative therapy has not bee documented in the medical record and there is no 
documented inability to tolerate compressive bandages or stockings and the reason for such intolerance. 
 
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 Bilateral Microphlebectomy have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a Bilateral Microphlebectomy (37765 and 37766).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the attendant control (E2331), and mount (K0108). 
 
You asked the Plan to pre-approve the attendant control and mount. You say that the items are medically 
necessary. The Plan denied your request. The Plan says the items are not covered. 
 
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 attendant control and mount. Our 
reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our 
physician reviewer found if an attendant control (E2331) is provided in addition to a beneficiary-operated drive 
control system, it will be denied as non-covered.  
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 attendant control and mount have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the attendant control (E2331), and mount (K0108).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for the cystourethroscopy provided on April 
14, 2022. 
 
You asked the Plan to reduce the coinsurance for the cystourethroscopy. You say that you were advised that 
you would only have a $250 copayment. 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 50% 
coinsurance for outpatient surgery at an ambulatory surgical center (out-of-network). 
 
You have been asked to pay 50% coinsurance for the cystourethroscopy. This item/service falls within the 
outpatient surgery at an ambulatory surgical center (out-of-network) 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 coinsurance for the cystourethroscopy provided on April 14, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on September 13, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that something 
was terribly wrong and you thought you might have been having a stroke. After the symptoms ceased you 
called to cancel the service, but they suggested they should come anyway. The Plan denied your request. The 
Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on September 13, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on September 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 83789 billed for date of service August 16, 
2022. 
 
You asked the Plan to pay for the billed services. You say that a more complex drug screening was provided. 
The Plan denied your request. The Plan says the testing is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. We find that the testing described by code 83789 is considered 
specimen validity testing which is not separately payable. Based on this information, we decided that Medicare 
rules for coverage of the billed services have not been met. Therefore, we decided that the Plan does not have 
to pay for procedure code 83789 billed for date of service August 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injections (20611) provided from August 18, 2022, to 
September 1, 2022. 
 
You asked the Plan to pay for the specialist services. You say that there should only be one copayment for 
these visits. You say that they are all part of one dose given into the knee. You also say that this should be 
billed at $30 total for all three injections and not $90. 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 $30 
copayment for Physician/Practitioner services.  
 
You have been asked to pay a total of $90 ($30 x 3 visits) for the specialist services. This item/service falls 
within the Physician/Practitioner 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 pay for the injections 
(20611) provided from August 18, 2022, to September 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bone replacement graft, biologic materials, and dental 
extraction (D4263, D4265, D7210) provided on October 5, 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 bone 
replacement graft, biologic materials, and dental extraction (D4263, D4265, D7210) provided on October 5, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 85060 billed for date of service August 29, 
2022. 
 
You asked the Plan to pay for the billed services. You say that the medical records document medical 
necessity. The Plan denied your request. The Plan says the place of service was billed inappropriately. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that CPT code 85060 was billed with an outpatient hospital facility place of service code (22). No 
payment is recognized for code 85060 furnished to hospital outpatients. Based on this information, we decided 
that Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 85060 billed for date of service August 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost-sharing for endodontic therapy, molar tooth (D3330) 
provided on September 26, 2022. 
 
You asked the Plan to waive the cost-sharing for endodontic therapy, molar tooth (D3330). You say that this 
service was an emergency palliative treatment which is covered at 100%. You also say that you feel you should 
have no liability for this service. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
You have been asked to pay $53.50 towards the cost of the root canal services provided on September 26, 
2022. This is because your annual $1,500 benefit cap had been reached. The Plan provided documentation 
showing that they made payments of $908 for dental services provided on March 11, 2022, $459 for dental 
services provided on September 26, 2022, and $133 for dental services provided on October 22, 2022.  This totals $1,500 in payments towards dental services and exhausted your 2022 dental benefit allowance.  You 
are liable for the cost of any dental services provided in 2022 beyond the $1,500 maximum paid by the Plan. 
Therefore, we decided that the Plan does not have to waive the cost-sharing for endodontic therapy, molar tooth 
(D3330) provided on September 26, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a catheter placement in coronary artery(s) for coronary 
angiography (93458). 
 
You asked the Plan to pre-approve a catheter placement in coronary artery(s) for coronary angiography. You 
say that you highly recommend cardiac catheterization to assess for coronary artery disease and to undertake 
appropriate treatment. The Plan denied your request. The Plan says the left heart catheterization is not 
medically necessary. 
 
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 a catheter placement in coronary 
artery(s) for coronary angiography. Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found non-invasive imaging, such as a 
stress test, has not been performed. Our reviewer found that the documentation does not support the rationale 
for this invasive imaging study. Guidelines do not support a need for cardiac catheterization in this setting. 
 
 
 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 catheter placement in coronary artery(s) for coronary angiography have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a catheter placement in coronary 
artery(s) for coronary angiography (93458).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that this ventilator is medically necessary. The 
Plan denied your request. The Plan says a ventilator is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our reviewer says 
that a ventilator is not medically necessary. Our physician reviewer found based on the medical records 
provided, the medical criteria for a home ventilator have not been met. 
 
  
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray of the swallowing function (74230) and x-ray of the upper gastrointestinal tract (74240) provided on September 2, 2022.

You asked the Plan to pay for the x-ray of the swallowing function and x-ray of the upper gastrointestinal tract. You say that the services provided were medically necessary. The Plan denied your request. The Plan says these services were performed at a nursing home, which are denied as an excluded place of service.

The Plan must follow Medicare rules. Medicare rules say that procedures involving fluoroscopy and procedures involving the use of contrast media are not covered under the portable x-ray provision.

We looked at the file and Medicare rules. The services provided were for a barium swallow study in the portable mobile radiology setting. That imaging requires both the use of fluoroscopy and contrast. Based on this information, we decided that Medicare rules for coverage of the x-ray of the swallowing function and x-ray of the upper gastrointestinal tract have not been met. Therefore, we decided that the Plan does not have to pay for the x-ray of the swallowing function (74230) and x-ray of the upper gastrointestinal tract (74240) provided on September 2, 2022.