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

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), complete series 
of intraoral x-rays (D0210), and prophylaxis (D1110) provided on March 8, 2022 by an out-of-network (OON) 
provider. 
 
You asked the Plan to pay for the dental services. You say that you feel you should not be held responsible for 
these services. 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 the comprehensive oral evaluation (D0150), complete series of intraoral x-rays (D0210), and 
prophylaxis (D1110) provided on March 8, 2022 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on March 28, 2022. 
 
You asked the Plan to pay for the dental service. You say that you were told that you went two times. You say 
that you only went one time. You also say that you should not have to pay for the service that should be 
covered. The Plan denied your request. The Plan says your benefit for the limited oral evaluation has already 
been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the limited oral evaluation was exhausted on date of service March 18, 2022. Therefore, 
we decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on March 28, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for cardiac risk assessment genetic screening coded as 81411, 81413, 81414 and 81410 provided September 27, 2021.
You asked the Plan to pay for the genetic screening. You say that please see attached medical records supporting billed charges. The Plan denied your request. The Plan says genetic cardiovascular screening testing does not meet the definition of cardiovascular disease screening.
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, the genetic screening, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Genetic cardiovascular screening testing does not meet the definition of cardiovascular disease screening. Therefore, we decided that the Plan does not have to pay for cardiac risk assessment genetic screening coded as 81411, 81413, 81414 and 81410 provided September 27, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for air ambulance services provided on December 16, 2019.
You asked the Plan to pay for air ambulance services. The Plan denied your request. The Plan says services
from non-participating providers are not covered under open access unless preauthorized.
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 did not pre-approve the
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we
decided that the Plan does not have to pay for air ambulance services provided on December 16, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for retreatment of previous root canal therapy on tooth #19 
(D3348) provided on February 9, 2022. 
 
You asked the Plan to pay for the dental services. You say that you do not understand why you are being 
charged $917. The Plan denied your request. The Plan says your annual allowance amount has been met. 
 
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 your annual allowance amount has been met and you are responsible for any amount over the 
allowance amount. Therefore, we decided that the Plan does not have to pay for retreatment of previous root 
canal therapy on tooth #19 (D3348) provided on February 9, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric treatment. 
 
You asked the Plan to pre-approve inpatient psychiatric treatment. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric treatment. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found based upon review 
of the records provided, the enrollee does not meet the criteria for July 28, 2022, forward as this enrollee was not shown to be a danger to herself or others. No delusions, auditory or visual hallucinations were noted. She 
was cooperative/compliant with treatment while not showing any threats the safety as she awaited placement. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric treatment have not been met. Therefore, we decided that 
the Plan does not have to pre-approve inpatient psychiatric treatment.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve a lumbar epidural steroid injection. 
 You asked the Plan to pre-approve a lumbar epidural steroid injection. You say that the services are necessary. 
The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has 
not been met. 
 
The Plan follows Medicare rules. Medicare rules say that epidural steroid injection (ESI) will be considered 
medically reasonable and necessary when specific criteria are met. 
 
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 lumbar epidural steroid injection. Our 
reviewer says that the services are medically necessary. Our physician reviewer found in this case, the enrollee 
has had radicular pain despite 3 months of consecutive physician monitored conservative care including, 
physical therapy, home exercises, and medications including, opiates and NSAIDs. The review has determined 
that the enrollee meets the coverage criteria detailed in the LCD. 
 
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 lumbar epidural steroid injection have been met. Therefore, we decided that 
the Plan has to pre-approve a lumbar epidural steroid injection.  
 
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 pay for the simple extractions (D7140) and deep sedation (D9222) 
provided on March 8, 2022, by the out-of-network provider. 
 
You asked the Plan to pay for the dental services. You say that your regular dentist referred you to this 
provider. You say that other providers were quite a distance away from you. You also say that these services 
should be covered. 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 Plan's coverage rules apply in this case. 
 
The record shows you received the dental services from an out-of-network provider. Though the Plan offers a 
dental benefit in excess of Medicare coverage, the dental 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 the 
simple extractions (D7140) and deep sedation (D9222) provided on March 8, 2022, by the out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and prophylaxis 
(D1110) provided on July 29, 2021 by a Medicare opt out provider. 
 
You asked the Plan to pay for the comprehensive oral evaluation and prophylaxis. You say that the office 
manager never said the office had opted out of Medicare. You also say if the enrollee had known, they would 
not have gone there. The Plan denied your request. The Plan says the treating provider is not eligible for 
payment under the Medicare guidelines as a dentist. The Plan also says that the treating provider opted out of 
Medicare effective May 7, 2015, to May 7, 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, the requested items or services are not 
covered whey then are rendered by a provider who has opted out of Medicare. Therefore, we decided that the 
Plan does not have to pay for the comprehensive oral evaluation (D0150) and prophylaxis (D1110) provided on 
July 29, 2021 by a Medicare opt out provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140), bone replacement graft 
(D7953), and an extraction (D7210) provided on November 16, 2020. 
 
You asked the Plan to pay for the dental services. You say that you did not know the provider had opted out of 
Medicare. The Plan denied your request. The Plan says the provider has opted out of Medicare and is not 
eligible for payment. 
 
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 pay for a limited 
oral evaluation (D0140), bone replacement graft (D7953), and an extraction (D7210) provided on November 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core build up (D2950) for tooth # 18 provided on March 
2, 2022. 
 
You asked the Plan to pay for the dental service. You say that tooth # 18 had a large existing resin filling. You 
say that less than 50% tooth structure was remaining. You also say that the provided x-rays support the need 
for this service. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the core build up for tooth # 18 was exhausted on date of service August 19, 2020. 
Therefore, we decided that the Plan does not have to pay for the core build up (D2950) for tooth # 18 provided 
on March 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on March 
18, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says your benefit for the requested item or service has already been 
exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service May 4, 2021. Therefore, 
we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on March 
18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve complete upper dentures (D5110). 
 
You asked the Plan to pre-approve the dental services. You say that the item is necessary. The Plan denied your 
request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service February 4, 2021. 
Therefore, we decided that the Plan does not have to pre-approve complete upper dentures (D5110).
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pre-approve 5 physical therapy sessions provided by an out-of-network 
provider. 
 
You asked the Plan to pre-approve physical therapy. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that additional PT sessions are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 physical therapy. Our reviewer says 
that additional physical therapy is medically necessary. Our physician reviewer found clinical documentation 
shows that the enrollee is not yet stable on a home exercise plan and the judgement of a professional therapist 
is needed thus 5 physical therapy sessions is medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of physical therapy have been met. Therefore, we decided that the Plan has to pre-
approve 5 physical therapy sessions provided by an out-of-network provider.  
 
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for Oxygen equipment (E0431, E1390) provided on August 22, 2021.
You asked the Plan to waive the copayment for the oxygen equipment. You say that the services should be covered as you disagree with the charges, were not made aware of them, and they accumulated over time. The Plan denied your request. The Plan says the coinsurance 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). The enrollee's contract with the Plan clearly says that enrollees must pay a 20% coinsurance for Durable Medical Equipment (DME) and related supplies.
The enrollee has been asked to pay a 20% coinsurance for the oxygen equipment (allowed is $136.32 x 20% = $27.26). Oxygen equipment falls within the Durable Medical Equipment (DME) and related supplies benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for Oxygen equipment (E0431, E1390) provided on August 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for extractions of tooth #23, 24, 25, and 26 (D7140) provided on 
March 3, 2022. 
 
You asked the Plan to pay for the extractions. You say that you disagree with the denial of dental services. The 
Plan denied your request. The Plan says extractions (D7140) are not covered by your supplemental 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 
extractions of tooth #23, 24, 25, and 26 (D7140) provided on March 3, 2022.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pay for the skilled nursing facility (SNF) services provided from November 11, 
2021, through November 24, 2021. 
 
You asked the Plan to pay for the SNF services as billed. You say that you would like this SNF claim paid as it 
was originally billed. The Plan denied your request. The Plan says that the Health Insurance Prospective 
Payment System (HIPPS) code that was approved is not the same as the one that was billed on the claim. 
 
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. We find that the Plan did not submit a compelling denial rationale in this case. 
The claim was denied due to lack of authorization for the SNF services. However, the Plan has attested that the 
SNF services were authorized with a HIPPS code that was calculated at the time that the approval was 
requested. Based on how the HIPPS code is calculated, however, it is not reasonable to expect or require that 
the code requested for authorization be the code that is billed. The HIPPS code billed must correspond to the 
enrollees actual condition and the services actually rendered during the statement period of the claim. It would 
therefore be expected that the billed code would differ from a code that was estimated prior to the services 
being rendered. The Plan has not made any argument that any of the digits of the billed HIPPS code are 
incorrect or not supported, only that the code, as a whole, was not approved. We find that this denial of 
payment has not been substantiated. Therefore, we decided that the Plan has to pay for the skilled nursing 
facility (SNF) services provided from November 11, 2021, through November 24, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 5, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says this testing is bundled into dialysis services 
and is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the laboratory services provided on January 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve power wheelchair repairs. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says your 
current wheelchair is adequate to meet her functional needs. 
 
The Plan must follow Medicare rules. Medicare rules say that wheelchair options and accessories are only 
covered under certain medical indications.  
 
The file shows that power recline, headrest pads, leg rets, adjustable foot plates, controller, and a center mount 
batter door were requested. We looked at the file and Medicare rules. In this case, the records provided do not 
include a specialty evaluation to assess your seating and positioning needs. There are insufficient records to 
show that the Medicare rules for coverage of the requested services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve power wheelchair repairs.