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

 
We decided that the Plan does not have to pay for the four scalings and debridements in the presence of 
inflammation or mucositis of a single implant (D6081 x4) provided on October 18, 2021. 
 
You asked the Plan to pay for the scalings and debridements. You say that you believe scaling is another word 
for cleaning, and there is no reason why the Plan should not cover these procedures. The Plan denied your 
request. The Plan says these services are not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's 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 four scalings and debridements in the presence of inflammation or mucositis of a single implant (D6081 x4) provided on October 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic radiographic image (D0330) provided on 
December 8, 2021. 
 
You asked the Plan to pay for a panoramic radiographic image. You say that the amount the Plan would pay for 
bitewings should go towards the panoramic x-ray. You also say that the panoramic x-ray should not be denied, 
as the objective is the same as bitewings. The Plan denied your request. The Plan says the requested service is 
not a listed 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 a 
panoramic radiographic image (D0330) provided on December 8, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve six (6) additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve additional PT visits. You say that the enrollee requires additional physical 
therapy as they still have pain in their right knee. The Plan denied your request. The Plan says they have agreed 
to approve five additional physical therapy visits to finalize and reinforce the importance of a home exercise 
program; however, the additional 6 visits 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 additional PT visits. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that the additional requested therapy generally is not accepted as 
specific and effective therapy for the enrollee's condition beyond what was approved by the plan. The enrollee 
has had prior therapy and the documentation does not reveal that the enrollee requires the unique skills of a 
professional therapist to safely and effectively provide treatment, or that the services can only be safely and 
effectively performed only by a therapist, or by or under the supervision of a therapist. The enrollee has been 
trained in an independent home exercise program. The requested services are not part of a maintenance 
program, and the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, 
design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further 
deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional PT visits have not been met. Therefore, we decided that the Plan does 
not have to pre-approve six (6) additional physical therapy (PT) visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve electronic connection between wheelchair controller and 
one power seating system motor (CPT code E2310). 
 
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your 
request. The Plan says the DME is not necessary. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the DME have not been met. Review of the file shows that the 
enrollee can control the power tilt function through the switch, which is included in the base power wheelchair; 
therefore, the request for the electronic connection is an upgrade and not medically necessary. Therefore, we 
decided that the Plan does not have to pre-approve electronic connection between wheelchair controller and 
one power seating system motor (CPT code E2310).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) 
provided on December 15, 2021. 
 
You asked the Plan to pay for the problem focused limited oral evaluation. You say that this service was for a 
removal of an old loose filling which was stuck between two teeth. You also say that you would like this claim 
to be reconsidered for coverage. The Plan denied your request. The Plan says this service exceeds the 
frequency limitation in 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, problem focused limited oral 
evaluation (D0140) is limited to one procedure per plan year. The record shows that you received a problem 
focused limited oral evaluation (D0140) on February 11, 2021 and your problem focused limited oral 
evaluation (D0140) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for 
the problem focused limited oral evaluation (D0140) provided on December 15, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. 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 must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation supports that the criteria for inpatient admission are met in this case. Our 
physician reviewer found the review has determined that the record did show that at the time of inpatient 
admission the admitting physician reasonably expected that the enrollee's necessary hospital care would span 
two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pre-approve acute inpatient hospital care.  
 
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 an abutment supported porcelain/ceramic crown 
(D6058). 
 
You asked the Plan to pre-approve the abutment supported porcelain/ceramic crown. The Plan denied your 
request. The Plan says this service is not a covered benefit under your 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 an 
abutment supported porcelain/ceramic crown (D6058).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mandibular partial denture  resin base (including, 
retentive/clasping materials, rests, and teeth) (D5212). 
 
You asked the Plan to pre-approve a lower partial denture. You say that you need a new lower denture. The 
Plan denied your request. The Plan says you will exceed the frequency limit for your dentures. 
 
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 a lower 
partial denture once every five plan years.  
 
We looked at the file and Medicare rules. The Plan previously covered a lower denture on August 8, 2019. 
Based on this information, we decided that the Plan's frequency limit for coverage of a lower partial denture 
will be exceeded. Therefore, we decided that the Plan does not have to pre-approve a mandibular partial 
denture  resin base (including, retentive/clasping materials, rests, and teeth) (D5212).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the insertion of a non-indwelling bladder 
catheter (51701) provided on February 4, 2021. 
 
You asked the Plan to waive the copayment for the insertion of a non-indwelling bladder catheter. You say that 
the services should be covered as you disagree with the charges and are on a fixed income. The Plan denied 
your request. The Plan says the cost-sharing applied correctly based on the services provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $350 
for Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical 
centers.  
 You have been asked to pay a $121.01copayment for the insertion of a non-indwelling bladder catheter, which 
is less than the standard $350. Insertions of bladder catheters fall within the Outpatient surgery, including 
services provided at hospital outpatient facilities and ambulatory surgical centers 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 insertion of a non-indwelling bladder catheter (51701) provided 
on February 4, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. 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 IRF admission is covered only when it is medically 
reasonable and necessary as described 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 pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found while the enrollee may benefit from physical therapy and occupational therapy, the enrollee's rehabilitation can be safely provided at a lower intensity and alternate setting such as in a skilled 
nursing facility or in-home with services. Documentation does not support the necessity for admission to an 
IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient hospital services. 
 
You asked the Plan to pre-approve inpatient hospital services. You say that this surgery should be done at the 
inpatient level of care. The Plan denied your request. The Plan says that you do not have significant 
comorbidities that require more prolonged postoperative treatment or monitoring at the inpatient level of care. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
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 inpatient hospital services. Our reviewer 
says that inpatient hospital services are not medically reasonable and necessary. You do not have an unstable 
condition or an expected complication or need for a prolonged recovery and have been cleared for surgery. 
There is no expectation that you would require hospital services for this typically ambulatory procedure that 
would likely cross 2 midnights. Our physician reviewer found that your condition does not meet criteria for 
inpatient hospital services. 
 
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 hospital services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve inpatient hospital services.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Zilretta to treat unilateral primary osteoarthritis of the right knee. 
 
You asked the Plan to pre-approve the medication. You say that the Zilretta injection is for the enrollee's right 
knee. The Plan denied your request. The Plan says that this drug is not approved by the Food and Drug 
Administration (FDA) for a repeat treatment, and the safety and efficacy of repeat administration has not been 
established. The Plan states the records show that the enrollee has been given this drug previously for their 
right knee. The Plan states they do not have supporting information on why the enrollee needs this drug. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the medication. Our physician reviewer 
found the documentation supports that Zilretta is medically reasonable and necessary for the enrollee and is 
safe and effective for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the medication have been met. Therefore, we decided that the Plan has to pre-
approve Zilretta to treat unilateral primary osteoarthritis of the right knee.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. 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 IRF admission is covered only when it is medically 
reasonable and necessary as described 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 pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not require the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen hours per week of rehabilitative services and regular 
physician evaluation. Your care needs can be met at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the targeted genomic sequence analysis (81445) rendered by 
the out-of-network (OON) provider on July 6, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the targeted genomic sequence analysis (81445) rendered by the out-of-network 
(OON) provider on July 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a Freestyle Libre continuous glucose monitor sensor kit 
(K0553) provided on November 29, 2021. 
 
You asked the Plan to pay for a Freestyle Libre sensor kit. You say that the item at issue was a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment for continuous 
glucose monitors and related supplies have not been met. 
 The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not require 
frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this 
information, we decided that Medicare rules for coverage of a Freestyle Libre sensor kit have not been met. 
Therefore, we decided that the Plan does not have to pay for a Freestyle Libre continuous glucose monitor 
sensor kit (K0553) provided on November 29, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance service, advanced life 
support, emergency transport (A0427) provided on November 29, 2021. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 
copayment for each one-way Medicare-covered ground trip for ambulance services.  
 
  
You have been asked to pay a $250 copayment for the one-way Medicare-covered ground ambulance trip 
provided. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for the ambulance service, advanced life support, 
emergency transport (A0427) provided on November 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral exam (D0120), cleaning (D1110), and filling 
(D2392) provided from November 18, 2021, to December 8, 2021. 
 
You asked the Plan to pay for the dental services. You say that you do not understand how your maximum has 
been reached. The Plan denied your request. The Plan says there is a $500 annual maximum benefit for dental 
services. The Plan says that the annual maximum benefit has been exhausted. The Plan also says that after the 
annual maximum is exhausted, any remaining charges are your responsibility. 
 
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 $500 annual maximum benefit has been exhausted. The record shows that the Plan paid $70.40 for dental services received on July 8, 2021, $250 
for services you received on May 20, 2021, and $179.60 for services you received on June 10, 2021. $70.40 + 
$250 + $179.60 = $500. Therefore, we decided that the Plan does not have to pay for the oral exam (D0120), 
cleaning (D1110), and filling (D2392) provided from November 18, 2021, to December 8, 2021.