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

 
We decided that the Plan does not have to pre-approve ophthalmologic care from an out-of-network provider. 
 
You asked the Plan to pre-approve out-of-network care. You say that you saw an out-of-network provider for 
services, and would like to continue seeing this provider. You also say that one of the providers suggested by 
the Plan is outside of the accessible distance to you. The Plan denied your request. The Plan says out-of-
network care is only covered in certain limited circumstances. The requested care is not urgent or emergent and 
can be performed by an in-network provider. 
 
Medicare rules say that plans must make care accessible to enrollees. According to Medicare rules, care is 
considered accessible to an enrollee if contract providers are available within reasonable distance and travel time from the enrollees home. The Plan says that enrollees must use contract providers.  
 
The provider is a non-contract provider. We were able to confirm that the Plan has contract providers located 
within reasonable distance and travel time from your home who can provide ophthalmologic care. Please note 
that for your county, Medicare requires that one ophthalmologist be available within 35 miles and 50 minutes 
of driving distance. One of the network providers suggested by the Plan is 15 minutes from you with less than 
ten miles of driving distance. Under Medicare rules, this means that contract providers are accessible to you. 
Therefore, we decided that the Plan does not have to pre-approve ophthalmologic care from an out-of-network 
provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prosthodontics fixed, pontic - porcelain/ceramic, tooth 
30 (D6245) and retainer crown - porcelain/ceramic (D6740) teeth 29 and 31. 
 
You asked the Plan to pre-approve prosthodontics fixed, pontic - porcelain/ceramic, tooth 30 (D6245) and 
retainer crown - porcelain/ceramic (D6740) teeth 29 and 31. You say that you would like to request 
reconsideration of the denied authorization. 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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
prosthodontics fixed, pontic - porcelain/ceramic, tooth 30 (D6245) and retainer crown - porcelain/ceramic 
(D6740) teeth 29 and 31.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs IV antibiotics, daily 
wound care and hyperbaric oxygen therapy twice-a-day. You say that they recommend LTACH care due to the 
complexity and duration of the enrollee's discharge needs. The Plan denied your request. The Plan says the 
guidelines for coverage have not been met. The Plan says that the enrollee's needs may be met in the current 
hospital setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no documentation provided indicating medical necessity for admission to a 
LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not 
require services at the LTACH that are not available at the acute care hospital where she is currently receiving 
care. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis 
and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.  
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
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 requested are medically necessary. The 
Plan denied your request. The Plan says the inpatient rehabilitation facility (IRF) services you are requesting do 
not meet the requirements for approval. 
 
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 the enrollee with history as described above does not meet the coverage criteria 
for an IRF admission. 
 
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: 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 abutment supported cast metal crowns and implant supported 
porcelain/ceramic crowns. You say that these services were denied but you have been getting this procedure for 
over a year. 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 pay for the re-cement or re-bond crown (D2920) and problem 
focused limited oral evaluation (D0140) provided on April 7, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the re-cement or re-bond crown and problem focused limited oral evaluation. 
You say that your wife contacted the Plan and was told you were in-network and had a copay of $120.00. You 
also say that these services were provided due to an emergency. The Plan denied your request. The Plan says 
the re-cement or re-bond crown is not a covered expense under your dental plan. Services performed by an 
OON provider are not covered because your healthcare plan does not have OON benefits. The Plan also says 
that you did not contact the Plan to confirm benefits prior to this date of service. 
 
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, re-cement or re-bond crown (D2920) is 
not among those covered under this benefit. You are also responsible for 100% of the cost for dental services 
rendered by an OON provider. Therefore, we decided that the Plan does not have to pay for the re-cement or 
re-bond crown (D2920) and problem focused limited oral evaluation (D0140) provided on April 7, 2022 by an 
out-of-network (OON) provider.  
 
Please Note: The records indicate that the re-cement or re-bond crown (D2920) was covered at 50 percent, and 
the problem focused limited oral evaluation (D0140) was covered at 100 percent under the plan that you are a 
dependent on.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve eight crowns (D2740 x8), six core buildups, including 
any pins when required (D2950 x6), maxillary partial denture (D5213), and precision attachment (D5862). 
 
You asked the Plan to pre-approve the crowns, core buildups, maxillary partial denture, and precision 
attachment. You say that you would like these services to be covered under your medical plan because of your 
autoimmune diseases. The Plan denied your request. The Plan says these services are not covered benefits. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement 
of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or 
paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve eight crowns (D2740 
x8), six core buildups, including any pins when required (D2950 x6), maxillary partial denture (D5213), and 
precision attachment (D5862).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete maxillary denture (D5110), mandibular 
immediate denture (D5140), and seven simple extractions (D7140 x7) provided on March 31, 2022. 
 
You asked the Plan to pay for the complete maxillary denture, mandibular immediate denture, and simple 
extractions. You say that you assumed the Plan would pay for these services. You also say that you cannot 
afford to pay for these services. The Plan denied your request. The Plan says these services are not covered 
benefits under your insurance plan. The Plan also says that you did not purchase an Optional Supplemental 
Dental plan which covers restorative services. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.  
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
complete maxillary denture (D5110), mandibular immediate denture (D5140), and seven simple extractions 
(D7140 x7) provided on March 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for a senior discount membership fee received on 
February 2, 2022. 
 
You asked the Plan to reimburse you for a membership fee. You say that you are requesting to be reimbursed 
for this dental expense. The Plan denied your request. The Plan says a senior discount membership fee is not 
covered by 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 reimburse you for 
a senior discount membership fee received on February 2, 2022.
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 you would like to request reconsideration of the 
denied authorization. The Plan denied your request. The Plan says the inpatient rehabilitation facility (IRF) 
services you are requesting do not meet the requirements for approval. 
 
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 the complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for arterial catheterization (36620) and removal of small 
intestine (44120) provided on July 25, 2021. 
 
You asked the Plan to pay for arterial catheterization and removal of small intestine. You say that you have 
provided medical records to support the services at issue. The Plan denied your request. The Plan says rules for 
payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules do not allow separate payment for an additional 
procedure(s) with a global surgery fee period if furnished during the postoperative period of a prior procedure 
and if billed without modifier -58, -78, or -79.  
We looked at the file and Medicare rules. In this case, the services at issue each have a global surgery fee 
period. The case record documents that the services at issue were furnished during the postoperative period of a 
prior procedure. The services at issue were not billed with the necessary modifiers. Based on this information, 
we decided that Medicare rules for coverage of arterial catheterization and removal of small intestine have not 
been met. Therefore, we decided that the Plan does not have to pay for arterial catheterization (36620) and 
removal of small intestine (44120) provided on July 25, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service March 22, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service March 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation of basivertebral nerve. 
 
You asked the Plan to pre-approve radiofrequency ablation of basivertebral nerve. You say that radiofrequency 
ablation of basivertebral nerve is medically necessary. The Plan denied your request. The Plan says 
radiofrequency ablation of basivertebral nerve 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 radiofrequency ablation of basivertebral 
nerve. Our reviewer says that radiofrequency ablation of basivertebral nerve is not considered medically 
reasonable and necessary in this case. Our physician reviewer found this is considered an experimental/ 
investigational procedure. Therefore, the request is deemed not medically reasonable or 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 radiofrequency ablation of basivertebral nerve have not been met. Therefore, we 
decided that the Plan does not have to pre-approve radiofrequency ablation of basivertebral nerve.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140), core build up (D2950), 
endodontic therapy on tooth #31 (D3330), and periapical x-rays (D0220) provided on April 6, 2022. 
 
You asked the Plan to pay for the dental services. You say that you needed a root canal as soon as possible. The 
Plan denied your request. The Plan says a limited oral evaluation (D0140), core build up (D2950), and 
endodontic therapy (D3330) is not covered by your supplemental dental benefits. The Plan also says that 
periapical x-rays (D0220) are not covered when received from an out-of-network provider. 
 
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, periapical x-rays are not covered under this benefit 
when received from an out-of-network provider. A limited oral evaluation (D0140), core build up (D2950), and 
endodontic therapy (D3330) are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140), core build up (D2950), endodontic therapy on 
tooth #31 (D3330), and periapical x-rays (D0220) provided on April 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the comprehensive oral evaluation (D0150), first 
intraoral periapical x-ray (D0220), bitewing x-rays (D0272), and prophylaxis (D1110) provided on March 9, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay more for the dental services. You say that you did not know the treating provider 
was not in-network. The Plan denied your request. The Plan says the total $129.00 OON amount applied 
correctly as your liability. The Plan also says that cost share is a contractual obligation under the Plan and 
cannot be waived. 
 
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, you are responsible for the difference 
between the billed amount and allowed amount for covered dental services received OON. Therefore, we 
decided that the Plan does not have to pay more for the comprehensive oral evaluation (D0150), first intraoral 
periapical x-ray (D0220), bitewing x-rays (D0272), and prophylaxis (D1110) provided on March 9, 2022, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on February 28, 2022. 
 
You asked the Plan to pay for the services provided. You say that you understood that out-of-network provider 
would be covered. The Plan denied your request. The Plan says you must receive services through a Medicare 
certified provider. 
 
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 the office 
visit provided on February 28, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vabysmo (J3590). 
 
You asked the Plan to pre-approve Vabysmo. You say that the requested drug is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee has not tried and failed the preferred drug, 
bevacizumab. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Vabysmo. Our reviewer says that the 
step therapy criteria have not been met. Our physician reviewer found the provided records do not indicate that 
the enrollee has tried and failed the plan's preferred step one alternative, bevacizumab. The record does not 
indicate that the enrollee has a contraindication to or would have an adverse effect from the plan's preferred 
step one alternative. Therefore, the reviewer found that the step therapy criteria 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 Vabysmo have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Vabysmo (J3590).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transesophageal echocardiography (TEE) rendered on 
February 3, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 93318 
is a column II code to column I code 00562 with a modifier indicator of 0. The column II code is therefore not payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for the transesophageal echocardiography (TEE) rendered on February 3, 2022.