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

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and 
first intraoral periapical x-ray (D0220) provided on September 22, 2020 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the problem focused limited oral evaluation and first intraoral periapical x-ray. 
You say that this claim was submitted on the date of service and continuously resubmitted a total of 3 times 
during the allotted time frame. The Plan denied your request. The Plan says there is no coverage for problem 
focused limited oral evaluation or services that are rendered by an OON provider. The Plan also says that 
neither the member or your office contacted the Plan prior to the date of service to verify benefits and provider 
eligibility. 
 
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 
covered when they are rendered by an OON provider. The contract also does not list problem focused limited 
oral evaluation (D0140) as a covered benefit. Therefore, we decided that the Plan does not have to pay for the 
problem focused limited oral evaluation (D0140) and first intraoral periapical x-ray (D0220) provided on 
September 22, 2020 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that medical studies haven't proven that this procedure is helpful for 
treatment of the enrollee's health problem. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Detailed 
documentation is not evident regarding a specific indication provided to support the request for bone marrow 
aspirate for the approved surgery. There is limited published, large-scale, long-term peer-reviewed literature 
that shows this request to be an effective and/or safe treatment for the enrollee's pathology. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve bone marrow aspirate for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service January 5, 
2021. 
 You asked the Plan to pay for procedure code 76705. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for 
code 93976. 
 
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 76705 
is a column II code to column I code 93976. 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 76705 billed for date of service January 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve fourteen abutment-supported cast metal crowns (D6063). 
 
You asked the Plan to pre-approve crowns. You say that these services are necessary. The Plan denied your 
request. The Plan says these services are not covered by your dental benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 pre-approve 
fourteen abutment-supported cast metal crowns (D6063).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and panoramic 
x-ray (D0330) provided on January 27, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the comprehensive oral evaluation and panoramic x-ray. You say that the Plan 
made this appointment for you, and you did not know the dentist was OON. The Plan denied your request. The 
Plan says services performed by an OON provider are not covered because your healthcare plan does not have 
OON benefits. The Plan also says that when you contacted the Plan you were given the information for an in-
network provider, but you chose to go to another provider who is OON. 
 
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, you are 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 comprehensive oral evaluation (D0150) and panoramic x-ray (D0330) provided on January 27, 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 problem focused limited oral evaluation (D0140), first 
intraoral periapical x-ray (D0220), and resin-based composite (D2393) provided on December 30, 2021. 
 
You asked the Plan to pay for the problem focused limited oral evaluation, first intraoral periapical x-ray, and 
resin-based composite. You say that you would like this claim to be reconsidered. The Plan denied your 
request. The Plan says the problem focused limited oral evaluation and first intraoral periapical x-ray are not 
covered expenses under your dental plan. The Plan also says that your benefits for resin-based composites have 
been satisfied and the frequency limitation has been exceeded. 
 
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) and first intraoral periapical x-ray (D0220) are not among those covered under this benefit. 
The contract says that restorations are limited to one procedure code per calendar year the record shows that 
you received a resin-based composite (D2391) on December 30, 2021 which was covered by the Plan, and your 
restorations benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the 
problem focused limited oral evaluation (D0140), first intraoral periapical x-ray (D0220), and resin-based 
composite (D2393) provided on December 30, 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 enrollee is most appropriate for acute 
rehabilitation for continued medical management and oversight. The Plan denied your request. The Plan says 
based on Medicare guidelines, the requested IRF services 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 that the complexity of the enrollees nursing, medical and rehabilitation needs 
does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
Medical problems are stable. There are no complex nursing or rehabilitation needs. While the documentation 
does support a need for physical and/or occupational therapy, there is no documented need for an intensive, 
multi-disciplinary rehabilitation program. There is not a reasonable expectation that the enrollee will be able to 
fully participate in and benefit from the intensive rehabilitation therapy program provided in 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a surgical implant placement (D6010) for tooth #19. 
 
You asked the Plan to pre-approve a dental implant. You say that this service is necessary. The Plan denied 
your request. The Plan says this service is not covered by your dental benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
surgical implant placement (D6010) for tooth #19.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and 
first intraoral periapical x-ray (D0220) provided on September 20, 2021. 
 
You asked the Plan to pay for the problem focused limited oral evaluation and first intraoral periapical x-ray. 
The Plan denied your request. The Plan says these services are not covered expenses under your dental plan. 
The Plan also says that you did not contact the Plan prior to the date of service to verify benefits and provider 
eligibility. 
 
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 
problem focused limited oral evaluation (D0140) and first intraoral periapical x-ray (D0220) provided on 
September 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyeglasses (V2020, V2025, V2302, V2744, V2755) 
provided on February 1, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for OON vision services. You say that you were unaware that you were not 
contracted with the Plan and required authorization to provide covered services. The Plan denied your request. 
The Plan says out-of-network care is covered only in certain limited circumstances. The requested services 
were not urgent or emergent, nor were they pre-approved. 
 
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 items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the eyeglasses (V2020, V2025, V2302, V2744, 
V2755) provided on February 1, 2021, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve neuropsychological testing services (96161, 96121, 
96146, 96116). 
 
You asked the Plan to pre-approve neuropsychological testing. You say that you have had varying degrees of 
cognitive impairment for several years, and you need these tests to find the cause and receive the necessary 
treatment. The Plan denied your request. The Plan says the provided records do not include a description of 
your symptoms and do not indicate that your symptoms require quantification, monitoring of change, 
differentiation of cause or confirmation of diagnosis which will change the treatment plan. Submitted 
documentation did not include any cognitive screening test results. The criteria for medical necessity are not 
met in this case. 
 
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 neuropsychological testing. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that based on the records provided, you have had difficulty with feeling as 
though you are in a fog since 2014. Documentation shows that you have a history of depression, post-traumatic stress disorder and sleep apnea. You have had a Montreal Cognitive Assessment (MoCA) which was scored to 
be 28/30 and considered the normal range. Your labs, neurological examination and brain MRI were normal. 
You do not meet the criteria for neuropsychological testing and therefore is not medically necessary or 
reasonable in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of neuropsychological testing have not been met. Therefore, we decided that the 
Plan does not have to pre-approve neuropsychological testing services (96161, 96121, 96146, 96116).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided from 
September 24, 2021, through October 1, 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 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 $225 per 
day, for days 1-6 and $0 for additional days, for each Medicare-covered hospital admission.   
 
 You have been asked to pay $1350 ($225 copayment x 6 days) for the Medicare-covered inpatient hospital care 
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 inpatient hospital care provided from 
September 24, 2021, through October 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation services provided on August 23, 2021. 
 
You asked the Plan to pay for the services provided. You say that the code is the medication that was 
administered to the enrollee. The Plan denied your request. The Plan says the code remains not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  We find that CPT code 99153 is a technical component only code and not payable as billed. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the moderate sedation services provided on August 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the Part B drugs, therapeutic injections, and 
the office visit provided by network providers on October 7, 2021, to October 8, 2021. 
 
You asked the Plan to waive the cost share for the Part B drugs and the therapeutic injections. You say that the 
copayment for the subsequent visits should be considered a continuation of the first service. The Plan denied 
your request. The Plan says you have been asked to pay the correct cost-sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for each in-network Medicare-covered Part B drug and non-chemotherapy drugs to treat cancer 
and a $25 copayment for services obtained from an in-network primary care provider or under certain 
circumstances, treatment by a nurse practitioner or physician's assistant or other non-physician health care 
professionals in a primary care provider's office.  
 
You have been asked to pay $39.33 for the Part B drugs and the therapeutic injections. The Part B drugs falls 
under the Medicare Part B Prescription Drugs benefit category. The therapeutic injections fall within the 
Physician/Practitioner Services, Including Doctors Office Visit benefit category. See chart below. 
 
Date of Service Service Allowed Amount Coinsurance/ 
Copayment 
Member Liability 
October 7, 2021 Therapeutic 
injection 
$26.58 $25.00 $25.00 
October 7, 2021 Part B drugs $3.20 20% $0.64 
October 8, 2021 Therapeutic 
injection 
$13.29 $25.00 $13.29 
October 8, 2021 Part B drugs $2.00 20% $0.40 
Total    $39.33 
 
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 cost share for the Part B drugs, therapeutic injections, and the office visit 
provided by network providers on October 7, 2021, to October 8, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve therapeutic procedure, 1 or more areas, each 15 
minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility (97710 x 12). 
 
 
 You asked the Plan to pre-approve the physical therapy services. You say that you feel you need additional 
therapy so that you can progress from using a cane to not needing any assistance. You also say that this is 
medically necessary. The Plan denied your request. The Plan says the requested physical therapy (PT) 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 the physical therapy services. 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 the provided documentation indicates that you have 
had prior therapy. The documentation does not indicate that you require the unique skills of a professional 
therapist to safely and effectively provide treatment, that the services can be safely and effectively performed 
only by a therapist, or by or under the supervision of a therapist. 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 your current condition or to prevent or slow further 
deterioration. The reviewer found there has been instruction in an independent home program. Therefore, the 
reviewer found that ongoing skilled therapy is not 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 the physical therapy services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic 
exercises to develop strength and endurance, range of motion and flexibility (97710 x 12).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the limited oral evaluation (D0140), prophylaxis 
(D1110 x 2), periodic oral evaluation (D0120 x 2), bitewing x-rays (D0274), periapical x-ray (D0220), and 
fluoride varnish (D1206 x 2) provided from January 28, 2021, to September 23, 2021. 
 
You asked the Plan to reimburse you for the dental services. You say that your plan changed your policy 
without making the information clearly available in a timely manner. You say that there was no mention of this 
change in the Annual Notice of Changes. You also say that The Plan denied your request. The Plan says the 
provider in this case has opted out of Medicare. The Plan also says that payment cannot be made for services 
received by a provider that has opted out of Medicare. 
 
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, dental services received by a provider 
that has opted out of Medicare are not covered. The record shows that the Annual Notice of Coverage states 
that it is a summary of changes in your benefit. It also refers you to the Evidence of Coverage for a more 
detailed description of your plan benefits. Therefore, we decided that the Plan does not have to reimburse you 
for the limited oral evaluation (D0140), prophylaxis (D1110 x 2), periodic oral evaluation (D0120 x 2), 
bitewing x-rays (D0274), periapical x-ray (D0220), and fluoride varnish (D1206 x 2) provided from January 
28, 2021, to September 23, 2021.