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

 
We decided that the Plan does not have to pay for the scaling in presence of generalized moderate or severe 
gingival inflammation (D4346) provided on December 21, 2021. 
 
You asked the Plan to pay for the scaling. You say that your plan offers a $0 copay for exams, cleanings, x-
rays, and fluoride. You also say that after not going to the dentist for a number of years, your cleaning was 
extensive resulting in code D4346 that the dentist put the cleaning under. The Plan denied your request. The 
Plan says this service is not covered 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 pay for the 
scaling in presence of generalized moderate or severe gingival inflammation (D4346) provided on December 
21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composite (D2335) provided on January 25, 
2022. 
 
You asked the Plan to pay for the resin-based composite. You say that you pay the additional $25.00 per month 
for the optional supplemental dental benefits premium. You also say that you would like the Plan to reconsider 
any reimbursement that may be due to you for this service. The Plan denied your request. The Plan says this 
procedure is not a covered 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 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 resin-
based composite (D2335) provided on January 25, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Repatha Sureclick. 
 
You asked the Plan to pre-approve Repatha Sureclick. You say that the requested drug is medically necessary. 
The Plan denied your request. The Plan says the enrollee does not have pharmacy benefits administered under 
this contract. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Repatha Sureclick.  
 Benefits for Repatha Sureclick may be available under Medicare Part D. Contact the Plan that administers Part 
D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care services provided on December 2, 
2021, by an OON provider. 
 
You asked the Plan to pay for the nursing facility care services. You say that you sent the medical records to 
justify the medical necessity on treating the enrollee. The Plan denied your request. The Plan says the rendering 
provider is an OON provider and there was no referral from an in-network provider or an approved 
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 requested 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 nursing facility care services provided on 
December 2, 2021, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an urgent care visit provided on November 
1, 2021. 
 
You asked the Plan to waive the copayment for an urgent care visit. You say that you went to urgent care 
because you fell. You say that they informed you that they couldn't staple the injury and that you needed to go 
the ER. The Plan denied your request. The Plan says you have been charged the correct coinsurance 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 a $65 
copayment for Medicare-covered urgently needed care services. Urgent care is available at urgent care centers 
and/or walk-in clinics.  
 
 
 
 You have been asked to pay a $65 copayment for an urgent care visit. The urgent care visit falls within the 
Urgently needed services benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an urgent 
care visit provided on November 1, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health occupational therapy services. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
enrollee has been directed on a home exercise program. 
 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
The file shows that 6 home health occupational therapy visits were requested. The Plan has agreed to pre-
approve 2 visits. 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 services. 
Our physician reviewer found that in this case, the documentation does not support that the enrollee requires 
additional skilled rehabilitation services to provide treatment in order to improve her condition or perform a 
maintenance program to maintain her condition or prevent deterioration. She has been medically stable without 
any recent exacerbations of chronic medical problems or hospitalizations. She has not had a functional decline. 
Therefore, the requested home health services are 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health occupational therapy services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on April 14, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the denied codes are not supported in the records submitted. 
 
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, the CPT Code Manual definition of the denied codes is: 
 
CPT 15734: 
 
Muscle, myocutaneous, or fasciocutaneous flap; trunk 
 
CPT 44238: 
 
Unlisted laparoscopy procedure, intestine (except rectum) 
 We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that in terms of CPT 15734, the 
operative report describes undermining for closure. The documentation does not support a flap rotated from a 
donor site and sutured in place.  Therefore, this procedure cannot be verified. In terms of CPT 44238, the 
operative report does not clarify and support an unlisted intestine laparoscopy procedure was performed. When 
performing an unlisted procedure, additional documentation to be included to support the procedure being 
reported. In this case, this procedure cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for surgical services provided to the enrollee on April 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist services provided from August 
10, 2021, to October 5, 2021. 
 
You asked the Plan to waive the copayment for specialist services. You say that you should only be assessed 
one $25 copayment for the hyperbaric oxygen treatments received, not for each session. The Plan denied your 
request. The Plan says the copayments were applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay, when 
in-network, a $25 copayment for each Medicare-covered service received from a specialist or specialist's 
office.  
 
 
  You have been asked to pay a total of $775 (31 sessions x $25 copayment = $775) for the specialist services. 
Specialist services fall within the Physician/Practitioner services, including doctors office visits benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for the specialist services provided from August 
10, 2021, to October 5, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the two dimensional (2D) cephalometric radiographic image (D0340), 
occlusal orthotic device (D7880), and outpatient office visit (99203) provided from April 30, 2021, to May 6, 2021. 
 
You asked the Plan to pay for the 2D cephalometric radiographic image, occlusal orthotic device, and 
outpatient office visit. You say that the charges in this claim are not about dental work but concern a medical 
condition that could only be treated by a dentist. The Plan denied your request. The Plan says that these 
services are not covered expenses under your dental plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers treatment for TMJ syndrome only 
when the condition or symptom is medical in nature. The treatment must also be medically 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 pay for the 2D cephalometric radiographic image, 
occlusal orthotic device, and outpatient office visit. Our reviewer says that the documentation meets the criteria 
for coverage of medically reasonable and necessary and is related to a medical condition. Our physician 
reviewer found these services were medically reasonable and necessary to determine a diagnosis and etiology 
of the of your pain. Our reviewer found that a diagnosis of articular disc disorder and arthralgia was made. Our 
physician reviewer also found that this is a medical condition, and the treatment does not involve the care, 
treatment, removal or replacement of the teeth or supporting structures of the teeth. 
 
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 2D cephalometric radiographic image, occlusal orthotic device, and 
outpatient office visit have been met. Therefore, we decided that the Plan has to pay for the two dimensional 
(2D) cephalometric radiographic image (D0340), occlusal orthotic device (D7880), and outpatient office visit 
(99203) provided from April 30, 2021, to May 6, 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 comprehensive cancer panel provided on September 13, 
2021. 
 
You asked the Plan to pay for the comprehensive cancer panel. You say that this is medically necessary testing. 
The Plan denied your request. The Plan says this was not billed correctly for a panel. 
 
The Plan must follow Medicare rules. Medicare rules say that if one laboratory procedure evaluates multiple 
genes using a next generation sequencing procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code.  
 
We looked at the file and Medicare rules. We find that this is a next-generation sequencing panel which was 
not billed correctly with a single panel code. Based on this information, we decided that Medicare rules for coverage of the comprehensive cancer panel have not been met. Therefore, we decided that the Plan does not 
have to pay for the comprehensive cancer panel provided on September 13, 2021.
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 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 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 the documentation does not support that you require services at the LTACH that are 
not available at the acute care hospital where you are currently receiving care. The documentation does not 
support that an additional 25 days of hospitalization are reasonably expected for you. Consequently, the 
requested LTACH services are not medically necessary, reasonable, and appropriate for your diagnosis and 
condition. 
 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 waive the copayment for an inpatient hospital stay provided from 
September 13, 2021, to September 30, 2021. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you should not be billed 
for services since you contracted an infection during your hospital stay after you broke your hip. The Plan 
denied your request. The Plan says you have been charged the correct 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 a $360 
copayment per day for days 1-5 for an in-network inpatient hospital stay. The contract also says there is a $0 copayment for additional days. 
 
The record shows you had met your maximum out-of-pocket during the processing of this claim and are 
responsible for a cost share amount. You have been asked to pay a total of $1,083.61, which is less than the 
$360 copayment per day for days 1-5 for an inpatient hospital stay. An inpatient hospital stay falls within the 
Inpatient Hospital Care 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 an inpatient 
hospital stay provided from September 13, 2021, to September 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care services provided on February 7, 
2022, by an OON provider. 
 
You asked the Plan to pay for the nursing facility care services. You say that you have provided the medical 
records to justify the treatment of the enrollee. The Plan denied your request. The Plan says the rendering 
provider is an OON provider and there was no referral from an in-network provider or an approved 
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 requested 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 nursing facility care services provided on 
February 7, 2022, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bilateral genicular nerve block (CPT 64454) provided on 
November 9, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the bilateral genicular nerve block 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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found genicular nerve blocks are considered experimental/investigational and are the subject of ongoing 
clinical trials. Their role in the management of osteoarthritis of the knee is still under evaluation. 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for a bilateral genicular nerve block (CPT 64454) provided on November 9, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve panniculectomy. 
 
You asked the Plan to pre-approve panniculectomy. You say that the services are necessary. The Plan denied 
your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not 
been met. 
 
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 panniculectomy. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the record provided does not establish the medical necessity and reasonableness, as defined by 
Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied. The requested 
service is not recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of panniculectomy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve panniculectomy.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene panel testing provided on August 20, 2021. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says one code must 
be submitted for the panel. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We looked at the file and the rules. We find that the gene panel was billed with multiple codes. If a single 
procedure is performed, only one code with one unit of service may be reported for the procedure. Based on 
this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that 
the Plan does not have to pay for the gene panel testing provided on August 20, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an electrocardiogram provided to the enrollee on September 
12, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the claim was received past the 12 month timeframe. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the services was not filed until January 17, 2022. This means that more than 
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the 
Plan does not have to pay for an electrocardiogram provided to the enrollee on September 12, 2020.