Persius/hicric huggingface dataset:
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. The Plan denied your request. The Plan says the enrollee does not 
need three hours of therapy a day. 
 
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 physician reviewer found 
that the enrollee was admitted to the acute care hospital for an elevated blood pressure. She is at a minimal 
assist level for transfers and bed mobility. She does not need rehabilitation supervision 3 times a week or the 
ongoing management of any active or acute exacerbations of chronic medical conditions. At the current high 
functional level, she does not need intensive therapies, consisting of at least 3 hours of therapy per day. 
 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 pay for the gingival irrigation (D4921 x 4), drug or medicament 
(D9630 x 2), antimicrobial agents (D4381 x 4), scaling and root planing (D4341 x 2), adjunctive prediagnostic 
testing (D0431), and crown (D2790) provided from November 2, 2021, to November 23, 2021. 
 
You asked the Plan to pay for the dental services. You say that the claims processed as out of network. You say 
that the provider is in network. You also say that the claims should be paid at the in network rate. The Plan 
denied your request. The Plan says the maximum benefit for dental services 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the maximum benefit of $1,000 has been exhausted. The record shows that the Plan paid $1,000 for services that you received on November 2, 2021. The Evidence of coverage clearly states that you are responsible for any amount above the dental coverage limit. Therefore, we decided that the Plan does not have to pay for the gingival irrigation (D4921 x 4), drug or medicament (D9630 x 2), antimicrobial agents (D4381 x 4), scaling and root planing (D4341 x 2), adjunctive prediagnostic testing (D0431), and crown (D2790) provided from November 2, 2021, to November 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete maxillary denture (D5110) and complete 
mandibular denture (D5120) provided on July 8, 2021. 
 
You asked the Plan to pay for the complete dentures. You say that your old dentures no longer fit. You also say 
that you checked with the Plan, and nothing was said about dentures not being covered. The Plan denied your 
request. The Plan says these services exceed the maximum counts allowed per period. 
 
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, complete maxillary denture (D5110) 
and complete mandibular denture (D5120) are each limited to one procedure every five plan years. The record 
shows that you received a complete maxillary denture (D5110) and complete mandibular denture (D5120) on 
August 30, 2017 and your complete maxillary denture (D5110) and complete mandibular denture (D5120) 
benefits have been exhausted. Therefore, we decided that the Plan does not have to pay for the complete 
maxillary denture (D5110) and complete mandibular denture (D5120) provided on July 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the case presentation, detailed and extensive treatment 
planning (D9450) provided on October 21, 2021. 
 
You asked the Plan to pay for the case presentation, detailed and extensive treatment planning. You say that it 
is x-rays that you always had, and you feel something is wrong with the code. 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 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 case 
presentation, detailed and extensive treatment planning (D9450) provided on October 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay the in network rate for the conscious sedation (D9248), take 
home drug (D9630), implants (D6010 x 2), bone replacement graft (D7953), and alveoloplasties (D7310 x 2) 
provided from June 8, 2021, to June 11, 2021.  
You asked the Plan to pay the in network rate for the conscious sedation, take home drugs, implants, bone 
replacement graft, and alveoloplasties. You say that you were advised by a plan representative prior to 
receiving the services that this provider was in network. You say that there were no notes recorded for this call. 
You also say that you would like this denial to be reversed. The Plan denied your request. The Plan says the 
services you received 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the conscious sedation, take home 
drugs, implants, bone replacement graft, and alveoloplasties are not among those covered under this benefit 
regardless of the providers network status. Therefore, we decided that the Plan does not have to pay the in 
network rate for the conscious sedation (D9248), take home drug (D9630), implants (D6010 x 2), bone 
replacement graft (D7953), and alveoloplasties (D7310 x 2) provided from June 8, 2021, to June 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial upper denture (D5213) and partial lower 
denture (D5214). 
 
You asked the Plan to pre-approve the dental services. You say that you need dentures. You say that you have 
2 front teeth missing. You also say that you can only eat soft foods. The Plan denied your request. The Plan 
says partial dentures are not covered 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 partial dentures are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
partial upper denture (D5213) and partial lower denture (D5214).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a receiver (monitor), dedicated, for use with therapeutic 
glucose continuous monitor system (K0554) and supply allowance for therapeutic continuous glucose monitor 
(CGM) includes all supplies and accessories, 1 month supply (K0553). 
 
You asked the Plan to pre-approve the CGM monitor and supplies. You say that the FreeStyle Libre 2 is 
essential to reduce the enrollee's risk of hypoglycemia and the associated life-threatening events. The Plan 
denied your request. The Plan says the enrollee does not meet the Medicare criteria for the requested 
therapeutic CGM as the enrollee is not on 3 insulin injections per day. 
 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 perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of the CGM monitor and supplies have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a receiver (monitor), dedicated, for use with 
therapeutic glucose continuous monitor system (K0554) and supply allowance for therapeutic continuous 
glucose monitor (CGM) includes all supplies and accessories, 1 month supply (K0553).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110). 
 
You asked the Plan to pre-approve a complete upper denture. You say that the item at issue is a necessity for 
your care. The Plan denied your request. The Plan says rules for coverage for dental services have not been 
met. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers a complete 
upper denture every 5 plan years.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of a complete upper denture have not been met. Specifically, the Plan has documented that the item 
coded D5110 was previously provided within the past 5 years. Therefore, we decided that the Plan does not 
have to pre-approve a complete upper denture (D5110).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two dental extractions to be provided by an oral 
surgeon. 
 
You asked the Plan to pre-approve the oral surgeon services. You say that you need these extractions and are 
willing to go to whichever oral surgeon the plan prefers. The Plan denied your request. The Plan says your 
dental benefit only covers services from general dentists, not oral surgeons. 
 
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 when performed by an oral surgeon. Therefore, we decided that the 
Plan does not have to pre-approve two dental extractions to be provided by an oral surgeon.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the routine periodic exam (D0120) provided on October 20, 2021. 
 
You asked the Plan to pay for dental code D0120. You say that you would like the Plan to reconsider your 
request. The Plan denied your request. The Plan says you are limited to two routine periodic exams, dental code 
D0120, per Plan year. You received a routine periodic exam on March 9, 2021, and July 27, 2021, which is the 
limit you can receive for the 2021 benefit year. 
 
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. 
 
We looked at the file, the Plan's contract and Medicare rules. The Plan's contract clearly says that you are limited to two routine periodic exams (D0120) per plan year. The file shows the Plan paid for the two routine 
exams you received on March 9, 2021, and July 27, 2021. This means this benefit was exhausted by the time 
you received the routine periodic exam (D0120) on October 20, 2021. Therefore, we decided that the Plan does 
not have to pay for the routine periodic exam (D0120) provided on October 20, 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 meets criteria for IRF care. The Plan 
denied your request. The Plan says IRF admission is not medically necessary. The enrollee is near 
preadmission baseline and can be managed at a lower level of care. 
 
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 does not require the intensity of services provided at an 
IRF.  Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and 
regular physician evaluation.  The enrollees 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 hereditary cancer panel provided on September 14, 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. The claim shows the cancer 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 hereditary cancer panel provided on September 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Emerg AutoEmersion therapy mattress. 
 
You asked the Plan to pre-approve an Emerg therapy mattress. You say that the requested item is a medical 
necessity for you. The Plan denied your request. The Plan says rules for coverage for durable medical 
equipment have not been met. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
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 an Emerg therapy mattress. Our 
reviewer says that the requested item is not medically reasonable and necessary. Our physician reviewer found 
that the requested item has deluxe features that are not medical in nature. Equipment which basically serves 
comfort or convenience functions does not constitute medical equipment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an Emerg therapy mattress have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an Emerg AutoEmersion therapy mattress.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (92004) and a determination of refractive state 
(92015) provided on September 14, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an office visit and a determination of refractive state. You say that you did not 
know that these procedure codes required any prior authorization. The Plan denied your request. The Plan says 
the rendering provider is a non-participating provider and there is no referring provider involved in these 
services, and they did not authorize any services for this provider. 
 
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 an office visit (92004) and a determination of 
refractive state (92015) provided on September 14, 2021, by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve twenty-four (24) physical therapy (PT) visits (97035, 
97110, 97032) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve PT visits. You say that the requested PT visits are medically necessary. The 
Plan denied your request. The Plan says the clinical documentation does not show that special skills are 
required from an out of network provider. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
twenty-four (24) physical therapy (PT) visits (97035, 97110, 97032) to be provided by an out-of-network 
(OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on April 27, 2021 
 
You asked the Plan to pay for the lab services. You say that the testing is needed to monitor opioid abuse. The 
Plan denied your request. The Plan says the code cannot be separately reimbursed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We looked at the file and the rules. We find that CPT code 83789 was billed for specimen validity testing. 
Validity testing on urine specimens used for drug testing shall not be separately billed. Based on this 
information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we 
decided that the Plan does not have to pay for the lab services provided on April 27, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have reduce the copayment for the specialist office visit provided on 
November 10, 2021. 
 
You asked the Plan reduce the copayment for the specialist office visit. You say that this was a routine hearing 
exam, and you should be charged a $45 copayment. The Plan denied your request. The Plan says the services 
provided were diagnostic, so the $50 copayment for specialist services is correct. 
 
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 $50 
copayment for per in-network visit for a specialist.  
 
 
 
 
 
 You have been asked to pay a $50 copayment for the specialist office visit. A specialist office visit falls 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 reduce the copayment for the specialist office visit provided on November 10, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Ambulance service on September 12, 2021. 
 
You asked the Plan to waive the copayment for Ambulance service. You say that you believe you shouldn't be 
financially responsible. The Plan denied your request. The Plan says The copayment applied was correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay a $250 copayment for Ambulance service.  
 
The enrollee has been asked to pay a $250 copayment for Ambulance service. Ambulance service falls within 
the Ambulance service benefit category. This means that the enrollee has been asked to pay the correct amount 
based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay 
upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
Ambulance service on September 12, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mass spectrometry provided along with drug testing on 
April 15, 2021, billed with code 83789. 
 
You asked the Plan to pay for the mass spectrometry. You say that this should be paid as it was medically 
necessary. The Plan denied your request. The Plan says the drug testing was paid; however, no separate 
payment can be made for the validity testing. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
We looked at the file and Medicare rules. We find that the billed services represent specimen validity testing. 
Based on this information, we decided that Medicare rules for coverage of the mass spectrometry have not been 
met. Therefore, we decided that the Plan does not have to pay for the mass spectrometry provided along with 
drug testing on April 15, 2021, billed with code 83789.