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. You say that the services are necessary to address the enrollee's 
complex medical condition complicated by comorbidities which resulted in functional impairments. The Plan 
denied your request. The Plan says the enrollee can safely receive the services needed in another setting such as 
a skilled nursing facility, home with home health services or home with outpatient therapy. 
 
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. The 
enrollees care needs can be met at a lower level of care in a skilled nursing facility or in a sub-acute rehab. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you require intensive therapies to regain skills and 
optimize your medical and functional outcome. The Plan denied your request. The Plan says you do not meet 
all the required Medicare criteria for admission to an inpatient rehabilitation facility. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you have no acute rehab nursing needs identified or documented. While you may 
benefit from physical and occupational therapy, you rehab needs can be provided in a lower intensity and 
alternate setting such as in a skilled nursing facility. 
 
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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the copayments for the international normalized ratio (INR) services 
provided from March 13, 2022, to August 15, 2022. 
 
You asked the Plan to waive the copayments for the INR services. You say that you would like the Plan to 
reconsider your request. The Plan denied your request. The Plan says that they were unable to make a 
determination within the allotted time frame. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. In this case, the Plan has not provided enough evidence to support the $35 
copayment applied for each date of service at issue. The file does not explain why the Plan waived the 
copayment for these same services provided by the same provider in January and February of 2022, and why 
the dates of service at issue do not follow the same ruling. Furthermore, it is not clear if the correct benefit 
category was applied for the services at issue in this case. The Plan provided no Medicare criteria showing that 
these procedure codes should be billed a certain way. Therefore, we decided that the Plan has to waive the 
copayments for the international normalized ratio (INR) services provided from March 13, 2022, to August 15, 
2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation, cone beam CT scan, and pulp 
vitality tests (D0140, D0364, D0460) provided on October 24, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within 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 pay for a limited 
oral evaluation, cone beam CT scan, and pulp vitality tests (D0140, D0364, D0460) provided on October 24, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral radiographic image (D0220), an amalgam 
(D2161), and the resin-based composite (D2394) for tooth #15 provided by an out-of-network provider on 
August 15, 2022. 
 
You asked the Plan to pay for the dental services. You say that the dental services should be covered even if the 
provider is an out-of-network provider. The Plan denied your request. The Plan says the dental services were 
received from an out-of-network provider and are not covered by your supplemental 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. 
 
  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, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for the intraoral radiographic image (D0220), an amalgam (D2161), and the resin-based composite 
(D2394) for tooth #15 provided by an out-of-network provider on August 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on 
October 25, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says you have exceeded the allowable frequency 
for this 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.   
 
We looked at this case file and the Plans rules. Based on this information, we decided that the Plan's rules for 
coverage of this service have not been met. Specifically, the Plan contract covers one oral exam every six 
months. You previously received an oral exam on May 10, 2022, which was paid for by the Plan. Therefore, 
you have exceeded the allowable frequency for this service. Therefore, we decided that the Plan does not have 
to pay for the comprehensive oral evaluation (D0150) provided on October 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the limited oral evaluation-problem focused (D0140), 
intraoral-complete series of radiographic images (D0210), and the extraction, of an erupted tooth or exposed 
root (D7140) provided on October 17, 2022. 
 
You asked the Plan to pay more for these dental services. You say that you are requesting a reconsideration of 
the Plan's denial for payment. The Plan denied your request. The Plan says you are responsible for any charged 
amount above the Plans cost-sharing amount when your services are received from an out-of-network 
provider. Additionally, the extraction, of an erupted tooth or exposed root is 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. 
  
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Additionally, the extraction, of an erupted tooth or exposed root is not a covered benefit. Therefore, we decided 
that the Plan does not have to pay more for the limited oral evaluation-problem focused (D0140), intraoral-
complete series of radiographic images (D0210), and the extraction, of an erupted tooth or exposed root 
(D7140) provided on October 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a dental consultation (D9310) provided on October 19, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within 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 pay for a dental 
consultation (D9310) provided on October 19, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure code G0482 provided on August 29, 2022. 
 
You asked the Plan to pay for procedure code G0482. You say that you would like the plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered as billed. 
 
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 
code G0482 is Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs 
and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to 
gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, 
eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other 
universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and 
variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control 
material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all 
sources, includes specimen validity testing, per day; 15-21 drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0482 is supported in the medical record. Specifically, the records provided support 
that 19 drug classes were test, including Amphetamines, Benzodizepines, Buprenorphine, Cannabinoids-
natural, Cocaine, Fentanyls, Gabapentin-non-blood, Heroin metabolite, Methadone, 
Methylenedioxyamphetamines, Methylophenidate, Opiates, Opioids and opiate analogs, Oxycodone, 
Phencyclidine, Pregabalin, Skeletal muscle relaxants, Tapentadol, and Tramadol. Based on this information, we 
decided that Medicare rules for coverage of procedure code G0482 have been met. Therefore, we decided that 
the Plan has to pay for procedure code G0482 provided on August 29, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids provided on November 17, 2022. 
 
You asked the Plan to pay for the hearing aids. You say that you were told you had a $500 allowance towards 
hearing aids, and you were not informed it had to be in-network. The Plan denied your request. The Plan says 
the service is not a covered benefit. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only provided by a network provider.  
 
We looked the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage 
of the hearing aids have not been met. Specifically, the provider was out-of-network. Therefore, we decided 
that the Plan does not have to pay for the hearing aids provided on November 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an external defibrillator (K0606) provided on September 4, 
2021. 
 
You asked the Plan to pay for the external defibrillator. You say that this item was medically necessary. The 
Plan denied your request. The Plan says the claim was not filed timely. 
 
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 external defibrillator was not filed until November 7, 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 external defibrillator (K0606) provided on September 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2750) provided on August 30, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the dental services were received from an out-of-
network provider and are not covered by your supplemental 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. 
 
 
  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, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a crown (D2750) provided on August 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an out-of-network dentist on July 
14, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for this. The Plan 
denied your request. The Plan says the dental services were received from an out-of-network provider and are 
not covered by your supplemental 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. 
 
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, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for dental services provided by an out-of-network dentist on July 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a dental cleaning (D1110) provided on October 11, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service February 2, 2022, and 
June 7, 2022. Therefore, we decided that the Plan does not have to pay for a dental cleaning (D1110) provided 
on October 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cone beam computed tomography (CT) capture and 
interpretation with limited field of viewless than one whole jaw (D0364) provided on September 22, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this 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 service provided is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the cone beam 
computed tomography (CT) capture and interpretation with limited field of viewless than one whole jaw 
(D0364) provided on September 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99202) provided on September 19, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit (99202) provided on September 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown repair (D2980) for tooth #13 provided on October 
11, 2022. 
 
You asked the Plan to pay for the dental service. You say that you are appealing the denied dental service. The 
Plan denied your request. The Plan says the denial of payment for this service is correct, because the crown 
repair is not covered by the 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 item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a crown 
repair (D2980) for tooth #13 provided on October 11, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the extracapsular cataract removals with insertion of intraocular lens 
prostheses (66984) provided on September 8, 2021, and September 22, 2021. 
 
You asked the Plan to pay for the extracapsular cataract removals with insertion of intraocular lens prostheses. 
You say that you spoke with a Plan representative prior to receiving these services, and you were advised that 
aside from your deductible, there would be no out-of-pocket expense. You also say that because someone was 
not forthright with you, you do not feel obligated to pay. The Plan denied your request. The Plan says that you 
pay 10% of the total amount for services from an in-network or out-of-network provider. The Plan also says 
you pay a $212.90 in-network or out-of-network deductible for the cataract removal provided on September 8, 
2021. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not provide a copy of the applicable 2021 Schedule of Cost Sharing 
for this case. Without this information we cannot determine that the Plan's coverage rules support the denial of 
payment in this case, or that the enrollee has been adequately notified of the Plan's coverage rules and benefits. 
Consequently, the Plan has not substantiated their denial of payment in this case. Therefore, we decided that 
the Plan has to pay for the extracapsular cataract removals with insertion of intraocular lens prostheses (66984) 
provided on September 8, 2021, and September 22, 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. 
 
Your complaint about being provided with misinformation when you contacted the Plan is not a valid appeal 
for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare 
does not permit us to make a decision about these types of complaints.