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

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140), jaw x-rays (D0330), tooth 
extractions (D7140), and an extraction of roots with bone (D7250), provided by an out-of-network provider on 
May 5, 2022. 
 
You asked the Plan to pay for the dental services. You say that these services are medically necessary. 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 Plan's 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 limited oral evaluation (D0140), jaw x-rays (D0330), tooth extractions (D7140), and an extraction 
of roots with bone (D7250), provided by an out-of-network provider on May 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the partial denture (D5214). 
 
You asked the Plan to pre-approve the dental services. You say that you need this dental service completed. 
The Plan denied your request. The Plan says the denial of authorization for this service is correct, because 
partial dentures are 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
partial denture (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an extraction (D7140) provided on June 7, 2022. 
 
You asked the Plan to pay for an extraction. You say that you do not understand why this service is not 
covered. The Plan denied your request. The Plan says the service at issue is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an 
extraction (D7140) provided on June 7, 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 (D0364) and incision and drainage of abscess (D7510) provided on February 11, 2022. 
 
You asked the Plan to pay for the cone beam CT capture and interpretation and incision and drainage of 
abscess. You say that these services were provided during an emergency visit for an abscessed tooth. The Plan 
denied your request. The Plan says these services 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 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 cone 
beam computed tomography (CT) capture and interpretation (D0364) and incision and drainage of abscess 
(D7510) provided on February 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a surgical procedure for isolation of tooth with rubber 
dam (D3910) provided by a participating provider. 
 
You asked the Plan to pre-approve a surgical procedure for isolation of tooth with rubber dam. You say that 
you would like these services approved. The Plan denied your request. The Plan says the requested dental 
service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
surgical procedure for isolation of tooth with rubber dam (D3910) provided by a participating provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital admission for a laminectomy 
procedure. 
 
You asked the Plan to pre-approve inpatient admission. You say that the requested inpatient admission is a 
medical necessity for the enrollee. The Plan denied your request. The Plan says medical-necessity rules for an 
inpatient admission have not been met. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.   
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 inpatient admission. Our reviewer says 
that the documentation does not support that the criteria for inpatient admission are met in this case. Our 
physician reviewer found that detailed documentation is not evident regarding a significant past and/or current 
medical history that would place the enrollee at increased risk for peri-surgical complications requiring an 
inpatient stay. There is no compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve acute inpatient hospital admission for a laminectomy procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a retainer crown (D6740), and a pontic (D6245) provided by 
an out-of-network provider on March 30, 2022. 
 
You asked the Plan to pay for a retainer crown and a pontic. You say that you say that you would like the Plan 
to pay for this. The Plan denied your request. The Plan says the rendered dental services are not covered 
benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a retainer 
crown (D6740), and a pontic (D6245) provided by an out-of-network provider on March 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an after-hours office visit (D9440) provided on May 2, 2022. 
 
You asked the Plan to pay for an office visit. You say that you feel this visit was not after regular office hours. 
The Plan denied your request. The Plan says an after-hours office visit (D9440) is not covered by your dental 
benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 an after-
hours office visit (D9440) provided on May 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an exam (D0140) and an x-ray (D0220) for tooth #32 
provided by an out-of-network (OON) provider on June 22, 2022. 
 
You asked the Plan to pay for the dental services. You say that you did not know the provider was an OON 
provider and would like the Plan to cover the charged. The Plan denied your request. The Plan says the dental 
services were received from an OON 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 an exam (D0140) and an x-ray (D0220) for tooth #32 provided by an out-of-network (OON) 
provider on June 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tetanus and diphtheria toxoids adsorbed (Td) (90714), 
and administration (90471) provided on April 12, 2022. 
 
You asked the Plan to pay for the immunization. You say that the tetanus shot you received is considered 
preventive. You also say that you do not believe you should be responsible for the cost of this. The Plan denied 
your request. The Plan says this vaccine is covered under your Part D benefit. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the immunization. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the immunization. 
Therefore, we decided that the Plan does not have to pay for the Tetanus and diphtheria toxoids adsorbed (Td) 
(90714), and administration (90471) provided on April 12, 2022.  
 
Benefits for the immunization 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on January 6, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that the 
emergency medical technicians highly advised you to not be transported to the hospital because of a high 
volume of COVID-19 patients that day. The Plan denied your request. The Plan says since you were not 
transported by the ambulance, this service is not covered under your plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on January 6, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
The record shows that you stated you did not want to go to the hospital, and you would follow up with your 
doctor as needed. Therefore, we decided that the Plan does not have to pay for the ambulance response and 
treatment with no transport (A0998) provided on January 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve wheelchair accessories. 
 
You asked the Plan to pre-approve the requested items. The Plan denied your request. The Plan says the 
services are not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
 The file shows that a tire insert, wheel lock brake extension, and transit option were requested. These items do 
not serve a purpose that is primarily medical in nature. A solid seat base was also requested. The records do not 
show that a sling seat has been tried and failed. Therefore, we decided that the Plan does not have to pre-
approve wheelchair accessories.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transcutaneous electrical nerve stimulator (TENS) 
device. 
 
You asked the Plan to pre-approve the requested device. You say that you need this to help with your day-to-
day life. The Plan denied your request. The Plan says the device is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. 
 
We looked at the file and Medicare rules. The requested device for chronic low back pain is not considered 
medically necessary. Based on this information, we decided that Medicare rules for coverage of the requested 
device have not been met. Therefore, we decided that the Plan does not have to pre-approve a transcutaneous 
electrical nerve stimulator (TENS) device.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urinalysis provided on May 18, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the urinalysis. You say that the service was medically necessary. The Plan denied 
your request. The Plan says no prior authorization was obtained. 
 
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 did not pre-approve the 
urinalysis. We found no exception that would require the Plan to pay for the urinalysis. The records provided 
for review do not show that the urinalysis was urgent or emergent. Therefore, we decided that the Plan does not 
have to pay for the urinalysis provided on May 18, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 7, 2022 billed with 
codes 0031U, 0032U, 0033U, 81227, 81230, 81231, 81232, 81306, 81328, 81335, & 81355. 
 
You asked the Plan to pay for the genetic testing billed. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) 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. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
March 7, 2022 billed with codes 0031U, 0032U, 0033U, 81227, 81230, 81231, 81232, 81306, 81328, 81335, & 
81355.
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically 
necessary. 
 
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 do not require intensive therapy and do not need frequent physiatry oversight. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a recliner lift chair. 
 
You asked the Plan to pre-approve the requested chair. You say that your chair does not support your 
condition, and it is hard for you to get out of bed. The Plan denied your request. The Plan says the item is not 
covered by Medicare. 
 The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The rules say that seat lift chairs are not covered. The recliner chair does not serve a purpose that is primarily 
medical in nature. This item is available to the general public and would be helpful even to those who are not 
sick or injured. The medical records do not show that you meet the coverage criteria for a seat lift mechanism. 
Therefore, we decided that the Plan does not have to pre-approve a recliner lift chair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic image (D0330) provided on May 12, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to appeal for the denied dental 
benefit. The Plan denied your request. The Plan says the denial of payment for this service is correct, because 
the panoramic imaging 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a 
panoramic image (D0330) provided on May 12, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically 
necessary. 
 
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 do not require the intensity of rehabilitation physician oversight provided in the 
acute inpatient rehabilitation setting. You do not require rehabilitation nursing for complex wound care, 
parenteral nutrition or tube feedings, tracheostomy management or bowel and bladder management. Your 
medical and rehabilitation needs do not require the intensive interdisciplinary approach provided on acute 
inpatient rehabilitation. 
 
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: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy, 60 minutes, (90837) provided on April 4, 
2022. 
 
You asked the Plan to pay for the outpatient mental health service. You say that you were seeing this provider 
to get your life back on track. You say that you are no longer seeing them. You also say that you cannot afford 
to cover this bill. The Plan denied your request. The Plan says the provider is not eligible to bill Medicare 
because provider is a Licensed Independent Mental Health Practitioner (LIMHP). The Plan also says a LIMHP 
is not eligible to bill Medicare for mental health services. 
 
The Plan must follow Medicare rules. Medicare rules say that plans must pay for a medical service or item if 
regular Medicare would pay for it in this case. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the outpatient mental health service have not been met. Therefore, we decided that the Plan does 
not have to pay for the psychotherapy, 60 minutes, (90837) provided on April 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 97 additional office visits. 
 
You asked the Plan to pre-approve 97 additional office visits. You say that the services are necessary. The Plan 
denied your request. The Plan says there are in network providers in the enrollee's area that can provide this 
care. 
 
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. 
 
You are not a network provider with the Plan. The Plan has confirmed there are network primary care 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 
97 additional office visits.