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

 
We decided that the Plan does not have to pre-approve bone replacement graft for ridge preservation (D7953) 
for teeth # 6, 7, 8 and 12. 
 
You asked the Plan to pre-approve the dental services. You say that the services are medically necessary. The 
Plan denied your request. The Plan says bone replacement graft for ridge preservation is not listed as a covered 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested bone replacement graft 
for ridge preservation is not among those covered under this benefit. Therefore, we decided that the Plan does 
not have to pre-approve bone replacement graft for ridge preservation (D7953) for teeth # 6, 7, 8 and 12.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance imaging (MRI) of the 
brain provided on January 23, 2022. 
 
You asked the Plan to waive the copayment for an MRI. You say that you already paid a copayment at the time 
of service and do not know why you must pay this copayment as well. The Plan denied your request. The Plan 
says you have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $350 
copayment for diagnostic radiology services, including MRIs.  
 
The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay 
the allowed amount of $257.54, which is less than the $350 copayment for an MRI. An MRI falls within the 
Outpatient Diagnostic Tests and Therapeutic Services and Supplies 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 a magnetic resonance imaging (MRI) of the brain provided on January 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a recliner chair. 
 
You asked the Plan to pre-approve a recliner chair. You say that you feel the chair should be covered with the 
seat lift mechanism. The Plan denied your request. The Plan says the requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that seat lift chairs are not covered. Coverage is limited to 
a seat lift mechanism.  
 
Although a seat lift chair may be appropriate, Medicare does not cover this item and the Plan must provide 
coverage only for items that Medicare covers. Based on this information, we decided that Medicare rules for 
coverage of a recliner chair have not been met. Therefore, we decided that the Plan does not have to pre-
approve a recliner chair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a retainer crown (D6752), pontic (D6242), and crown 
(D2752) for tooth #28. 
 
You asked the Plan to pre-approve a retainer crown, pontic, and crown. You say that you would like these 
services to be approved for coverage. The Plan denied your request. The Plan says retainer crown and pontic 
are not covered under your benefit package. The Plan also says that the information submitted by your dentist 
was insufficient to demonstrate the dental necessity of the crown for tooth #28. 
 
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 Plan covers a crown when 
the services are medically necessary and reasonable.  
 
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 crown. Our reviewer says that the 
crown (D2752) is not medically reasonable and necessary. Our physician reviewer found a crown was 
requested for tooth #28, however there is minimal structural damage to tooth #28 such that a full coverage 
crown is not medically necessary, and any restoration needed can be placed with a conventional amalgam or 
composite restoration. Our reviewer found that crowns are sometimes indicated where there is less than 50% 
remaining structure due to fracture or damage from decay, however in this instance the x-rays do not support 
that amount of damage being present. Our physician reviewer also found that given the provided information 
there is no medical necessity for the requested crown. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of a retainer crown, pontic, and crown have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a retainer crown (D6752), pontic (D6242), and crown (D2752) for 
tooth #28.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for laboratory services provided on January 24, 2022. 
 
You asked the Plan to pay for laboratory services. You say that although you are currently not a contracted 
provider with the Plan, your procedures were performed at the request of an in-network physician and the 
specimen was directed to your laboratory without direct involvement from the enrollee. The Plan denied your 
request. The Plan says that they found that the analysis was performed by an out-of-network provider, and 
therefore these services are not a benefit of the member's Plan. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for laboratory services by a contract provider. The file does not show that the Plan provided 
notice that laboratory services would not be covered. Under Medicare rules, this means laboratory services is 
considered approved by the Plan. Therefore, we decided that the Plan has to pay for laboratory services 
provided on January 24, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system. 
 
You asked the Plan to pre-approve a power seat elevation system. You say that you disagree with the plan's 
denial. The Plan denied your request. The Plan says the requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature is non-covered. 
 
We looked at the file and Medicare rules. The requested item is strictly not covered. Based on this information, 
we decided that Medicare rules for coverage of a power seat elevation system have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a power seat elevation system.
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 service is medically necessary. The 
Plan denied your request. The Plan says the service is not medically necessary. 
 
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 enrollee does not require services at the LTACH that are not available at the acute 
care hospital where he/she is currently receiving 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 the LTACH services have not been met. Specifically, medically necessary 
services are being obtained at the enrollee's current level of care. This means admission into an LTACH is not 
medically necessary. Therefore, we decided that the Plan does not have to pre-approve long term acute care 
hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services (81455) provided on January 7, 
2022. 
 
You asked the Plan to pay for the genetic testing services. You say that this testing was medically necessary for 
the enrollee's condition. The Plan denied your request. The Plan says genetic testing services coded with 81455 are unlikely to impact therapeutic decision making in the clinical management of the patient and will be denied 
automatically as not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that testing services are subject to the criteria listed in the 
Medicare rule 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 pay for the genetic testing services. Our reviewer 
says that the requested genetic testing was not medically reasonable and necessary. Our physician reviewer 
found in this case, the record indicates that the enrollee underwent excision of a groin mass. The record 
provided is insufficient to establish the medical necessity of the requested service. 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. 
 
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 genetic testing services have not been met. Therefore, we decided that the 
Plan does not have to pay for the genetic testing services (81455) provided on January 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an evaluation for an orthosis (99243) to be provided by 
an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the evaluation. You say that this service is medically necessary. The Plan 
denied your request. The Plan says there are network providers available. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve an 
evaluation for an orthosis (99243) to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve five (5) lap band adjustments (CPT code 43999). 
 
You asked the Plan to pre-approve the services. You say that the enrollee had lap band procedure in 2002 and 
has had several adjustments since and has already been educated on the risks and benefits. You state the 
enrollee has participated in a bariatric program and the goal for adjustment is to ensure the enrollee feels 
satisfied when they eat and are losing weight gradually. The Plan denied your request. The Plan says the 
Medicare rules have not been met. 
 
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 services. Our physician reviewer 
found the record indicates that the plan has approved three adjustments during the time period of June 1 
through July 1, 2022. An additional five adjustments are requested. The record provided is insufficient to 
establish the establish the medical necessity and reasonableness, as defined by Medicare rules, of the number of 
units of the requested service in the time frame provided. 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve five (5) lap band adjustments (CPT code 43999).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the in-network rate for a sleep study in a facility 
(95810) and continuous positive airway pressure (CPAP) titration (95811) to be performed out of area. 
 
You asked the Plan to pre-approve the in-network rate for the outpatient diagnostic testing. You say that you 
live out of state 6 months out of the year. You also say that you need to have a sleep study done. The Plan 
denied your request. The Plan says in network coverage cannot be provided for an out of plan referral. 
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and 
pre-approved care.   
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the outpatient diagnostic testing have not been met. Specifically, the requested service is not urgent 
or emergent in nature. Therefore, we decided that the Plan does not have to pre-approve the in-network rate for 
a sleep study in a facility (95810) and continuous positive airway pressure (CPAP) titration (95811) to be 
performed out of area.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gingival flap procedures (D4240) for all four quadrants. 
 
You asked the Plan to pre-approve gingival flap procedures. You say that these services are necessary. The 
Plan denied your request. The Plan says these services are not covered by the Plan's dental benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
gingival flap procedures (D4240) for all four quadrants.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve massage therapy visits. 
 
You asked the Plan to pre-approve massage therapy visits. You say that your shoulder hurts doing all physical 
activities and you don't want to take narcotics for the pain. You say that you still constantly suffer from severe 
nerve pain, your physical therapist cannot do anything else and massage therapy should be covered. The Plan 
denied your request. The Plan says massage therapy is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore, 
we decided that the Plan does not have to pre-approve massage therapy visits.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health aide and skilled nursing visits. 
 
You asked the Plan to pre-approve home health services. You say that the enrollee needs these services. The 
Plan denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that an enrollee must be homebound for home health care 
services to be covered.  
 The file does not show that the enrollee is homebound. Therefore, we decided that the Plan does not have to 
pre-approve home health aide and skilled nursing visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and 
first intraoral periapical x-ray (D0220) provided on January 19, 2022. 
 
You asked the Plan to pay for the problem focused limited oral evaluation and first intraoral periapical x-ray. 
You say that you believe these services should be submitted as a medical claim. The Plan denied your request. 
The Plan says problem focused limited oral evaluation is not a covered expense under your dental plan. The 
Plan also says that your first intraoral periapical x-ray benefit has been satisfied and the frequency limitation 
has been exceeded.  
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, problem focused limited oral 
evaluation (D0140) is not among those covered under this benefit. The contract says that intraoral x-rays are 
limited to 1 procedure code per calendar year. The record shows that you received a first intraoral periapical x-
ray (D0220) on January 22, 2022 and your intraoral x-rays benefit has been exhausted. Therefore, we decided 
that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and first intraoral 
periapical x-ray (D0220) provided on January 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two intra-orifice barriers (D3911). 
 
You asked the Plan to pre-approve intra-orifice barriers. You say that these services are necessary. The Plan 
denied your request. The Plan says these services are not covered by your dental benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 two 
intra-orifice barriers (D3911).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit and testing to be provided by the 
requested out-of-network provider. 
 
You asked the Plan to pre-approve an office visit and testing. The Plan denied your request. The Plan says 
services with a Tertiary level facility 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 pre-approve an office visit and testing. Our reviewer 
says that the requested office visit and testing are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there was no medical indication suggesting seeing the requested provider 
verses an in-network Otolaryngologist would be superior or better satisfy your needs for a workup for a sore 
throat and odynophagia. There was no special circumstances that would support using this physician. 
Therefore, this request will be considered not medically necessary at this time.  
 
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 office visit and testing to be provided by the requested provider have not been met. Therefore, we decided that the Plan does not have to pre-approve an office visit and testing to be 
provided by the requested out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on January 14, 
2022. 
 
You asked the Plan to waive the copayment for an office visit. You say that you received your smart summary 
and there is a claim for a visit you know you did not have. The Plan denied your request. The Plan says you 
have been charged the correct copayment 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 $30 
copayment for an in-network specialist's office visit.  
 
 
 
 You have been asked to pay a $30 copayment for an office visit. The office visit falls within the 
Physician/Practitioner services, including doctor's 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 an office visit provided on January 14, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on February 
15, 2022. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you are on a limited income. 
The Plan denied your request. The Plan says you have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 
copayment for ground ambulance services.  
 
You have been asked to pay a $250 copayment for ambulance services. Ambulance services fall within the 
Ambulance 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 ambulance services 
provided on February 15, 2022.