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

 
We decided that the Plan does not have to reduce the cost share for a Cerec onlay on tooth #4 (D2644) and 
resin-based composite fillings on tooth #8 and 9 (D2331) provided on March 7, 2022. 
 
You asked the Plan to reduce the cost share for the dental services. You say that you were overcharged for 
these services. 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 $400 
copayment for an onlay (D2644). If an onlay is made of high noble metal, an additional fee up to $100 per 
tooth will be charged for the upgrade. Also, porcelain and other tooth-colored materials on molars are 
considered a material upgrade with a maximum additional charge to the enrollee of $150. The contract also 
says that enrollees must pay a $65 copayment for each resin-based composite filling (D2331). 
 
The record shows this claim was approved, and you have a cost sharing amount. The record also shows you 
received a material upgrade for the onlay on tooth #4. You have been asked to pay a total of $825 for the onlay. 
You have also been asked to pay a $65 copayment for each filling. Onlays and fillings fall within the Dental 
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 reduce the cost share for a Cerec onlay on tooth #4 
(D2644) and resin-based composite fillings on tooth #8 and 9 (D2331) provided on March 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the sales tax (D9985) provided on April 21, 2022. 
 
You asked the Plan to pay for sales tax. You say that you do not understand why this claim was partially 
covered. The Plan denied your request. The Plan says sales tax (D9985) is not covered by your routine 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 the sales 
tax (D9985) provided on April 21, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the periodontal maintenance (D4910) provided March 31, 2022. 
 
You asked the Plan to pay for the dental services. You say that you need dental care every three months. The 
Plan denied your request. The Plan says that your benefit for the requested item or service has already been 
exhausted. 
 
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.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. 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 has provided documentation showing only one previously covered periodontal 
maintenance. There is no evidence showing your benefit for the requested item or service was previously 
exhausted. Therefore, we decided that the Plan has to pay for the periodontal maintenance (D4910) provided 
March 31, 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 comprehensive oral evaluation (D0150) and an intraoral x-
ray (D0210) provided on April 18, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says your benefit for the requested items or services 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 an intraoral x-ray was exhausted on date of service September 21, 2020. The record also 
shows your benefit for a comprehensive oral evaluation was exhausted on date of service June 8, 2021. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and an 
intraoral x-ray (D0210) provided on April 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional payment for the occlusal guard  hard appliance, 
full arch (D9944) and resin-based composite - two surfaces, posterior (D2392) provided February 14, 2022. 
 
You asked the Plan to provide additional payment for the occlusal guard and filling. You say that you 
confirmed coverage prior to the services being rendered. The Plan denied your request. The Plan says the claim 
has been reprocessed and your remaining dental allowance was applied to the claim. 
 
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 dental 
services up to $1,000 every year. 
 
We looked at the file and Medicare rules. The Plan provided documentation showing that at the time the claim 
was processed you had $734 remaining in your dental allowance. This amount was applied towards the 
occlusal guard. You have been asked to pay the remaining amount above your dental allowance for the occlusal 
guard and the filling. This means you have been asked to pay the correct amount based on your contract with the Plan. Therefore, we decided that the Plan does not have to provide additional payment for the occlusal 
guard  hard appliance, full arch (D9944) and resin-based composite - two surfaces, posterior (D2392) 
provided February 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation services rendered on October 14, 
2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that a professional component (PC)/technical component 
(TC) indicator of 3 represents TC only codes.  
 
We looked at the file and Medicare rules. Billed procedure code 99153 has a PC/TC indicator of 3 and no 
separate professional component payment. Therefore, we decided that the Plan does not have to pay for the 
moderate sedation services rendered on October 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an additional periapical image (D0230) provided by a 
participating provider on April 26, 2022. 
 
You asked the Plan to pay for the dental services. You say that you believe the Plan should pay for this. 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 April 26, 2022. 
Therefore, we decided that the Plan does not have to pay for an additional periapical image (D0230) provided 
by a participating provider on April 26, 2022.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Pegfilgrastim-jmdb. 
 
You asked the Plan to pre-approve Pegfilgrastim-jmdb. You say that the services are necessary. The Plan 
denied your request. The Plan says that based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Pegfilgrastim-jmdb. Our reviewer says 
that the services are medically necessary. Our physician reviewer found Pegfilgastrim is indicted for prevention 
of neutropenic fever in patients with a >20% risk of neutropenic fever. Adriamycin and cyclophosphamide 
(AC) is associated with a high risk of neutropenic fever. The service is reasonable and medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Pegfilgrastim-jmdb have been met. Therefore, we decided that the Plan has to 
pre-approve Pegfilgrastim-jmdb.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Simponi. 
 
You asked the Plan to pre-approve Simponi. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Simponi.  
 
Benefits for Simponi 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for occupational therapy provided on January 
25, 2022. 
 
You asked the Plan to waive the copayment for occupational therapy. You say that you cannot afford to pay for 
each visit. The Plan denied your request. The Plan says the copayment applied 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 $35 
copayment for each Medicare-covered occupational therapy visit.  
 
You have been asked to pay $35 copayment for occupational therapy. Occupational therapy falls within the 
Outpatient Rehabilitation 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 
occupational therapy provided on January 25, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve an epidural steroid injection. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
he Plan follows Medicare rules. Medicare rules say that epidural steroid injection (ESI) will be considered 
medically reasonable and necessary when specific criteria are 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 an epidural steroid injection. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found the record does not 
indicate that there was at least 50% of sustained improvement in pain relief and/or improvement in function 
measured from baseline using SAME scale* for at least three months following the last injection. 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 an epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an epidural steroid injection.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy (PT) provided on April 22, 2022, and April 
25, 2022, by an out-of-network provider. 
 
You asked the Plan to pay for the PT. The Plan denied your request. The Plan says the enrollee did not obtain 
authorization for services performed by a non-participating provider with the health plan. 
 
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 physical therapy (PT) provided on April 22, 2022, 
and April 25, 2022, by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a miscellaneous durable medical equipment (DME) 
supply, accessory, and/or service component. 
 
You asked the Plan to pre-approve a miscellaneous supply, accessory, and/or service component. You say that 
the item is necessary. The Plan denied your request. The Plan says there is no documentation as to what this 
code is pertaining to. Therefore, it cannot be determined whether this item is primarily medical in nature or 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal 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. Therefore, we 
decided that the Plan does not have to pre-approve a miscellaneous durable medical equipment (DME) supply, 
accessory, and/or service component.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CxBladder testing identified with code 0012M provided 
on February 16, 2022. 
 
You asked the Plan to pay for the CxBladder testing. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services rendered are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that CxBladder testing identified with code 0012M is 
not covered. 
 
We looked at the file and Medicare rules. Review of the file shows that the service at issue is the CxBladder 
testing. This service is specifically not covered. Based on this information, we decided that Medicare rules for 
coverage of the CxBladder testing have not been met. Therefore, we decided that the Plan does not have to pay 
for the CxBladder testing identified with code 0012M provided on February 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical laparoscopy (44206) provided on February 1, 
2022. 
 
You asked the Plan to pay for the surgical laparoscopy (44206). You say that the out-of-network provider was 
the only available assistant at the time of the procedure and the services were specifically requested by the in-
network physician. The Plan denied your request. The Plan says a surgical technologist is not payable by 
Medicare. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
  In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of 
practitioners. Therefore, we decided that the Plan does not have to pay for the surgical laparoscopy (44206) 
provided on February 1, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the services are medically 
necessary. The Plan denied your request. The Plan says that the services are not medically necessary. 
 
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 pay for acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient admission are met in this case. Our physician 
reviewer found the enrollee was admitted with left facial droop and left sided weakness for 4.5 hours. Physical 
exam confirmed left facial droop and left upper extremity weakness. The enrollee was admitted for further 
evaluation and management of cerebrovascular accident. The record shows that at the time of inpatient 
admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including 
earlier emergency department and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pre-approve acute inpatient hospital care.  
 
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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for speech language pathology provided on March 14, 2022. 
 
You asked the Plan to pay for the speech language pathology. The Plan denied your request. The Plan says 
original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for speech language pathology provided on March 14, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cosentyx pen. 
 
You asked the Plan to pre-approve Cosentyx pen. You say that the medication is necessary. The Plan denied 
your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Cosentyx pen.  
 
Benefits for Cosentyx pen 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the determination of refractive state (92015) provided on 
April 11, 2022. 
 
You asked the Plan to pay for the determination of refractive state. You say that you needed to have your eyes 
tested to get better vision following eye surgeries for detached retinas. The Plan denied your request. The Plan 
says this service is not covered. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. 
 
We looked at the file and the Plan's rules. The contract clearly states that Original Medicare does not cover 
routine eye exams (eye refractions) for eyeglasses/contacts. Based on this information, we decided that the 
Plan's rules for coverage of the determination of refractive state have not been met. Therefore, we decided that 
the Plan does not have to pay for the determination of refractive state (92015) provided on April 11, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tagrisso. 
 
You asked the Plan to pre-approve Tagrisso. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Tagrisso.  
 
Benefits for Tagrisso may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.