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 requested IRF care is a medical necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for IRF care have not been met.
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 that the enrollee is medically stable and does not need physical medicine and rehabilitation physician supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. The enrollee does not need intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the general health panel (80050) and the prostate-specific antigen (PSA) testing provided on February 24, 2021.
You asked the Plan to pay for the general health panel and PSA testing. You say that this should be paid. The Plan denied your request. The Plan says this is excluded from coverage.
The Plan must follow Medicare rules. The rules say that code 80050 (general health panel) is considered a non-covered code. PSA testing is only covered when certain criteria are met. You have requested payment for services billed under code 80050. Medicare does not cover or pay for services billed under this code. In addition, the documentation does not show the presence of any of the covered indications for PSA testing. Therefore, we decided that the Plan does not have to pay for the general health panel (80050) and the prostate-specific antigen (PSA) testing provided on February 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a privacy flap and electronic connection.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the services are not covered.
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 an electronic connection is covered to control one or more power options.
The privacy flap does not serve a purpose that is primarily medical in nature. The electronic connection is not
needed to control the approved power options. Therefore, we decided that the Plan does not have to preapprove
a privacy flap and electronic connection.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a radiology exam provided on October 22, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for a radiology exam. You say that services were provided to the enrollee so the 
claim should be paid. The Plan denied your request. The Plan says the rendering and referring providers are 
both out-of-network providers with no approved authorization. Also, the service provided was not urgent or 
emergent. 
 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 a radiology exam provided on October 22, 2021, 
by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prefabricated post and core in addition to a crown 
(D2954) provided on September 30, 2021. 
 
You asked the Plan to pay for the dental service. You say that you were told when you signed up for the policy 
that crowns and related procedures are covered. You also say that The Plan denied your request. The Plan says 
prefabricated post and core in addition to a crown is not 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the post and core in addition to a 
crown is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the prefabricated post and core in addition to a crown (D2954) provided on September 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation - established patient (D0120) 
provided November 2, 2021. 
 
You asked the Plan to pay for the periodic oral exam. You say that this was not a normal visit and the services 
were necessary. The Plan denied your request. The Plan says you have exceeded the frequency limit 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. The Plan covers two dental 
exams per year.  
 
We looked at the file and Medicare rules. The Plan provided documentation showing that dental exams were 
previously covered on April 15, 2021, and July 22, 2021. Based on this information, we decided that the Plan's frequency limit for coverage of the periodic oral exam has been exceeded. Therefore, we decided that the Plan 
does not have to pay for the periodic oral evaluation - established patient (D0120) provided November 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the scaling and root planing (D4341 x 4), and periapical x-
rays (D0220, D0230) provided from October 21, 2021, to November 1, 2021. 
 
You asked the Plan to pay for the dental services. You say that you were not told that the x-rays would not be 
covered. You also say that had you known the x-rays would not be covered, you would not have accepted 
because of the high cost. The Plan denied your request. The Plan says scaling and root planing is not listed as a 
covered service. The Plan also says periapical x-rays are not listed as covered services either. 
 
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 scaling and root planing and 
periapical x-rays are not among those covered under this benefit. Therefore, we decided that the Plan does not 
have to pay for the scaling and root planing (D4341 x 4), and periapical x-rays (D0220, D0230) provided from 
October 21, 2021, to November 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), 
complete series of intraoral x-rays (D0210), and core buildup, including any pins when required (D2950) 
provided on October 5, 2021. 
 
You asked the Plan to pay for the problem focused limited oral evaluation, complete series of intraoral x-rays, 
and core buildup. You say that on October 18, 2021 you spoke to a Plan representative who informed you that 
you could get 50% of the cost of the crown you needed if you were to go to an in-network dentist. The Plan 
denied your request. The Plan says these services are not covered expenses under your dental plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
problem focused limited oral evaluation (D0140), complete series of intraoral x-rays (D0210), and core 
buildup, including any pins when required (D2950) provided on October 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bitewing x-rays (D0274) provided on October 26, 2021. 
 
You asked the Plan to pay for the dental service. You say that you changed dentists to one that was closer to 
you. You also say that you required bitewing x-rays since it had been 6 months. The Plan denied your request. 
The Plan says bitewing x-rays are covered once per plan years. The Plan also says that the frequency limit 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 and bitewings are listed as covered, the 
frequency limit has been exceeded. The record shows that the Plan paid for bitewing x-rays that you received 
on March 25, 2021. Therefore, we decided that the Plan does not have to pay for the bitewing x-rays (D0274) 
provided on October 26, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy (90834) provided on July 1, 2021, to July 28, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for psychotherapy. You say that you would like this claim reviewed for medical 
necessity. The Plan denied your request. The Plan says the services were not authorized because this provider is 
a non-network provider who does not work with the Plan and the member self-directed for care. The Plan also 
says that the member's primary care provider did not refer for services. The Plan also says that no medical 
necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented, and 
alternate network providers were found. 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 psychotherapy (90834) provided on July 1, 2021, 
to July 28, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the fuciclovine injection you received 
during a positron emission tomography (PET) scan on September 9, 2021. 
 
You asked the Plan to waive the coinsurance for the fuciclovine injection. You say that the facility gave you 
incorrect information about the cost of the procedure.  You said that you were told you would only have a $110 
copayment.  If you had known about the extra charge, you would not have agreed to the service. The Plan 
denied your request. The Plan says you were charged this coinsurance correctly. 
 
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 20% coinsurance for medical supplies.  
 
Your Evidence of Coverage says there is no separate charge for medical supplies routinely used in the course 
of an office visit and included in the provider's charges for that visit.  However, supplies for which an 
appropriate separate charge is made by providers (such as, chemical agents used in certain diagnostic 
procedures), are subject to the medical supply cost sharing.  That was the case here.  The fuciclovine injection 
you received is a chemical agent that was used during your PET scan.  According to your contract, separate 
cost sharing can apply for this, as it is considered a medical supply. You have been asked to pay 20% 
coinsurance for the fuciclovine injection. 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 coinsurance for the 
fuciclovine injection you received during a positron emission tomography (PET) scan on September 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral hygiene instructions (D1330) provided on October 
20, 2021. 
 
You asked the Plan to pay for the oral hygiene instructions. You say that you have been going to this dentist for 
several years and did not know that the provider was out-of-network. You also say that you called the dentist 
office and they stated that they accepted your plan benefits. The Plan denied your request. The Plan says this 
service is not a covered expense under your dental plan. The Plan also says that you did not contact the Plan 
prior to the date of service to verify benefits and provider eligibility. 
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 oral 
hygiene instructions (D1330) provided on October 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pontics (D6240 x 3), porcelain fused to high noble metal 
retainer crowns (D6750 x 3), and porcelain retainer crown (D6740) provided from April 19, 2021, to July 17, 
2021. 
 
You asked the Plan to pay for the 3 additional pontics, porcelain fused to high noble metal retainer crowns, and 
porcelain retainer crown. You say that you received a predetermination showing that these services would be 
covered. The Plan denied your request. The Plan says the frequency limits have been exceeded. 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage and 3 fixed prosthodontic services are 
covered per year, the frequency limit has been exceeded with the reprocessing of this claim. Additionally, 
porcelain retainer crown is not among those covered under this benefit. Therefore, we decided that the Plan 
does not have to pay for the pontics (D6240 x 3), porcelain fused to high noble metal retainer crowns (D6750 x 
3), and porcelain retainer crown (D6740) provided from April 19, 2021, to July 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an endosteal implant (D6010) to be provided by a participating provider.
You asked the Plan to pre-approve an endosteal implant. You say that you are unable to eat, and you need these implants. The Plan denied your request. The Plan says the requested dental benefits are not covered 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 pre-approve an endosteal implant (D6010) to be provided by a participating provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that the clinical value and effectiveness of bone marrow aspirate in the 
setting of spinal fusion surgery have not been demonstrated in the peer-reviewed literature. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Bone marrow 
aspirate remains experimental. More research is needed to show it is safe and effective as a bone graft. Our 
physician reviewer found that your condition does not meet criteria for coverage of these services. 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve bone marrow aspirate.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional periapical x-ray (D0230) and periodontal 
maintenance (D4910) provided on October 20, 2021. 
 
You asked the Plan to pay for the dental services. You say that this service is necessary to maintain the health 
and longevity of your teeth. You say that your dentist feels this way too. The Plan denied your request. The 
Plan says the claim processed correctly. 
 
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 and 1 periapical x-ray is covered per 
calendar year, the frequency limit has been exceeded.  The record shows that the Plan paid for the initial periapical x-ray that you received on the date of service in this case. Additionally, periodontal maintenance is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the additional periapical x-ray (D0230) and periodontal 
maintenance (D4910) provided on October 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a back brace provided on July 21, 2021. 
 
You asked the Plan to waive the coinsurance for a back brace. You say that you received the brace for after 
surgery from your doctor's office and thought it was included with the doctor's services. You also say the 
insurance charged ten times more than the online price for the same brace. 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 20% 
coinsurance for durable medical equipment.  
 
You have been asked to pay $274.79, which is 20% of the allowed amount for a back brace ($1,373.96 allowed 
amount x 20% coinsurance = $274.79). A back brace falls within the Durable Medical Equipment (DME) and 
Related 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 coinsurance for a back brace provided on July 21, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve six (6) additional physical therapy (PT) visits (97110). 
 
You asked the Plan to pre-approve additional PT visits. You say that the requested additional PT visits are 
medically necessary. The Plan denied your request. The Plan says the requested additional PT visits do not 
meet criteria. 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 additional PT visits. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the additional requested therapy is not generally accepted as specific 
and effective therapy for your condition beyond what was approved by the health plan. You have had extensive 
prior therapy approved and the records do not demonstrate that the unique skills of a professional therapist are 
required to safely and effectively provide treatment, that the services can be safely and effectively performed 
only by a therapist, or by or under the supervision of a therapist. You have been approved an ample amount of 
therapy and should be able to transition to a home exercise program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional PT visits have not been met. Therefore, we decided that the Plan does 
not have to pre-approve six (6) additional physical therapy (PT) visits (97110).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation feature (E2300). 
 
You asked the Plan to pre-approve a power seat elevation feature. You say that this is medically necessary. The 
Plan denied your request. The Plan says that this is statutorily non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature is non-covered 
because it is not primarily medical in nature. Therefore, we decided that the Plan does not have to pre-approve 
a power seat elevation feature (E2300).