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

 
We decided that the Plan does not have to pay for a re-evaluation (D0170) provided by a participating provider 
on June 21, 2022. 
 
You asked the Plan to pay for a re-evaluation. You say that you wanted to get a second opinion. The Plan 
denied your request. The Plan says the rendered 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 pay for a re-
evaluation (D0170) provided by a participating provider on June 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for sales tax (D9985) provided by an out-of-network provider on 
July 12, 2022. 
 
You asked the Plan to pay for sales tax. You say that you do not agree with this denial. The Plan denied your 
request. The Plan says the denied 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 pay for sales tax 
(D9985) provided by an out-of-network provider on July 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the crowns (D2740) for teeth # 2, 3 and 4 provided on 
July 12, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you had a crown last year and half of the 
bill was covered. You say that you were not told that your coverage changed this year. You also say that you 
were never told this provider was out-of-network. The Plan denied your request. The Plan says you are 
responsible for any charged amount above the Plans cost-sharing amount when your services are received 
from an out-of-network provider. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.  
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to pay more for the crowns (D2740) for teeth # 2, 3 and 4 
provided on July 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services provided from August 5, 2021, to 
November 18, 2021, by the out-of-network provider. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered. The Plan denied 
your request. The Plan says dental services that you receive out-of-network 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the dental services are not among those 
covered under this benefit when you receive them out-of-network. Therefore, we decided that the Plan does not 
have to pay for the dental services provided from August 5, 2021, to November 18, 2021, by the out-of-
network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral exam provided on January 19, 2022. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says your benefit for the oral exam 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 the Plan paid for an oral exam that you received on June 22, 2022, less than 6 months after the date of 
service in this case. Therefore, we decided that the Plan does not have to pay for the oral exam provided on 
January 19, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Nurtec tablet. 
 
You asked the Plan to pre-approve Nurtec. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for coverage for self-administered drugs have not 
been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drug requested here is not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Nurtec 
tablet.  
 Benefits for Nurtec 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Xalatan ophthalmic solution. 
 
You asked the Plan to pre-approve Xalatan. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for coverage for self-administered drugs have not 
been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drug requested here is not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Xalatan 
ophthalmic solution.  
 Benefits for Xalatan 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 a porcelain/ceramic crown on tooth #31 provided on July 13, 
2022. 
 
You asked the Plan to pay for the dental services. You say that you lost a crown and had to go an extended 
period of time without having it replaced. The Plan denied your request. The Plan says your benefit for the 
requested item or service has already been exhausted. Another crown procedure was performed on the same 
tooth within the five-year limit. 
 
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 May 19, 2021. Therefore, 
we decided that the Plan does not have to pay for a porcelain/ceramic crown on tooth #31 provided on July 13, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit (99202) provided May 13, 2022 
 
You asked the Plan to pay for the office visit. You say that you are appealing the below claims as they were 
denied and should be covered. The Plan denied your request. The Plan says this service is not covered when 
rendered by a chiropractor 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the outpatient office visit (99202) provided May 13, 2022
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a reline complete maxillary denture (D5750) provided on 
July 21, 2022. 
 
You asked the Plan to pay for the dental services. You say that you want to be reimbursed for dental fees that 
you spent out-of-pocket for the work that you were covered for. 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. The rules say they cover one 
upper and/or one lower partial denture every 5 calendar years. 
 
 
  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 March 7, 2022. 
Therefore, we decided that the Plan does not have to pay for a reline complete maxillary denture (D5750) 
provided on July 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140) and the radiographic 
image (D0220) provided on July 21, 2022. 
 
You asked the Plan to pay for the dental services. You say that you had a toothache, and the out-of-network 
(OON) provider was the closest dentist to your house. 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 and the 
limited oral evaluation 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. 
 
  The record shows you received the requested dental services from an OON provider. Though the Plan offers a 
dental benefit in excess of Medicare coverage, the radiographic image is  not covered under this benefit when 
received from an OON provider and the limited oral evaluation is not covered under the Plans dental benefits. 
Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) and the 
radiographic image (D0220) provided on July 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on May 11, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that the lab services should be 
covered. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related 
laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on May 11, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on December 21, 2021. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the 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 pay for the dental 
services on December 21, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit and pay for self-
administered drugs provided from June 19, 2022, to June 28, 2022. 
 
You asked the Plan to waive the copayment for an emergency room visit and pay for self-administered drugs. 
You say that you should not have to pay for these services. The Plan denied your request. The Plan says these 
services were processed 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 a $90 
copayment for emergency care.  
 
You have been asked to pay a $90 copayment for an emergency room visit. This item/service falls within the 
emergency care 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.  
 
The rules also 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 waive the copayment for an emergency room visit and pay for self-
administered drugs provided from June 19, 2022, to June 28, 2022.  
 
Benefits for self-administered drugs 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on May 6, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that the lab services should be 
covered. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related 
laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on May 6, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections.  
You asked the Plan to pre-approve facet joint injections. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that the primary indication of a diagnostic facet joint 
procedure is to diagnose whether the patient has facet syndrome. 
 
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 facet joint injections. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found the enrollee has sacroiliitis. 
Therefore, the request is considered not medically reasonable and 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 facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health services

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says home health services are not needed in this amount, frequency, or duration.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.

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 reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found that the clinical documentation shows that the enrollee is doing well on chronic opioid management plan, per the Primary Care Provider (PCP). There are no documented changes in medication regimen or clinical status; thus, you would not be expected to require clinical assessment by skilled nursing. continued home health skilled nursing is not 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 the services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health services
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gingival irrigation (D4921 x 4), and localized delivery of 
antimicrobial agents (D4381 x 8) provided on April 6, 2022. 
 
You asked the Plan to pay for the gingival irrigation and antimicrobial agents. You say that you should be 
reimbursed for the scaling and root planing. You also say that these services were medically necessary. The 
Plan denied your request. The Plan says ginival irrigation and localized delivery of antimicrobial agents are not 
listed as covered services. 
 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 ginival irrigation and localized 
delivery of antimicrobial agents are not among those covered under this benefit. Therefore, we decided that the 
Plan does not have to pay for the gingival irrigation (D4921 x 4), and localized delivery of antimicrobial agents 
(D4381 x 8) provided on April 6, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a CT scan (72131) provided on May 24, 
2022 to July 6, 2022 
 
You asked the Plan to waive the copayment for the CT scan. You say that the services should be covered as 
you disagree with the denial. The Plan denied your request. The Plan says this cost sharing was charged 
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 a $275 
copayment for the cost-sharing applied correctly based on the services provided.  
 
You have been asked to pay a $107.52 copayment for a CT scan, which is less than the standard $275 
copayment. This item/service falls within the cost-sharing applied correctly based on the services provided. 
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 CT scan (72131) provided on 
May 24, 2022 to July 6, 2022
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve facet joint injections. 
 
You asked the Plan to pre-approve facet joint injections. 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 follows Medicare rules. Medicare rules say that therapeutic intraarticular facet injections are not 
covered unless there is documentation on why RFA cannot be performed. 
 
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 facet joint injections. Our reviewer says 
that the services are medically necessary. Our physician reviewer found the request meets the criteria of the 
LCD and is medically reasonable and 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 facet joint injections have been met. Therefore, we decided that the Plan has to 
pre-approve facet joint injections.  
 
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 FreeStyle Libre 14 Day sensor. 
 
You asked the Plan to pre-approve a FreeStyle Libre 14 Day sensor. 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. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a FreeStyle Libre 14 Day sensor have not been met. Therefore, we decided that the Plan does not have to pre-
approve a FreeStyle Libre 14 Day sensor.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an eye exam (92014) provided on July 12, 
2022. 
 
You asked the Plan to waive the copayment for the eye exam. You say that the services should be covered as 
you disagree with the charges. The Plan denied your request. The Plan says this cost sharing was charged 
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 a $20 
copayment for Vision care.  
 
 
  You have been asked to pay a $20 copayment for the eye exam. This item/service falls within the Vision care 
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 eye exam (92014) provided 
on July 12, 2022.