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

 
We decided that the Plan does not have to pay for one beam CT capture and interpretation with limited field of 
view  less than one whole jaw (D0364) provided on January 12, 2023. 
 
You asked the Plan to pay for dental services. You say that you paid extra to make sure you had coverage for 
dental work. The provider needs to do this x-ray to proceed with my dental care, so you hope this will be 
approved. The Plan denied your request. The Plan says this service is not covered under your 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. Cone beam CT capture and 
interpretation with limited field of view  less than one whole jaw (D0364) is not covered under the Plans 
dental benefits 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D0364 is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for one beam CT 
capture and interpretation with limited field of view  less than one whole jaw (D0364) provided on January 
12, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance service provided on December 
19, 2022. 
 
You asked the Plan to waive the copayment for ambulance service. You say that you are disputing the share 
cost. 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 $325 
copayment for ambulance services. 
 
You have been asked to pay a $325 copayment for ambulance service. This item/service falls 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 service 
provided on December 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve comprehensive oral evaluation - new or established 
patient (D0150). 
 
You asked the Plan to pre-approve the dental services. You say that you would like the enrollee to see a 
provider that speaks their same language and that help with dental needs. The Plan denied your request. The 
Plan says dental services from an out-of-network provider are not covered by your supplemental benefits. Also, 
interpreters are available. 
 
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 are requesting dental services from an out-of-network provider. Though the Plan offers a dental benefit in 
excess of Medicare coverage, the requested items or services are not covered under this benefit when received 
from an out-of-network provider. Therefore, we decided that the Plan does not have to pre-approve 
comprehensive oral evaluation - new or established patient (D0150).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Ziextenzo (Q5120). 
 You asked the Plan to pre-approve Ziextenzo. You say that Ziextenzo is a medical necessity for the enrollee. 
The Plan denied your request. The Plan says step-therapy rules for coverage of Ziextenzo have not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Ziextenzo. Our reviewer says that 
Ziextenzo is not medically reasonable and necessary in this case. Our physician reviewer found that the Plan 
requires a trial of Neulasta/Neulasta OnPro and Udenyca before they will approve the requested drug. The 
requested drug is a new start. The provided records do not indicate that the enrollee has tried and failed the 
plan's preferred step-one alternatives. The record does not indicate that the enrollee has a contraindication to, or 
would have an adverse effect from, the Plan's preferred step-one alternatives. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Ziextenzo have not been met. Therefore, we decided that the Plan does not have 
to pre-approve treatment with Ziextenzo (Q5120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible the eye examination and the fundus 
photography provided on September 7, 2022. 
 
You asked the Plan to waive the deductible the eye examination and the fundus photography. You say that this 
bill should have been paid completely. 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. Your 
contract with the Plan says that there is 40% coinsurance, which applies to after your $1,600 plan deductible, 
for services for the diagnosis and treatment of diseases and injuries of the eye. 
 
The eye examination and the fundus photography you asked the Plan to waive the deductible falls within the 
vision care benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is 40% coinsurance, which applies to after your $1,600 plan deductible, for services for the diagnosis and 
treatment of diseases and injuries of the eye. This cost sharing is a contractual obligation that had not been met 
at the time the eye examination and the fundus photography was received on September 7, 2022. Therefore, we 
decided that the Plan does not have to waive the deductible the eye examination and the fundus photography 
provided on September 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for dental services provided on July 21, 2022. 
 
You asked the Plan to pay more for the dental services. You say that this should be covered. 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 dental services provided on July 21, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Mounjaro. 
 
You asked the Plan to pre-approve the requested medication. The Plan denied your request. The Plan says the 
medication is not covered as a medical benefit under the Plan. 
 
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 Mounjaro.  Benefits for the requested medication 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 topical application of fluoride varnish (D1206) provided 
on September 29, 2022. 
 
You asked the Plan to pay for the topical application of fluoride varnish. You say that you would think that a 
fluoride varnish treatment would be required along with the periodontal maintenance every three months to 
maintain proper dental health, post periodontal surgery. 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 dates of service January 19, 2022, and 
May 4, 2022. Therefore, we decided that the Plan does not have to pay for the topical application of fluoride 
varnish (D1206) provided on September 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (code 99213) provided by a chiropractor on 
January 9, 2023. 
 
You asked the Plan to pay for office visit. You say that your condition is helped by these visits, and they have 
always been paid for in the past. The Plan denied your request. The Plan says this service is not covered by 
Medicare or the Plan when performed 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 an office visit (code 99213) provided by a chiropractor on January 9, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee scooter (crutch substitute). 
 
You asked the Plan to pre-approve a knee scooter. 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 crutch substitutes (knee scooters) are non-
covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a knee scooter have not been met. Therefore, we decided that the Plan does not have to pre-
approve a knee scooter (crutch substitute).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services provided on December 05, 2022. 
 
You asked the Plan to pay for psychotherapy services. You say that this is supported in the records. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for psychotherapy services 
provided on December 05, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incomplete endodontic therapy; inoperable, 
unrestorable, or fractured tooth (D3332). 
 
You asked the Plan to pre-approve dental services. You say that your provider has referred you to a different 
provider for a root canal, that you hope will be approved. The Plan denied your request. The Plan says this 
service is not covered under your 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. Incomplete endodontic 
therapy: inoperable, unrestorable, or fractured tooth (D3332) is not covered under the Plans dental benefits. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D3332 is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve incomplete 
endodontic therapy; inoperable, unrestorable, or fractured tooth (D3332).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network magnetic resonance imaging 
(MRI) provided on January 13, 2023. 
 
You asked the Plan to waive the copayment for an in-network magnetic resonance imaging (MRI). You say 
that you are on a fixed income and cannot afford this copayment, as well as needing these tests done again. 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 $150 
copayment for other diagnostic and nuclear medicine radiological services. 
 
You have been asked to pay a $150 copayment for an in-network magnetic resonance imaging (MRI). This 
item/service falls within the other diagnostic and nuclear medicine radiological 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 an in-network magnetic resonance imaging (MRI) provided 
on January 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a nursing facility visit provided on January 11, 2023. 
 
You asked the Plan to pay for a nursing facility visit. You say that we depend on the facility staff to verify 
eligibility and to obtain authorization. The Plan denied your request. The Plan says that unauthorized, out-of-
network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a nursing facility visit 
provided on January 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pain management office visit provided on October 24, 
2022. 
 
You asked the Plan to pay for a pain management office visit. You say that you were unaware that this provider 
was out of network when you saw them. The Plan denied your request. The Plan says that unauthorized, out-of-
network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a pain management 
office visit provided on October 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pain management office visit provided on May 25, 2022. 
 
You asked the Plan to pay for a pain management office visit. You say that this was medically necessary and 
should be covered. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a pain management 
office visit provided on May 25, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room visit provided on 
January 08, 2023. 
 
You asked the Plan to waive the copayment for the emergency room visit. You say that you should not have a 
copayment for your second ER visit. 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 $120 
copayment for emergency care. 
 
You have been asked to pay a $120 copayment for the 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 emergency room copayment applies to each visit. Therefore, we decided that the Plan does not have 
to waive the copayment for the emergency room visit provided on January 08, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services on May 17, 2022, to June 15, 2022. 
 
You asked the Plan to pay for home health services. You say that you would like to request reconsideration of 
the denied claim. The Plan denied your request. The Plan says the NOA was not received timely. As such, this 
final claim was correctly denied. 
 The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is March 18, 2022. The NOA was not received by the Plan until August 3, 
2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services on May 
17, 2022, to June 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99203-57 provided on July 29, 2022. 
 
You asked the Plan to pay for procedure code 99203-57. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says payment is included in the global surgery 
payment. 
 
The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for global 
surgery procedures includes payment for services related to the surgery when furnished by the physician who 
performs the surgery. 
 
We looked at the file and Medicare rules. Payment for procedure code 99203-57 is included in the global 
surgery payment for procedure code 46050 provided on July 29, 2022. Separate payment cannot be made for 
procedure code 99203-57. Furthermore, the file shows that the evaluation and management services were 
provided on the same day as the minor surgery with modifier 57. Modifier 57 is not used with minor surgeries 
because the global period for minor surgeries does not include the day prior to the surgery, and the decision to 
perform the minor procedure is typically done immediately before the service. It is then considered a routine 
preoperative service and a visit or consultation is not billed in addition to the procedure. Based on this 
information, we decided that Medicare rules for coverage of procedure code 99203-57 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 99203-57 provided on July 29, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implant supported porcelain/ceramic crowns (D6065) 
for tooth #'s 24, 27, 29, and 31. 
 
You asked the Plan to pre-approve the implant supported porcelain/ceramic crowns. You say that you need 
these procedures and would like complete approval. 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 that implant supported porcelain/ceramic crowns (D6065) for tooth #'s 18, 20, 22, and 25 were pre-
approved on February 22, 2023, and your implant benefit has been exhausted. Therefore, we decided that the 
Plan does not have to pre-approve implant supported porcelain/ceramic crowns (D6065) for tooth #'s 24, 27, 
29, and 31.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on January 5, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you had 
fallen and could not get up. You also say when the emergency medical technicians arrived, they assessed the 
situation, took your vitals and everything was normal, and it took the three young men to get you up. The Plan 
denied your request. The Plan says you were treated but refused transportation to the hospital. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on January 5, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport (A0998) provided on January 5, 2023.