Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a cystourethroscopy procedure provided 
on March 16, 2023. 
 
You asked the Plan to waive the coinsurance for a cystourethroscopy procedure. You say that you were not 
notified about the coinsurance. 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 10% 
coinsurance for in and out-of-network Medicare-covered surgery or other services at an outpatient hospital or 
ambulatory surgical center.  
You have been asked to pay 10% coinsurance for a cystourethroscopy procedure. This item/service falls within 
the in and out-of-network Medicare-covered surgery or other services at an outpatient hospital or ambulatory 
surgical center 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 total you owe is $802.35 ($8023.49 allowed amount x 10% = $802.35 rounded up). Therefore, we 
decided that the Plan does not have to waive the coinsurance for a cystourethroscopy procedure provided on 
March 16, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing (81456). 
 
You asked the Plan to pre-approve genetic testing. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the enrollee had previous genetic testing. A repeat panel is not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that Next Generation Sequencing testing for patients 
with advanced cancer is reasonable and necessary only when performed in a CLIA-certified laboratory, when 
ordered by a treating physician, and when the patient has not been previously tested with a Comprehensive 
Genetic Panel for the same cancer genetic content.  
 
We looked at the file and Medicare rules. The enrollee had an NGS panel performed previously (81455). Based 
on this information, we decided that Medicare rules for coverage of genetic testing have not been met. 
Therefore, we decided that the Plan does not have to pre-approve genetic testing (81456).
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 services are medically necessary for your care 
needs. The Plan denied your request. The Plan says you do not meet the criteria for admission to an IRF.  
 
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 you do not require treatment by multiple therapies. While the medical record 
supports a need for physical or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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 an abdominal x-ray provided on January 19, 2023, by an 
OON provider.  
 
You asked the Plan to pay for an abdominal x-ray. You say that you are appealing the denial with supporting 
documentation. The Plan denied your request. The Plan says the service was not authorized. 
 
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 an abdominal x-ray provided on January 19, 2023, 
by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an upper eyelid repair procedure provided 
on March 07, 2023. 
 
You asked the Plan to waive the copayment for an upper eyelid repair procedure. You say that you think that 
this service should be covered. 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 in-network Medicare-covered surgery or other services provided at an ambulatory surgical 
center.  
You have been asked to pay a $275 copayment for an upper eyelid repair procedure. This item/service falls 
within the in-network Medicare-covered surgery or other services provided at an ambulatory surgical center 
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 upper eyelid repair procedure 
provided on March 07, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for in-network denosumab injections provided 
from January 5, 2022, to August 5,2022. 
 
You asked the Plan to waive the copayment for in-network denosumab injections. You say that you had already 
met you out of pocket maximum and the plan should cover this. 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% 
coinsurance for Medicare Part B prescription drugs.  
 
The enrollee received the services and is responsible for the associated cost share involved with these services, 
totaling, $1,098.76 ($508.92 + $510.24 + $79.60=$1,098.76). You have been asked to pay a $1,098.76 coinsurance for in-network denosumab injections. This item/service 
falls within the Medicare Part B prescription drugs 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 in-network denosumab injections provided from January 5, 2022, to August 5,2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are medically necessary for 
the enrollee's complex medical needs.  The Plan denied your request. The Plan says the enrollee's records do 
not show that it is medically safe for the enrollee to go to an LTACH.  
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the documentation does not support that the enrollee in this case requires services at 
the LTACH that are not available at the acute care hospital where they are currently receiving care. There are 
no required medical services identified that are available at the LTACH, that are not available at the current 
health care setting being offered by the health plan.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injections provided on March 30, 2023, by an out-of-network 
(OON) provider.  
 
 You asked the Plan to pay for injections. You say that you are requesting reconsideration. The Plan denied your 
request. The Plan says the enrollee must receive their care from a network provider (for more information 
about this, see Section 2 of Chapter 3). In most cases, care the enrollee receives from an out-of-network 
provider (a provider who is not part of the plans network) will not be 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 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 injections provided on March 30, 2023, by an out-
of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department visit (99285) and 
electrocardiogram (93010) provided on November 22, 2021. 
 
You asked the Plan to pay for the emergency department visit and electrocardiogram. You say that this claim 
was submitted well within the payer limits. The Plan denied your request. The Plan says this claim was 
processed correctly due to the claim not being filed until March 1, 2023, without good cause. The Plan also 
says that this means more than one calendar year from the date of service had passed before the claim was 
filed. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 The record shows that a claim for the emergency department visit and electrocardiogram was not filed until 
March 1, 2023. This means that more than one calendar year from the date of service had passed before a claim 
was filed. Therefore, we decided that the Plan does not have to pay for the emergency department visit (99285) 
and electrocardiogram (93010) provided on November 22, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service February 27, 
2023. 
 You asked the Plan to pay for procedure code 76705. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 76705 is bundled into payment for code 93976. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 76705 
is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 76705 billed for date of service February 27, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pontics - porcelain fused to high noble metal (D6240 
x3) and retainer crown - porcelain fused to high noble metal (D6750 x3). 
 
You asked the Plan to pre-approve the pontics - porcelain and retainer crowns. The Plan denied your request. 
The Plan says the documentation did not meet the Plan's clinical criteria. 
 
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 the pontics - 
porcelain and retainer crowns when the services are medically necessary and reasonable.  
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the pontics - porcelain and retainer 
crowns. Our reviewer says that the requested dental services are not medically necessary. Our physician 
reviewer found the appeal is being made for the denial of coverage for fixed bridges replacing missing teeth #'s 
19, 30 and 31 with pontics (D6240) using teeth #'s 18, 20, 29 and 32 as abutment retainers (D6750). According 
to the plan, fixed bridges may be covered to replace a single maxillary anterior tooth or two adjacent 
mandibular anterior teeth if no posterior teeth are missing. In this case bilateral missing mandibular posterior 
teeth are to be replaced. The documentation provided does not meet the coverage for fixed bridges replacing 
posterior teeth #'s 19, 30 and 31. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the pontics - porcelain and retainer crowns have not been met. Therefore, we 
decided that the Plan does not have to pre-approve pontics - porcelain fused to high noble metal (D6240 x3) 
and retainer crown - porcelain fused to high noble metal (D6750 x3).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve interim crowns (D2799 x 4). 
 
You asked the Plan to pre-approve the dental services. You say that these procedures are required to compete 
your restorations. The Plan denied your request. The Plan says this dental code cannot be used to bill for 
temporary crowns. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
interim crowns (D2799 x 4).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for crowns porcelain/ceramic (D2750), panoramic radiographic 
image (D0210), topical application of fluoride varnish (D1206) and oral hygiene instructions (D1330) provided 
on May 9, 2023, and May 24, 2023. 
 
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 crowns and panoramic radiographic images 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 crowns was exhausted on date of service June 28, 2021, and your benefit for the 
panoramic radiographic images was exhausted on May 5, 2022. Therefore, we decided that the Plan does not 
have to pay for crowns porcelain/ceramic (D2750), panoramic radiographic image (D0210), topical application 
of fluoride varnish (D1206) and oral hygiene instructions (D1330) provided on May 9, 2023, and May 24, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve retainer crowns for teeth number 10 and 11 (D6750 x 2) 
and a prefabricated post and core in addition to a crown for tooth number 10 (D2954). 
 
You asked the Plan to pre-approve the dental items. You say that you are requesting are requesting a 
reconsideration of the Plan's denial. The Plan denied your request. The Plan says your benefit for the requested 
items 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 items has already been exhausted.   
 
 
 
Specifically, the Plans contract states that up to four units of fixed dentures are covered per year. The Plan 
previously approved two retainer crowns for teeth number 6 and 7 and pontics for teeth number 8 and 9. 
Therefore, you have exhausted the allowable benefit for the requested items in this case. Therefore, we decided 
that the Plan does not have to pre-approve retainer crowns for teeth number 10 and 11 (D6750 x 2) and a 
prefabricated post and core in addition to a crown for tooth number 10 (D2954).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the extractions, of an erupted tooth requiring removal of 
bone and/or sectioning of tooth (D7210 x 5) and the removal of a torus mandibularis (D7473 x 2).  
 
You asked the Plan to pre-approve the dental services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says your benefit for the requested 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 the requested services has been exhausted. Specifically, the Plans contract states that 
there is a $2,000 maximum dental benefit each year. You received dental services on April 10, 2023 and  
July 14, 2023 that were paid for by the Plan in the amount of $1,483.10. The Plan previously approved 
additional dental services requested by your dental provider for the remaining allowable amount; therefore, the 
maximum annual dental benefit has now been exhausted. Additionally, removal of a torus mandibularis is not a 
covered benefit. Therefore, we decided that the Plan does not have to pre-approve the extractions, of an erupted 
tooth requiring removal of bone and/or sectioning of tooth (D7210 x 5) and the removal of a torus mandibularis 
(D7473 x 2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal maintenance (D4910). 
 
You asked the Plan to pre-approve the periodontal maintenance. You say that you are greatly in need of this 
periodontal maintenance being that you haven't been to a dentist in years. You also say that you can't afford to 
pay for these services out-of-pocket because of your income. The Plan denied your request. The Plan says 
periodontal maintenance code D4910 is not listed and is 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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
periodontal maintenance (D4910).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G7 continuous glucose monitor (CGM).  
You asked the Plan to pre-approve a CGM. You say that the enrollee would benefit from this CGM. The Plan 
denied your request. The Plan says the enrollee is not on insulin. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin.  
Based on this information, we decided that Medicare rules for coverage of a CGM have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Dexcom G7 continuous glucose monitor 
(CGM).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the paramedic intercept. 
 
You asked the Plan to pay for paramedic intercept. You say that you would like reconsideration because the 
requested paramedic intercept is medically necessary. The Plan denied your request. The Plan says the 
requested paramedic intercept is not a covered benefit.  
The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by 
an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. 
Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area as 
defined above. It is noted that the only State in which these criteria are met is New York. 
 
The paramedic intercept services at issue in this appeal were not furnished in an area that is considered rural 
according to the Medicare definition. Therefore, we decided that the Plan does not have to pay for the 
paramedic intercept.