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

 
We decided that the Plan does not have to pre-approve the crown - porcelain/ceramic tooth #'s 7, 8, 9 and 10 
(D2740). 
 
You asked the Plan to pre-approve the crown - porcelain/ceramic tooth #'s 7, 8, 9 and 10. You say that you 
asked the doctor to remove and put crowns on the four pieces because three of them have 25 year old crowns. 
You also say the teeth are weak and cause you a lot of pain. The Plan denied your request. The Plan says these 
services are not medically necessary. 
 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 crown - 
porcelain/ceramic tooth #'s 7, 8, 9 and 10  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 crown - porcelain/ceramic tooth #'s 
7, 8, 9 and 10 . Our reviewer says that the documentation does not meet the criteria for coverage for crowns 
(D2740) for teeth #'s 7, 8, 9 and 10. Our physician reviewer found there was no narrative indicating why the 
crowns presently in place (#8, 9 and 10) need replacement. Tooth #8 does not show significant coronal 
breakdown to warrant a crown. 
 
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 crown - porcelain/ceramic tooth #'s 7, 8, 9 and 10  have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the crown - porcelain/ceramic tooth #'s 7, 8, 9 
and 10 (D2740).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 9 months of supply allowance for a continuous glucose 
monitor (CGM). 
 
You asked the Plan to pre-approve the supply allowance for the CGM. You say that you are requesting a 12-
month supply allowance for the enrollee. The Plan denied your request. The Plan says the requested supply 
allowance exceeds the Medicare coverage allowance. 
 
The Plan must follow Medicare rules. Medicare rules say that only 1 UOS of code A4239 may be billed with 
no more than a 90-day supply.  
 
  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the supply allowance for the CGM have not been met. Therefore, we decided that the Plan does not 
have to pre-approve 9 months of supply allowance for a continuous glucose monitor (CGM).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Pantoprazole (J8499). 
 
You asked the Plan to pre-approve the medication. You say that the drug is medically necessary. 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 Pantoprazole (J8499).   
Benefits for the 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that you are currently under inpatient status and paying 
out-of-pocket. The Plan denied your request. The Plan says the SNF services you are requesting do not meet 
the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found You do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit services provided on February 9, 2023, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for the office visit services provided by an OON provider. You say that you would 
like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services 
provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network 
care. 
 
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 the office visit services provided on February 9, 
2023, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
February 7, 2022.  
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service February 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the AVISE CTD test panel (0312U) provided on June 23, 
2022. 
 
You asked the Plan to pay for the AVISE CTD test panel. You say that  this test was ordered by the enrollee's 
physician. The Plan denied your request. The Plan says this panel is considered experimental and 
investigational. 
 
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 pay for the AVISE CTD test panel. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that this panel is considered experimental and investigational, as it is unproven to 
alter disease prognosis or treatment outcomes and has not been proven to be superior to alternative tests and 
measures of disease activity. The review has determined that the items/services at issue in this case are not 
medically reasonable or 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 AVISE CTD test panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the AVISE CTD test panel (0312U) provided on June 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical pathology and special stain services provided on 
March 1, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the surgical pathology and special stain services. You say that you disagree with 
the Plan's denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 
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 at issue in this case is not a network provider with the Plan. We looked at the file and Medicare 
rules. Based on this information, we decided that Medicare rules for coverage of the surgical pathology and 
special stain services have not been met. The Plan has network providers available who can provide the 
items/services at issue in this appeal. We found no exception that would require the Plan to pay for the surgical 
pathology and special stain services. Therefore, we decided that the Plan does not have to pay for the surgical 
pathology and special stain services provided on March 1, 2023, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), gingival irrigation 
(D4921), an adjunctive pre-diagnostic test (D0431), and fluoride varnish (D1206), provided on February 16, 
2023. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for these 
services. 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 D0150 was exhausted on date of service December 14, 2022. D4921, D0431, and D1206 are not covered dental benefits. Therefore, we decided that the Plan does not have to pay for a 
comprehensive oral evaluation (D0150), gingival irrigation (D4921), an adjunctive pre-diagnostic test (D0431), 
and fluoride varnish (D1206), provided on February 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the diagnostic colonoscopy provided on 
January 26, 2023. 
 
You asked the Plan to waive the cost share for the diagnostic colonoscopy. You say that you were not told you 
would be billed prior to the procedure. 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 a $150 deductible which applies to in-network outpatient surgery. Your 
contract with the Plan also says that you must pay 10% coinsurance after meeting the deductible for in-network 
outpatient surgery. 
 
 You have been asked to pay $150 towards the deductible. The item or service you asked the Plan to waive the 
cost share for falls within the outpatient surgery benefit category. The Plan has followed Medicare rules by 
clearly disclosing in the contract that there is a $150 deductible which applies to in-network outpatient surgery. 
This cost sharing is a contractual obligation that had not been met at the time the diagnostic colonoscopy was 
received on January 26, 2023.  
 
You have also been asked to pay $2.36, which is less than the standard 10% coinsurance for the diagnostic 
colonoscopy. This item/service falls within the outpatient surgery benefit category. You have been asked to pay 
a total of $152.36 ($150 deductible + $2.36 coinsurance = $152.36). 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 
cost share for the diagnostic colonoscopy provided on January 26, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network biopsy provided on January 
26, 2023. 
 
You asked the Plan to waive the copayment for an in-network biopsy. You say that you thought this would be 
covered 100%, and now you are being charged a copayment. You want this waived. 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 $100 
copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and 
ambulatory surgical center.  
You have been asked to pay a $100 copayment for an in-network biopsy. This item/service falls within the 
outpatient surgery and other medical services provided at hospital outpatient facilities and 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 in-network biopsy provided 
on January 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery provided on March 06, 
2023. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that you say there shouldnt be a 
copayment. 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 $200 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers. 
 
You have been asked to pay a $200 copayment for outpatient surgery. This item/service falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 
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 outpatient surgery provided on 
March 06, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Rocklatan. 
 
You asked the Plan to pre-approve the medication. You say that the drug is medically necessary. 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 Rocklatan.   
Benefits for the 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office visits to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve the office visits. You say that you have been allowed to see this provider in 
the past. The Plan denied your request. The Plan says you must receive your care from a network provider. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the office visits to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the continuous positive airway pressure 
(CPAP) equipment and supplies provided on October 31, 2022. 
 
You asked the Plan to waive the coinsurance for the continuous positive airway pressure (CPAP) equipment 
and supplies. You say that you were told by the Plan there would be no copayment for this equipment. 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 20% 
coinsurance for in-network durable medical equipment and related supplies. 
 
You have been asked to pay 20% coinsurance for the continuous positive airway pressure (CPAP) equipment 
and supplies. This item/service falls within the in-network durable medical equipment 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 the continuous positive airway 
pressure (CPAP) equipment and supplies provided on October 31, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve therapeutic procedures to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve therapeutic procedures. You say that the services should be covered. The 
Plan denied your request. The Plan says this is available in-network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
therapeutic procedures to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the compression bandage application 
provided on March 24, 2023. 
 
You asked the Plan to waive the copayment for the compression bandage application. You say that you were 
charged with surgical services when it should have been an office 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 $225 
copayment for in-network outpatient surgery provided at an outpatient hospital. 
 
You have been asked to pay a $225 copayment for the compression bandage application. This item/service falls 
within the in-network outpatient surgery provided at an outpatient hospital 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. According to Medicare the 
compression bandage application (code 29581) is considered a surgical service. However, since the allowed 
amount is less than the standard copayment, you only owe $200.06. Therefore, we decided that the Plan does 
not have to waive the copayment for the compression bandage application provided on March 24, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a water circulating heat pad with pump (E0217) provided 
from July 21, 2022, to August 15, 2022. 
 
You asked the Plan to pay for a water circulating heat pad with pump. You say that this device was medically 
necessary. The Plan denied your request. The Plan says this device is not under Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that a water circulating heat pad with pump will be 
denied as not reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a water circulating heat pad with pump have not been met. Therefore, we decided that the Plan 
does not have to pay for a water circulating heat pad with pump (E0217) provided from July 21, 2022, to 
August 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on February 22, 
2023. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the services 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 subsequent nursing 
facility care provided on February 22, 2023.