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

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan 
provided on April 28, 2023. 
 
You asked the Plan to waive the copayment for a computed tomography (CT) scan. You say that you have 
never had to pay a copayment with previous CT scans. 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 $160 
copayment for outpatient diagnostic test. 
 
You have been asked to pay a $160 copayment for a computed tomography (CT) scan. This item/service falls 
within the outpatient diagnostic test 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 $100.39, which is less than the standard copayment for a 
CT scan. Therefore, we decided that the Plan does not have to waive the copayment for a computed 
tomography (CT) scan provided on April 28, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a computed tomography (CT) scan 
performed at an outpatient hospital facility provided on August 30, 2022. 
 
You asked the Plan to reduce the copayment for a computed tomography (CT) scan performed at an outpatient 
hospital facility. You say that the claim should be billed as an outpatient facility with a $50 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 $100 
copayment for outpatient diagnostic test. 
 
You have been asked to pay a $100 copayment for a computed tomography (CT) scan performed at an 
outpatient hospital facility. This item/service falls within the outpatient diagnostic test 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 
$99.01, which is less than the standard copayment for a CT scan provided at an outpatient hospital facility. 
Therefore, we decided that the Plan does not have to reduce the copayment for a computed tomography (CT) 
scan performed at an outpatient hospital facility provided on August 30, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance image (MRI) 
provided on April 14, 2023. 
 
You asked the Plan to waive the copayment for a magnetic resonance image (MRI). You say that you were not 
informed you were responsible for 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 $180 
copayment for outpatient diagnostic test. 
 
You have been asked to pay a $180 copayment for a magnetic resonance image (MRI). This item/service falls 
within the outpatient diagnostic test 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 
magnetic resonance image (MRI) provided on April 14, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the immediate denture maxillary (D5130), extractions 
(D7140 x 2) and unspecified adjunctive procedure (D9999) provided on February 20, 2023. 
 
You asked the Plan to pay for the dental services. You say that you are appealing the denial. The Plan denied 
your request. The Plan says the dental services were received from an out-of-network provider and are not 
covered by your supplemental benefits.  
 
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 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 pay for the immediate denture maxillary (D5130), extractions (D7140 x 2) and unspecified adjunctive 
procedure (D9999) provided on February 20, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for immediate denture - maxillary (D5130) and maxillary partial 
denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) 
(D5213) provided on June 7, 2022, and September 15, 2022. 
 
You asked the Plan to pay for dental services. You say that the plan representative advised that the services 
would be covered. 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. Immediate denture - maxillary 
(D5130) and maxillary partial denture - cast metal framework with resin denture bases (including 
retentive/clasping materials, rests and teeth) (D5213) are not covered under the Plans dental benefits. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D5130 and D5213 are 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
immediate denture - maxillary (D5130) and maxillary partial denture - cast metal framework with resin denture 
bases (including retentive/clasping materials, rests and teeth) (D5213) provided on June 7, 2022, and 
September 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on March 24, 2023. 
 
You asked the Plan to pay for the dental services. You say that this procedure was necessary and without 
treatment an infection could damage your heart. 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 date of service March 10, 2023. 
Therefore, we decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on March 
24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a 2D oral/facial photographic image, cone beam computed 
tomography (CT) scan, and oral hygiene instructions (D0350, D0367, D1330) provided on March 6, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the charges. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental benefits. 
 
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, 2D oral/facial photographic images, 
cone beam (CT) scans, and oral hygiene instructions are not among those covered under this benefit. The 
record indicates that the provider is not billing you for the 2D oral/facial photographic images (D0350 x4), 
Therefore, we decided that the Plan does not have to pay for a 2D oral/facial photographic image, cone beam 
computed tomography (CT) scan, and oral hygiene instructions (D0350, D0367, D1330) provided on March 6, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete upper denture (D5110) and a complete lower 
denture (D5120) provided on April 4, 2023. 
 
You asked the Plan to pay for the dental services. You say that the Plan should pay for the dentures. The Plan 
denied your request. The Plan says your benefit for the requested items or 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 the Plan paid for a complete upper denture (D5110) and a complete lower denture (D5120) on October 
10, 2019; therefore, your benefit for the requested items or services was exhausted on the date of service of 
October 10, 2019. Therefore, we decided that the Plan does not have to pay for a complete upper denture 
(D5110) and a complete lower denture (D5120) provided on April 4, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive oral evaluation (D0150) provided on March 
23, 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 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. Therefore, we decided that the Plan does 
not have to pay for comprehensive oral evaluation (D0150) provided on March 23, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an apicoectomy - molar (first root) (D3425), apicoectomy 
(each additional root) (D3426), and retrograde filling - per root (D3430) provided on March 7, 2023. 
 
You asked the Plan to pay for the apicoectomy - molar (first root), each additional root, and retrograde filling - 
per root. You say that that these procedures were dentally required due to a tooth infection. You also say that 
this procedure is classified as a basic restorative procedure. The Plan denied your request. The Plan says these 
services are not a covered benefit under your dental plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 an 
apicoectomy - molar (first root) (D3425), apicoectomy (each additional root) (D3426), and retrograde filling - 
per root (D3430) provided on March 7, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a maxillary partial denture (D5211) provided on February 
28, 2023. 
 
You asked the Plan to pay for the dental services. You say that your denture broken into pieces. You also say 
you took the denture with you to the dentist, and he could not fix it. 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 date of service April 2, 2021. Therefore, 
we decided that the Plan does not have to pay for a maxillary partial denture (D5211) provided on February 28, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a medical eye examination (92014) 
provided on February 27, 2023. 
 
You asked the Plan to waive the copayment for a medical eye examination (92014). You say that you did not 
have a refraction service at this visit and only asked for a routine examination. You also say you disagree with 
these 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 $40 
copayment for a consultation, diagnosis, and treatment by a specialist.  
 
 You have been asked to pay a $40 copayment for a medical eye examination (92014). This item/service falls 
within the consultation, diagnosis, and treatment by a specialist 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 medical eye examination (92014) provided on February 27, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drugs, self-administered. 
 
You asked the Plan to pay for drugs, self-administered. 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 pay for drugs, self-administered.   
Benefits for drugs, self-administered 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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for to pay for the procedure codes 11043, 11046, 99335 
rendered on June 28, 2022. 
 You asked the Plan to pay for the procedure codes 11043, 11046, 99335. You say that the services were 
medically necessary. The Plan denied your request. The Plan says Original Medicare is responsible for 
payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for to pay for the procedure codes 11043, 11046, 99335 rendered 
on June 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custom fabricated abutment (D6057) and 
implant/abutment supported fixed denture (D6114). 
 
You asked the Plan to pre-approve custom fabricated abutment and implant/abutment supported fixed denture. 
You say that this should be covered. The Plan denied your request. The Plan says this is not a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 
custom fabricated abutment (D6057) and implant/abutment supported fixed denture (D6114).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda (J9271). 
 
You asked the Plan to pre-approve Keytruda. You say that you would like pembrolizumab to be approved for 
therapy use. The Plan denied your request. The Plan says the use of Keytruda for ovarian cancer is not FDA 
approved or listed in the Medicare approved sources. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
 
 
 
 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 Keytruda. Our reviewer says that 
Keytruda is not medically reasonable and necessary for the enrollee. Our physician reviewer found the 
requested use of Keytruda (J9271) is FDA-approved for the enrollees diagnosis as monotherapy but in 
combination with lenvatinib. The use is not supported by one of the major drug compendia or by clinical 
research that appears in a Centers for Medicare and Medicaid Services (CMS) approved medical journal. Our 
reviewer also found that the use is not listed as not indicated, not supported or not recommended in any of the 
compendia. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda (J9271).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for topical application of fluoride varnish (D1206) provided on 
April 12, 2023. 
 
You asked the Plan to pay for topical application of fluoride varnish. You say that this should be covered. The 
Plan denied your request. The Plan says this is only a covered service for minors under the age of 19. 
 
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 topical 
application of fluoride varnish (D1206) provided on April 12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical placement of an implant (D6010), prefabricated 
abutment (D6056) and implant supported crown (D6066). 
 
You asked the Plan to pre-approve these dental services. You say that this should be covered. The Plan denied 
your request. The Plan says this is not a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 
surgical placement of an implant (D6010), prefabricated abutment (D6056) and implant supported crown 
(D6066).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 99204 provided on February 6, 2023. 
 
You asked the Plan to pay for procedure code 99204. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered as billed. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. In this case, the Plan has not provided enough evidence to support the denial of 
payment for procedure code 99204 based on Medicare criteria. The Plan says procedure code 99204 is a 
column II code to column I codes 95911 and 95886; however, upon further investigation, procedure code 
99204 is not showing up as having a National Correct Coding Initiative (NCCI) edit with procedure codes 
95911 and 95886. The Plan has not provided any documentation showing that code 99204 is included with 
codes 95911 and 95886. Therefore, we decided that the Plan has to pay for procedure code 99204 provided on 
February 6, 2023.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on December 01, 2022, to 
December 31, 2022. 
 
You asked the Plan to pay for laboratory services. You say that the service does not require 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 laboratory services 
provided on December 01, 2022, to December 31, 2022.