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

 
We decided that the Plan does not have to waive the copayment for an ER visit, a CT scan, and therapy 
services provided from July 25, 2023, to July 27, 2023. 
 
You asked the Plan to waive the copayment for an ER visit, a CT scan, and therapy services. You say that the 
services provided were medically necessary. 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 $95 
copayment for emergency care, a $225 copayment for advanced imaging services performed at an outpatient 
hospital, and a $20 copayment for outpatient rehabilitation services.  
 
You have been asked to pay $340 for an ER visit, a CT scan, and therapy services. This total included a $95 
copayment for an ER visit, a $225 copayment for a CT scan, and a $20 copayment for a PT visit ($95 + $225 + 
$20 = $340). The ER visit falls within the emergency care benefit category. The CT scan falls within the 
outpatient diagnostic tests benefit category. The therapy services fall within the outpatient rehabilitation 
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 ER visit, a CT scan, and 
therapy services provided from July 25, 2023, to July 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental service (D5214). 
 
You asked the Plan to pre-approve the dental service (D5214). You say that you would like to request 
reconsideration of the denied dental service and that the services requested are medically necessary. 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 September 15, 2020. 
Therefore, we decided that the Plan does not have to pre-approve the dental service (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110), a partial 
mandibular denture (D5214), surgical extractions (D7210), and an alveoloplasty (D7311). 
 
You asked the Plan to pre-approve the dental services. You say that the enrollee would benefit from this dental 
work. The Plan denied your request. The Plan says the requested dental services are not covered 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, 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 a 
complete maxillary denture (D5110), a partial mandibular denture (D5214), surgical extractions (D7210), and 
an alveoloplasty (D7311).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for gingival irrigation with a medicinal agent (D4921), 
scaling in presence of generalized moderate or severe gingival inflammation (D4346), core buildup (D2950), a 
porcelain or ceramic crown (D2740), oral hygiene instructions (D1330), topical application of fluoride varnish 
(D1206), and a 2 dimensional oral/facial photographic image (D0350) provided on February 14, 2023. 
 You asked the Plan to reimburse for gingival irrigation with a medicinal agent (D4921), scaling in presence of 
generalized moderate or severe gingival inflammation (D4346), core buildup (D2950), a porcelain or ceramic 
crown (D2740), oral hygiene instructions (D1330), topical application of fluoride varnish (D1206), and a 2 
dimensional oral/facial photographic image (D0350). You say that all the procedures done were denied. You 
also say you had the same procedure in a different state on January 12, 2022, and you were reimbursed. The 
Plan denied your request. The Plan says these services are not covered on your benefit 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 reimburse for 
gingival irrigation with a medicinal agent (D4921), scaling in presence of generalized moderate or severe 
gingival inflammation (D4346), core buildup (D2950), a porcelain or ceramic crown (D2740), oral hygiene 
instructions (D1330), topical application of fluoride varnish (D1206), and a 2 dimensional oral/facial 
photographic image (D0350) provided on February 14, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility provided on February 16, 2023. 
 
You asked the Plan to pay for skilled nursing facility. You say that you disagree with the denial of the claim. 
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 skilled nursing facility 
provided on February 16, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 61645 provided on October 27, 2022. 
 
You asked the Plan to pay for procedure code 61645. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We find that CPT code 61645 is not supported in the medical record. This code has a bilateral surgery indicator of 1. This means the code should be reported with 1 unit of service and modifier 50 (bilateral modifier) or an 
appropriate anatomical modifier (right or left) to be considered for payment. Based on this information, we 
decided that Medicare rules for coverage of code 61645 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 61645 provided on October 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).  
You asked the Plan to pre-approve a CGM. You say that you would benefit from this CGM. The Plan denied 
your request. The Plan says the medical criteria for a CGM have not been met. 
 
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 or 
have a history of problematic hypoglycemia. 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 
continuous glucose monitor (CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral - complete series of radiographic image (D0210) 
provided on June 26, 2023. 
 
You asked the Plan to pay for the dental services. You say that this is medically necessary. 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 November 11, 2022. 
Therefore, we decided that the Plan does not have to pay for intraoral - complete series of radiographic image 
(D0210) provided on June 26, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone replacement graft for ridge preservation - per site 
(D7953), and therapeutic parenteral drugs, two or more administrations, different medications (D9612). 
 
You asked the Plan to pre-approve the bone replacement graft and therapeutic parenteral drugs. You say that 
your back teeth need to be repaired. The Plan denied your request. The Plan says these services are not covered 
on 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. 
 
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 a bone replacement graft for ridge 
preservation - per site (D7953), and therapeutic parenteral drugs, two or more administrations, different 
medications (D9612).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental services (D7953, D6101 and D4266). 
 
You asked the Plan to pre-approve the dental services (D7953, D6101 and D4266). You say that you would 
like to request reconsideration of the denied dental services and that the services requested are medically 
necessary. The Plan denied your request. The Plan says the services requested are not covered 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, 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 the 
dental services (D7953, D6101 and D4266).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the prefabricated abutments  includes modification and 
placement (D6056), abutments supported porcelain fused to metal crown (high noble metal) (D6059), and 
surgical placement of implant body: endosteal implants (D6010). 
 
You asked the Plan to pre-approve the dental services. You say that you were informed by two representatives 
that the services would be covered. The Plan denied your request. The Plan says you are only covered for the 
dental services, codes and limits listed in the medical benefits chart. 
 
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 services are not among 
those covered under this benefit.  Therefore, we decided that the Plan does not have to pre-approve the prefabricated abutments  includes 
modification and placement (D6056), abutments supported porcelain fused to metal crown (high noble metal) 
(D6059), and surgical placement of implant body: endosteal implants (D6010).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture services provided on January 31, 2023. 
 
You asked the Plan to pay for acupuncture services. You say that the services were previously paid. The Plan 
denied your request. The Plan says that the acupuncture services were provided by an unqualified provider. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the provider is not and was not supervised by a 
physician, physician assistant, or nurse practitioner/clinical nurse specialist. Therefore, we decided that the Plan 
does not have to pay for acupuncture services provided on January 31, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on May 16, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you are 
asking to reconsider payment. The Plan denied your request. The Plan says these services are not a covered 
benefit.  
 
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 May 16, 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 provided on May 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital inpatient or observation care provided on May 
13, 2023. 
 You asked the Plan to pay for initial hospital inpatient or observation care. You say that the service was not 
related to the enrollee's hospice care. 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 initial hospital inpatient or observation care provided on May 
13, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy provided on July 11, 2023, to July 17, 2023. 
 
You asked the Plan to pay for physical therapy. You say that you were only reimbursed for one of the visits 
when it should have been all of 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 physical therapy 
provided on July 11, 2023, to July 17, 2023.
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 enrollee requires extensive therapy services with 
daily physician management to ensure a restoration of their functional status for a safe and sustainable 
discharge. The Plan denied your request. The Plan says the enrollee does 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 the enrollee does 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implant placement for teeth (D6010). 
 
You asked the Plan to pre-approve implant placement for teeth. You say that this is medically necessary. 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 
implant placement for teeth (D6010).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical placement of implant body (D6010), 
prefabricated abutment (D6056), alveoloplasty in conjunction with extractions (D7310) and interim implant 
abutment placement (D6051). 
 
You asked the Plan to pre-approve the dental services. You say that this should be covered. The Plan denied 
your request. The Plan says your benefit for the surgical placement of implant body has already been 
exhausted. Prefabricated abutment, alveoloplasty in conjunction with extractions and interim implant abutment 
placement are not covered services. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the surgical placement of implant body was exhausted. Prefabricated abutment, 
alveoloplasty in conjunction with extractions and interim implant abutment placement are not covered services. 
 Therefore, we decided that the Plan does not have to pre-approve surgical placement of implant body (D6010), 
prefabricated abutment (D6056), alveoloplasty in conjunction with extractions (D7310) and interim implant 
abutment placement (D6051).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the minimally invasive sacroiliac (SI) joint fusion 
surgery. 
 
You asked the Plan to pre-approve the minimally invasive SI joint fusion surgery. You say that due to the 
enrollee's debilitating pain, they would benefit from the surgery.  The Plan denied your request. The Plan says 
the SI joint fusion surgery is not medically necessary. The Plan says there is not documentation of a second 
sacroiliac joint injection with reduction of pain and no imaging of the SI joint.  
 
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 pre-approve the minimally invasive SI joint fusion 
surgery. Our reviewer says that the requested service is not considered medically reasonable and necessary in 
this case. Our physician reviewer found there is no SI joint instability fracture or lesion. The Si joint fusion for 
degenerative back pain is considered an experimental procedure. 
 
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 minimally invasive SI joint fusion surgery have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the minimally invasive sacroiliac (SI) joint fusion surgery.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Sprint peripheral nerve stimulator (PNS) (64555 
x2). 
 
You asked the Plan to pre-approve the Sprint PNS. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is not medically necessary. 
 
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 pre-approve the Sprint PNS. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Sprint PNS device is experimental for back pain. 
 
   
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 Sprint PNS have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Sprint peripheral nerve stimulator (PNS) (64555 x2).