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

 
We decided that the Plan does not have to pay more for an extraction (D7140) for tooth #19, #22, #23, #25, 
#26, #27, and #28 provided by an out-of-network provider on May 16, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you were given a predetermination from 
the Plan saying that all the dental services would be covered, and the Plan did not cover what they said they 
would. The Plan denied your request. The Plan says you are responsible for any charged amount above the 
Plans cost-sharing amount when your services are received from an out-of-network provider. Also, the proper 
cost share was applied. 
 
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 total amount billed for 1 extraction (D7140) was $244 and the total allowed amount was $66 leaving a 
difference of $178 ($244 billed - $66 allowed). The coinsurance amount for 1 extraction (D7140) was $36.30 
($66 allowed x 55% coinsurance). The total difference amount for all the extractions was $1,246 ($178 
difference x 7 extractions). The total coinsurance amount for all the extractions was $254.10 ($36.30 
coinsurance x 7 extractions). 
 
You have been asked to pay a 55% coinsurance and the difference between the out-of-network providers 
charges and the Plans payment. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to pay more for an extraction (D7140) 
for tooth #19, #22, #23, #25, #26, #27, and #28 provided by an out-of-network provider on May 16, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient hospital services provided from February 20, 2022, to 
February 22, 2022. 
 
You asked the Plan to pay for the inpatient hospital services. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says that they were unable to make a 
determination within the allotted time frame. 
 
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 the inpatient hospital services provided based on Medicare criteria. Therefore, we decided that the 
Plan has to pay for the inpatient hospital services provided from February 20, 2022, to February 22, 2022.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the precision attachments (D5862) provided on May 25, 
2023. 
 
You asked the Plan to pay for the dental services. You say that you were told a crown attachment to implants 
would have been approved in lieu of the precision attachments and they were necessary to attach the prothesis. 
The Plan denied your request. The Plan says the denial of payment for these services is correct, because the 
precision attachments are not covered by the 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 the 
precision attachments (D5862) provided on May 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit, and related services provided on February 8, 
2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the office visit, and related services. You say that prior authorization is not 
required for these services. The Plan denied your request. The Plan says enrollees must receive their 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 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 
items/services 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, and related services provided on 
February 8, 2023, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pay for drugs (J7503) provided on January 5, 2023. 
 
You asked the Plan to pay for the drugs. You say that this service was medically necessary. The Plan denied 
your request. The Plan says that the documentation does not support the billed code. The claim did not include 
a National Drug Code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code J7503 is supported in the medical record. Specifically, the claim does include a 
National Drug Code. Based on this information, we decided that Medicare rules for coverage of the drugs have 
been met. Therefore, we decided that the Plan has to pay for drugs (J7503) provided on January 5, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on May 
03, 2023. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you were told that you 
would not have 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 $40 
copayment for physician/Practitioner services, including doctors office visits. 
 
You have been asked to pay a $40 copayment for a specialist office visit. This item/service falls within the 
physician/Practitioner services, including doctors office visits 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 specialist office visit provided on May 03, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a dermatology visit provided on May 26, 2023. 
 
You asked the Plan to pay for a dermatology visit. You say that this was medically necessary and should be 
covered. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a dermatology visit 
provided on May 26, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on April 
10, 2023, to April 17, 2023. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you disagree with the 
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 $350 
copayment per day for days 1-5 and a $0 copayment after day 5 for inpatient hospital care.  
 
You have been asked to pay a $350 copayment per day for days 1-5 and a $0 copayment after day 5 for 
inpatient hospital care. The total amount you are being asked to pay is $1,750 ($350 x 5 days = $1,750). This item/service falls within the inpatient hospital care benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for inpatient hospital care provided on April 10, 2023, to April 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for resin-based composite - two surfaces, posterior tooth #29 
(D2392) and core buildup, including any pins when required tooth #31 (D2950) provided on April 24, 2023. 
 
You asked the Plan to pay for the dental services. You say that you are appealing the decisions to deny 
payments for services that you received in 2023. The Plan denied your request. The Plan says your benefit for 
the requested services $2,000 dollar limit was met 
 
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 was exhausted on date of service April 24, 2023.  
 The Plan made a payment of $1,708 for services D2790, D2950, and a partial payment for D2790 rendered on 
April 24, 2023. Therefore, we decided that the Plan does not have to pay for resin-based composite - two 
surfaces, posterior tooth #29 (D2392) and core buildup, including any pins when required tooth #31 (D2950) 
provided on April 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a periodic oral evaluation - established patient 
(D0120), bitewings - four radiographic images (D0274), and prophylaxis - adult (D1110) provided on May 18, 
2023. 
 
You asked the Plan to pay more for the dental services. You say that you visited your dentist for a routine 
dental exam and cleaning which are covered within your plan. You also say that you are now receiving a bill 
for a copayment and do not believe you should be required to pay. The Plan denied your request. The Plan says 
you are responsible for any charged amount above the Plans cost-sharing amount when your services are 
received from an out-of-network provider.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to pay more for a periodic oral evaluation - established 
patient (D0120), bitewings - four radiographic images (D0274), and prophylaxis - adult (D1110) provided on 
May 18, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 83789 and G0480 billed for date of service 
April 18, 2023. 
 
You asked the Plan to pay for procedure codes 83789 and G0480. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says payment for code 83789 is bundled into payment for code 
80307. The Plan also says that code G0480 is not supported. 
 
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 83789 
is a column II code to column I code 80307. This claim has not been billed with an appropriate modifier to 
bypass the edit. Code G0480 is not supported by the documentation. Specifically, the medical records do not 
contain sufficient detail to support the billed charges. In addition, the medical records submitted do not include 
an order that specifically lists what tests were to be performed in the custom panel. 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 codes 83789 and G0480 billed for date of service April 18, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a portable gaseous oxygen system. 
 
You asked the Plan to pre-approve the portable gaseous oxygen system. You say that you have O2 tanks from 
2020 that are so heavy you cannot lift them anymore. You also say that you have carpal tunnel syndrome of the 
wrists from lifting these heavy tanks. The Plan denied your request. The Plan says that there is no 
documentation that the equipment that you have is not functioning or is not repairable. 
 
The Plan must follow Medicare rules. The rules say that patients who are mobile in the home and would benefit 
from the use of portable oxygen in the home, may qualify for coverage of a portable oxygen system either by 
itself, or to use in addition to a stationary oxygen system. Oxygen is coverable when medically necessary for 
patients with hypoxemia who meet certain blood gas evidence requirements. In reviewing the arterial PO2 
levels and the arterial oxygen saturation percentages, variations in oxygen measurements that may result from 
such factors as the patient's age, the patients skin pigmentation, the altitude level, or the patient's decreased 
oxygen carrying capacity, must be taken into account. For patients who do not exhibit hypoxemia according to 
the above criteria, oxygen may be coverable when medically reasonable and necessary for patients who do not 
have a non-covered indication.  
 
 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 portable gaseous oxygen system 
Our reviewer says that this service is medically necessary. Our physician reviewer found you are on home 
oxygen currently but documentation states mobility is limited due to size of the home oxygen tank/container 
and carpal tunnel. You will have better activities of daily living if the oxygen tank is portable. There are no 
documented studies to show oxygen deficit but you are on home O2 and office notes shows saturations of 95% 
on 2 liters Normocephalic, Atraumatic (2L NC), hence a portable oxygen concentrator will benefit your 
mobility and activities of daily living. 
 
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 portable gaseous oxygen system have been met.  Therefore, we decided that 
the Plan has to pre-approve a portable gaseous oxygen system.  
 
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 procedure codes 81270, 81279, 81338, 81219 and G0452 
provided on March 28, 2023. 
 
You asked the Plan to pay for procedure codes 81270, 81279, 81338, 81219 and G0452. 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. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Additionally, we find that CPT code G0452 is not supported in the medical record. Specifically, 
Code G0452 is used to report a medically necessary interpretation and written report of a molecular pathology 
test, above and beyond the report of lab results. This code is intended to be used by more specialized providers 
such as pathologists, molecular pathologists, or geneticists who process the samples, interpret the results, and 
create a written report. The review of the test results is considered to be part of the medical decision-making 
key component and is not separately billable. Based on this information, we decided that Medicare rules for 
coverage of procedure codes 81270, 81279, 81338, 81219 and G0452 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 81270, 81279, 81338, 81219 and G0452 
provided on March 28, 2023.
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. The 
Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care and is 
currently unstable for transfer 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 enrollee appears to still be somewhat unstable and requires additional acute care 
services that can safely be provided at the current facility until more stable and appropriate for transfer. The 
enrollee does not require services at the LTACH that are not already available at the current facility.  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 pre-approve thermal destruction of basivertebral nerve. 
 
You asked the Plan to pre-approve thermal destruction of basivertebral nerve. You say that the member has a 
chronic history of low back pain. The pain has had a significant impact upon activities of daily living such as 
bending/lifting, standing, and walking. Nothing has provided significant relief. 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 thermal destruction of basivertebral 
nerve. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the intracept procedure is experimental. The cause of pain 
is not clear. SSA 1862a1A not met.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of thermal destruction of basivertebral nerve have not been met. Therefore, we 
decided that the Plan does not have to pre-approve thermal destruction of basivertebral nerve.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Go-Go Elite Traveler Scooter (K0800). 
 
You asked the Plan to pre-approve the power scooter. You say that the Elite Travel Scooter has been 
recommended due to the enrollees medical history. You say that the enrollee needs to continue with normal 
daily activities, as shopping, running errands, going to the pool, etcetera and requires the use of the power 
operated vehicle. The Plan denied your request. The Plan says they cover any durable medical equipment 
(DME) covered by Original Medicare from the brand and manufacturers on the list provided with your EOC. 
The Plan says that the requested power scooter is not listed and therefore cannot be covered. The Plan also says 
power scooters for outdoor use only are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a Go-Go Elite Traveler Scooter (K0800).