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

 
We decided that the Plan does not have to pay for the porcelain/ceramic retainer crowns (D6740 x 2) and the 
core buildup, including any pins when required (D2950) provided on January 18, 2023.   
 
You asked the Plan to pay for these items. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says these dental items are not covered under your 
supplemental dental policy.  
 
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 dental items provided are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
porcelain/ceramic retainer crowns (D6740 x 2) and the core buildup, including any pins when required (D2950) 
provided on January 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral-periapical first radiographic image (D0220), 
intraoral-periapical additional radiographic images (D0230 x 2), the re-cement or re-bond of a crown (D2920), 
a crown repair necessitated by restorative material failure (D2980), and the inhalation of nitrous 
oxide/analgesia, anxiolysis (D9280) provided on September 16, 2022. 
 
 
  
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the dental services provided are not covered 
under your supplemental dental policy.   
 
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 services provided are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the intraoral-
periapical first radiographic image (D0220), intraoral-periapical additional radiographic images (D0230 x 2), 
the re-cement or re-bond of a crown (D2920), a crown repair necessitated by restorative material failure 
(D2980), and the inhalation of nitrous oxide/analgesia, anxiolysis (D9280) provided on September 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cognitive assessment care plan provided on November 22, 
2022. 
 
You asked the Plan to pay for cognitive assessment care plan. You say that it is the responsibility of the facility 
to obtain 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 cognitive assessment 
care plan provided on November 22, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for the infliximab injections provided on 
January 12, 2022, to October 19, 2022. 
 
You asked the Plan to reduce the coinsurance for the infliximab injections. You say that you should not be 
responsible to pay this. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 10% 
coinsurance for Medicare Part B prescription drugs. 
 
You have been asked to pay 10% coinsurance for the infliximab injections. This item/service falls within the 
Medicare Part B prescription drugs benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to reduce the coinsurance for 
the infliximab injections provided on January 12, 2022, to October 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a targeted genomic sequence analysis panel provided on 
January 30, 2023.  
You asked the Plan to pay for a targeted genomic sequence analysis panel. You say that the claim should be 
reprocessed. 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. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on January 28, 2023. The services in question were provided 
before the end of that month.  Therefore, we decided that the Plan does not have to pay for a targeted genomic 
sequence analysis panel provided on January 30, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and infusion services provided on January 04, 
2022. 
 
You asked the Plan to pay for the office visit and infusion services. You say that you had COVID-19 and were 
cleared to receive the infusion treatment. 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 the office visit and 
infusion services provided on January 04, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental services. 
 
You asked the Plan to pre-approve the dental services. You say that you would like to request reconsideration 
of the denied authorization. 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. Therefore, 
we decided that the Plan does not have to pre-approve the dental services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve deep sedation/general anesthesiafirst 15 minutes 
(D9222) and deep sedation/general anesthesiaeach subsequent 15 minute increment (D9223). 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says the requested services are not covered under your 
supplemental dental policy.  
 
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 deep sedation/general anesthesiafirst 15 
minutes (D9222) and deep sedation/general anesthesiaeach subsequent 15 minute increment (D9223).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a computed tomography (CT) scan of the chest. 
 
You asked the Plan to pre-approve the CT scan of the chest. You say that the services are medically necessary. 
The Plan denied your request. The Plan says that the records do not show that the enrollee has had changes to 
their condition. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
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 CT scan of the chest. Our reviewer 
says that the CT scan is medically necessary. Our physician reviewer found that while the nodules described 
have remained unchanged between 2017 and 2021 the Fleischner Society guidelines for nodule surveillance 
specify that there are circumstances when altered management may be indicated and in this case the presence 
of a 9 mm non calcified nodule is of concern.  The guidelines explain that nodules exceeding 8 mm in diameter 
and are non-calcified may require different management.  Since there is such a non-calcified nodule in this case 
the request for a CT surveillance at this point in time is reasonable and should be approved. 
 
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 CT scan of the chest have been met. Therefore, we decided that the Plan has 
to pre-approve a computed tomography (CT) scan of the chest.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre Mis 2 Reader. 
 
You asked the Plan to pre-approve the Freestyle Libre Mis 2 Reader. You say that you need the reader to 
monitor sugars closely and so that you don't need to prick your finger multiple times per day. The Plan denied 
your request. The Plan says you do  not have documentation of a history of problematic hypoglycemia. 
 
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 you do not  have a history of 
problematic hypoglycemia.  Based on this information, we decided that Medicare rules for coverage of the 
Freestyle Libre Mis 2 Reader have not been met.  Therefore, we decided that the Plan does not have to pre-
approve a Freestyle Libre Mis 2 Reader.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a microprocessor knee. 
 
You asked the Plan to pre-approve a microprocessor knee. You say that the enrollee's current knee has a K2 
function which is not meeting their needs. The Plan denied your request. The Plan says the requested 
microprocessor knee is not medically necessary for the enrollee. 
 
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 a microprocessor knee. Our reviewer 
says that the requested microprocessor knee is not considered medically reasonable and necessary in this case.  
Our physician reviewer found the requested microprocessor knee has features such as intuitive use of a 
stationary indoor bicycle, adjustments from a smartphone with the Cockpit app, and convenience features of 
charging without removing the foam cover. The physician documentation does not support that the enrollee 
requires a microprocessor knee over a K3 mechanical knee. Therefore, the reviewer found that the requested 
microprocessor knee is 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 a microprocessor knee have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a microprocessor knee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on February 08, 
2023. 
 
You asked the Plan to waive the copayment for an office visit. You say that you are disputing the share cost. 
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 $35 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $35 copayment for an 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 an office visit provided on February 08, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an implant crown (D2750) and surgical placement of an 
implant (D6010) provided from February 19, 2021, to November 4, 2021. 
 
You asked the Plan to pay for dental services. You say that you should be reimbursed for your dental benefits. 
The Plan denied your request. The Plan says these services are not covered by the Plan's dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's 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 
implant crown (D2750) and surgical placement of an implant (D6010) provided from February 19, 2021, to 
November 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a bladder cancer exam provided on July 
26, 2022. 
 
You asked the Plan to waive the coinsurance for a bladder cancer exam. You say that you are disputing the 
share cost. 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 30% 
coinsurance for Outpatient hospital services. 
 
You have been asked to pay 30% coinsurance for a bladder cancer exam. This item/service falls within the 
Outpatient hospital 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 coinsurance for a bladder 
cancer exam provided on July 26, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each ambulance service provided on 
August 23, 2022, to October 21, 2022. 
 
You asked the Plan to waive the copayment for each ambulance service. You say that you are disputing the 
share cost. 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 $250 
copayment for ambulance services. 
 
You have been asked to pay a $250 copayment for each ambulance service. This item/service falls within the 
ambulance 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 each ambulance 
service provided on August 23, 2022, to October 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care billed with code 99232 for July 
25, 2022, to July 29, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are included in the global surgical package. 
 
The Plan must follow Medicare rules. The rules say that post-operative services are included in the global 
surgical package. 
 
We looked at the file and Medicare rules. The file shows that procedure code 99232 was related to and billed 
within 90 days of major surgical procedure 44150. Payment for code 99232 is included in the global surgical 
package for 44150. Therefore, we decided that the Plan does not have to pay for the subsequent hospital care 
billed with code 99232 for July 25, 2022, to July 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing, Signatera (81479). 
 
You asked the Plan to pre-approve genetic testing. You say that you disagree with the denial and request 
reconsideration. The Plan denied your request. The Plan says records do not show that the enrollee has 
advanced or recurrent colon cancer or that she is being treated with immune-checkpoint inhibitor therapy. The 
request 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 genetic testing. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the review indicates that the enrollee has a diagnosis of rectal cancer. The medical records 
show that she has stage I rectal cancer (T2N0M0) and are being treated with Capecitabine and radiation. The 
review has determined that the enrollee does not meet criteria for the requested genetic testing. The genetic 
testing is not medically necessary for the enrollee's condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not 
have to pre-approve genetic testing, Signatera (81479).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 88377 and G0452 billed for date of service 
December 13, 2022. 
 
You asked the Plan to pay for procedure codes 88377 and G0452. You say that these services are supported in 
the medical records. The Plan denied your request. The Plan says these codes are not supported for separate 
billing and payment. 
 
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 codes 88377 and G0452 are column II codes to column I code 81342; 
however, 88377 and G0452 were each billed with a modifier.  
 
We asked our coder 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 procedure codes 88377 and G0452. Our reviewer says that 
the 59 modifier is not supported with these services. Our reviewer found that the laboratory report does not 
support that these were distinct procedural services separate from 81342. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 88377 and G0452 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 88377 and G0452 billed for date of service December 
13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custom fabricated abutment (D6057 x 4), abutment 
supported crown (D6058 x 2), abutment supported retainer (D6068) and pontics (D6245 x 2). 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing the denial. 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 authorization A0230410141314. 
Therefore, we decided that the Plan does not have to pre-approve custom fabricated abutment (D6057 x 4), 
abutment supported crown (D6058 x 2), abutment supported retainer (D6068) and pontics (D6245 x 2).