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

 
We decided that the Plan does not have to pay for dental evaluation services (D0140) provided on March 8, 
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 on date of service March 1, 2023. 
Therefore, we decided that the Plan does not have to pay for dental evaluation services (D0140) provided on 
March 8, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of a subcutaneous cardiac rhythm monitor 
(33285). 
 
You asked the Plan to pre-approve insertion of a subcutaneous cardiac rhythm monitor. You say that this 
procedure is medically necessary. The Plan denied your request. The Plan says based on the clinical 
information provided, the enrollee has not had any recent syncopal episodes and ha not worn an external 
monitor.  
 
The Plan follows Medicare rules. Medicare rules say that an ILR is used when syncope is thought to be 
cardiac-related but is too infrequent to be detected by either a Holter monitor or a traditional pre-symptom 
MLR 
 
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 insertion of a subcutaneous cardiac 
rhythm monitor. Our reviewer says that the service is not medically necessary. Our physician reviewer found 
that the enrollee had no history of atrial fibrillation, nor were any significant cardiac arrhythmias noted on 
electrocardiogram (ECG) monitoring. A recent randomized clinical trial found that continuous monitoring for atrial fibrillation with an ILR (followed by treatment with oral anticoagulation if atrial fibrillation was detected) 
was not superior to usual care in reducing stroke or systemic embolism among patients at high risk of stroke 
but without a known prior history of atrial fibrillation. At this time, insertion of an ILR would not be 
considered medically appropriate and necessary in this enrollees clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of insertion of a subcutaneous cardiac rhythm monitor have not been met. 
Therefore, we decided that the Plan does not have to pre-approve insertion of a subcutaneous cardiac rhythm 
monitor (33285).
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 you are requesting an expedited 
reconsideration as the enrollee currently meets LTACH admission criteria. The Plan denied your request. The 
Plan says criteria for admission to the LTACH have not been met. 
 
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 does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. The Plan has approved ongoing care in the current acute 
care setting.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 81455 provided on January16, 2023. 
 
You asked the Plan to pay for procedure code 81455. 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. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for procedure code 81455 by a contract provider. The file does not show that the plan 
provided notice that procedure code 81455 would not be covered. Under Medicare rules, this means procedure 
code 81455 is considered approved by the plan. Therefore, we decided that the Plan has to pay for procedure 
code 81455 provided on January16, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on February 28, 2023, and March 
21, 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 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 dental services provided on February 28, 2023, and March 21, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on February 22, 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 $3,000 annual maximum 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 dental services provided on February 22, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composite-one surface, anterior (D2330), 
panoramic radiographic image (D0330), periodic oral evaluation (D0120), dental cleaning (D1110), and the 
bitewing x-rays-four radiographic images (D0274) provide on March 9, 2023. 
 
You asked the Plan to pay for these items/services. You say that you are requesting a reconsideration of the 
Plan's denial for payment.  The Plan denied your request. The Plan says these items/services provided are not a 
covered benefit.  
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The items/services you are asking the Plan to pay for involve the care, treatment, filling, removal or 
replacement of your teeth or the structures directly supporting your teeth. These are dental items/services that 
are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the resin-
based composite-one surface, anterior (D2330), panoramic radiographic image (D0330), periodic oral 
evaluation (D0120), dental cleaning (D1110), and the bitewing x-rays-four radiographic images (D0274) 
provide on March 9, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the custom fabricated abutmentincludes 
placement (D6057) and the abutment supported porcelain/ceramic crown (D6058) provided on February 24, 
2023. 
 
You asked the Plan to issue reimbursement for these dental 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 items are 
not a covered benefit.  
 
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 items provided are not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to issue reimbursement for the 
custom fabricated abutmentincludes placement (D6057) and the abutment supported porcelain/ceramic crown 
(D6058) provided on February 24, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve Keytruda. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 the 
services are not medically necessary. Our physician reviewer found the Food and Drug Administration has not 
stated that the requested drug is indicated for the enrollee's condition. The Medicare approved cancer drug 
compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. No literature from Medicare approved cancer journals were submitted for review. The elements of the 
coverage criteria are not satisfied. The requested service cannot be recommended. 
 
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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for extraction, erupted tooth requiring removal of bone and/or 
sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210) Tooth #19 and 30 
provided on December 2, 2022. 
 
You asked the Plan to pay for dental services. You say that you had six extractions and only four of them were 
covered, you feel they all should have been 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. This benefit includes simple 
extraction (non-surgical)  when performed by a DDS (Doctor of Dental Surgery). Exclusions: surgical 
extractions which are typically performed by an oral surgeon is not covered under the Plans dental benefit. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D7210 is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for extraction, 
erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal 
flap if indicated (D7210) Tooth #19 and 30 provided on December 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatment (98941) rendered by 
the out-of-network (OON) provider on December 28, 2022.  
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not payable as it was rendered 
by an out-of-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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. 
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the chiropractic manipulative treatment (98941) rendered by the out-of-network 
(OON) provider on December 28, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on October 14, 2022, to 
November 11, 2022. 
 
You asked the Plan to pay for the home health services. You say that the submitted medical records support the 
need for the home health services.  The Plan denied your request. The Plan says no provider or supplier shall 
receive payment for services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in 
the Medicare program. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for home health services provided on 
October 14, 2022, to November 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an additional unit of procedure code 99458 rendered on 
March 25, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services billed.  
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, the CPT Code Manual definition of code 99458 is "Remote physiologic monitoring treatment 
management services, clinical staff/physician/other qualified health care professional time in a calendar month 
requiring interactive communication with the patient/caregiver during the month; each additional 20 minutes 
(List separately in addition to code for primary procedure)." 
 
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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the records do not support that the 
extra unit was rendered, or medically necessary. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for an additional unit of procedure code 99458 rendered on March 25, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cone beam computed tomography (CT) image capture 
with field of view of one full dental arch (D0382), a single metal-ceramic crown restoration that is retained, 
supported and stabilized by an abutment on an implant (D6059) and bone replacement graft for ridge 
preservation, per site (D7953). 
 
You asked the Plan to pre-approve dental services. You say that you disagree with the denial and request 
reconsideration. The Plan denied your request. The Plan says the requested services are not covered by 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 
cone beam computed tomography (CT) image capture with field of view of one full dental arch (D0382), a 
single metal-ceramic crown restoration that is retained, supported and stabilized by an abutment on an implant 
(D6059) and bone replacement graft for ridge preservation, per site (D7953).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue additional reimbursement for the gym membership (S9970) 
purchased on January 1, 2022 
 
You asked the Plan to issue additional reimbursement for this service. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says you have 
exhausted the allowable benefit for this service.  
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.   
  
 
 
The Plans rules for coverage of gym benefits have not been met because you have exhausted the allowable 
benefit for this service. Specifically, the Plans contract states that reimbursement is issued up to $150 per 
calendar year towards your cost for membership in a qualified health club or fitness facility. The Plan issued 
reimbursement to you in the amount of $150 on March 3, 2023 for the gym membership purchased. Therefore, 
you have exhausted the allowable benefit for this service. Therefore, we decided that the Plan does not have to 
issue additional reimbursement for the gym membership (S9970) purchased on January 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0378 provided on December 22, 2022 to 
December 25, 2022. 
 
You asked the Plan to pay for the procedure code G0378. You say that this service was medically necessary. 
The Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
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 G0378 is not supported in the medical record. Specifically, code G0378 cannot be 
billed more than once per claim per Local Coverage Article: Billing and Coding - Outpatient Observation Bed 
and Room Services (A56673). Based on this information, we decided that Medicare rules for coverage of the 
procedure code G0378 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code G0378 provided on December 22, 2022 to December 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on January 5, 2023. 
 
You asked the Plan to pay for the dental services. You say that you didn't know the dentist was not in network.  
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 dental services provided on January 5, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for teledentistry  synchronous; real-time encounter (D9995) 
provided on March 2, 2023. 
 
You asked the Plan to pay for the teledentistry  synchronous. The Plan denied your request. The Plan says 
there is no coverage for D9995 teledentistry - synchronous, real-time encounter. 
 
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 teledentistry  synchronous; real-
time encounter are not among those covered under this benefit. Therefore, we decided that the Plan does not 
have to pay for teledentistry  synchronous; real-time encounter (D9995) provided on March 2, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic radiographic image (D0330) provided on 
March 7, 2023. 
 
You asked the Plan to pay for this dental service. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says your benefit for the service provided 
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 service provided was exhausted on date of service March 6, 2023.   
 
 
Specifically, the Plans contract states that a panoramic radiographic image or intraoral-complete series of 
radiographic images is covered once every three years. You previously received an intraoral-complete series of 
radiographic images on March 6, 2023, one day prior, which was paid for by the Plan. Therefore, you have 
exhausted the allowable benefit for this service. Therefore, we decided that the Plan does not have to pay for 
the panoramic radiographic image (D0330) provided on March 7, 2023.