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

 
We decided that the Plan does not have to pay for lab testing provided on June 05, 2023. 
 
You asked the Plan to pay for lab testing. You say that you are requesting reconsideration stating you were 
unable to obtain prior authorization as you are not a contracted provider. 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 lab testing provided on 
June 05, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve clinical crown lengthening  hard tissue tooth #'s 2 and 
16 (D4249). 
 
You asked the Plan to pre-approve the clinical crown lengthening. You say that these services are required by 
your doctor in order to have 2 crowns made. You also say that you are asking for consideration so that the 
service can be covered. The Plan denied your request. The Plan says this service is not included in your dental 
plan coverage. 
 
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 
clinical crown lengthening  hard tissue tooth #'s 2 and 16 (D4249).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve an office visit. You say that you do not trust other providers with your 
issues, just this one. The Plan denied your request. The Plan says there are other providers available who are in-
network, who are within the Medicare allowable distance from your residence. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve guided tissue regeneration, an alveoloplasty, and bone 
replacement graft (D7953, D4266, D7311, D7310). 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they do 
not fall within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, 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 
guided tissue regeneration, an alveoloplasty, and bone replacement graft (D7953, D4266, D7311, D7310).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on August 2, 2022, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the office visit. You say that the care provided was urgent. The Plan denied your 
request. The Plan says you must receive your 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 item/service at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for this item/service. Therefore, 
we decided that the Plan does not have to pay for the office visit provided on August 2, 2022, by an out-of-
network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the ultrasonic guidance for placement of radiation 
therapy to be provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve the ultrasonic guidance. You say that this service is medically necessary. 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the item/service at issue in this appeal. We found no exception that would require 
the Plan to pre-approve this item/service. Therefore, we decided that the Plan does not have to pre-approve the 
ultrasonic guidance for placement of radiation therapy to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve kyphoplasty at T12 (22513). 
 
You asked the Plan to pre-approve kyphoplasty at T12. You say that the services are necessary. The Plan 
denied your request. The Plan says that based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan follows Medicare rules. Medicare rules say that percutaneous vertebroplasty and percutaneous 
vertebral augmentation (PVA or Kyphoplasty) procedures will be considered medically reasonable and 
necessary for certain indications. 
 
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 kyphoplasty at T12. Our reviewer says 
that the services are medically necessary. Our physician reviewer found detailed documentation is not evident 
regarding the worsening of pain. Additionally, there is no documentation of a progression of the body height 
loss, greater than 25% vertebral body height loss, kyphotic deformity, or a severe impact on daily activities. 
Moreover, there is magnetic resonance imaging (MRI) corroboration of other plausible causes of pain. 
Therefore, the enrollee does not meet the coverage criteria detailed in the LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of kyphoplasty at T12 have been met. Therefore, we decided that the Plan has to 
pre-approve kyphoplasty at T12 (22513).  
 
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 pay for an office visit provided on December 22, 2022. 
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration for the services 
provided. 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 an office visit provided 
on December 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional one-way trips. 
 
You asked the Plan to pre-approve additional one-way trips. You say that you have no other way to get to your 
appointments for dialysis. The Plan denied your request. The Plan says this benefit has been exhausted. 
 
  Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 48 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional one-way trips.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the radiation therapy services provided 
from September 15, 2022, to September 23, 2022. 
 
You asked the Plan to waive the coinsurance for the radiation therapy. You say that you disagree with the cost 
share. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay 20% coinsurance for Medicare-covered therapeutic radiology services.  
 
The enrollee has been asked to pay $107.76, which is 20% coinsurance of the allowed amount for each 
radiation therapy provided on September 15, 2022, September 16, 2022, September 19, 2022, September 20, 
2022, September 21, 2022, and September 22, 2022 ($530.17 allowed amount x 20% = $107.76). The record 
shows you had met your maximum out-of-pocket amount during the radiation therapy. You have only been 
asked to pay $51.08, which is less than 20 % coinsurance for the radiation therapy provided on September 23, 
2022. These items/services fall within the outpatient diagnostic tests and therapeutic services and supplies 
benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract 
with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. 
Therefore, we decided that the Plan does not have to waive the coinsurance for the radiation therapy services 
provided from September 15, 2022, to September 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on February 2, 2022. 
 
You asked the Plan to pay for dental services. You say that your claim was combined with your spouse. You 
also say you had the dentist separate your dental accounts. The Plan denied your request. The Plan says 
because they did not receive the request within 365 from the original date of service, this request for 
reimbursement was correctly denied for dental services received on February 2, 2022. 
 The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for dental services was not filed until May 12, 2023. This means that more than 
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the 
Plan does not have to pay for dental services provided on February 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a porcelain/ceramic crown (D2740) provided on March 9, 
2023. 
 
You asked the Plan to pay for the dental services. You say that you are appealing with supporting records. 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 9, 2023, and May 
4, 2023. Specifically, your $500 maximum allowable benefit of $500 has been reached. Therefore, we decided 
that the Plan does not have to pay for a porcelain/ceramic crown (D2740) provided on March 9, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a retainer crown (D6750) for tooth number 13 and tooth 
number 15 and a porcelain pontic (D6240) for tooth number 14 provided on May 15, 2023. 
 
You asked the Plan to pay for a retainer crown (D6750) for tooth number 13 and tooth number 15 and a 
porcelain pontic (D6240) for tooth number 14. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says these services are not covered under this 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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a retainer 
crown (D6750) for tooth number 13 and tooth number 15 and a porcelain pontic (D6240) for tooth number 14 
provided on May 15, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a crown - porcelain/ceramic (D2740 x2), core buildup, 
including any pins when required (D2950 x2) provided on April 27, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you are requesting reconsideration and 
have submitted the needed x-rays and clinical narrative. The Plan denied your request. The Plan says your 
benefit for the requested services $4,000 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 dental services has been exhausted. The Plan has provided evidence of having made 
payments totaling $4,000 towards the cost of dental services provided in 2023.  This included a partial payment of $788 towards the appealed claim. Since your annual maximum has been 
satisfied no additional payment will be make towards the appealed services. Therefore, we decided that the 
Plan does not have to pay more for a crown - porcelain/ceramic (D2740 x2), core buildup, including any pins 
when required (D2950 x2) provided on April 27, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6532. 
 
You asked the Plan to pre-approve the compression stockings. You say that you would like to request 
reconsideration of the denied claim and that the services requested are medically necessary. The Plan denied 
your request. The Plan says there is no qualifying wound and the items you are requesting do not meet the 
requirements for approval. 
 
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6532 
are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that 
compression bandages and gradient compression wraps are covered only when they are used as dressings over 
a qualifying wound. 
 
The record does not show that the enrollee has open venous stasis ulcers or a qualifying wound. This means 
that the enrollee does not have a medical condition for which compression stockings can be covered or paid for 
by Medicare. Therefore, we decided that the Plan does not have to pre-approve compression stockings 
identified with code A6532.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a removable unilateral partial denture  one piece 
flexible base (including retentive/clasping materials, rests, and teeth)  per quadrant tooth 30  (D5284). 
 
You asked the Plan to pre-approve the removable unilateral partial denture. You say that you need to replace 
one tooth that you lost that was an implant. You also say that you are not requesting a whole denture. The Plan 
denied your request. The Plan says this service is not covered in your dental 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 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 
removable unilateral partial denture  one piece flexible base (including retentive/clasping materials, rests, and 
teeth)  per quadrant tooth 30  (D5284).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility provided on July 21, 2023. 
 
You asked the Plan to pay for skilled nursing facility. You say that you were unaware a prior authorization was 
needed. 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 July 21, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on May 19, 2023. 
 
You asked the Plan to pay for the dental service. You say that from the Plan's published schedule examination 
and x-rays have a $0 copayment and the denial seems to be an error. 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 the Plan paid for a limited oral evaluation (D0140) on January 4, 2023; therefore, your benefit for the 
requested item or service was exhausted on the date of service of January 4, 2023. Therefore, we decided that 
the Plan does not have to pay for a limited oral evaluation (D0140) provided on May 19, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 3, 2023, billed with 
codes 87481, 87491, 87500, 87563, 87640, 87641, 87653, and 87798. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says panel testing should be billed using one 
CPT code on the claim. 
 
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. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
April 3, 2023, billed with codes 87481, 87491, 87500, 87563, 87640, 87641, 87653, and 87798.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral radiographic image (D0220), a crown (D2740) 
for tooth #27, the core buildup (D2950) for tooth #27, and a root canal (D3310) for tooth #27 provided by an 
out-of-network provider on June 8, 2023. 
 
You asked the Plan to pay for the dental services. You say that it was a medical emergency that you saw an 
out-of-network provider and you could not return home to have the work done. The Plan denied your request. 
The Plan says the dental services were received from an out-of-network provider and are not covered by your 
supplemental benefits.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for the intraoral radiographic image (D0220), a crown (D2740) for tooth #27, the core buildup (D2950) 
for tooth #27, and a root canal (D3310) for tooth #27 provided by an out-of-network provider on June 8, 2023.