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

 
We decided that the Plan does not have to pay for a nursing home visit, a chest x-ray, and the portable 
equipment setup provided on January 30, 2023, by an OON provider. 
 
You asked the Plan to pay for the nursing home visit and imaging services. You say that there was no time to 
obtain prior authorization. The Plan denied your request. The Plan says that these services were not authorized. 
 
 
 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 contract also says that the enrollees POS benefit only 
applied to dental services. 
 
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 
item/service 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 a nursing home visit, a chest x-ray, and the 
portable equipment setup provided on January 30, 2023, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services provided by an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve the dental services. You say that you like this dentist you have gone to them 
in the past and would like to go again. The Plan denied your request. The Plan says dental services from an out-
of-network provider 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. 
 
You are requesting 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 pre-approve dental 
services 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 inhalation of nitrous oxide/analgesia, anxiolysis 
(D9230), interim complete denture (maxillary) (D5810), and interim complete denture (mandibular) (D5811). 
 
You asked the Plan to pre-approve the dental services represented by codes D9230, D5810 and D5811. You 
say that this dental work is needed and the lack of dentures is a major issue in your life. You also say that you 
need dentures because you are unable to eat and it is uncomfortable. The Plan denied your request. The Plan 
says these services are not covered under the benefit package. 
 
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 
inhalation of nitrous oxide/analgesia, anxiolysis (D9230), interim complete denture (maxillary) (D5810), and 
interim complete denture (mandibular) (D5811).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve an epidural steroid injection. You say that an epidural steroid injection is 
medically necessary. The Plan denied your request. The Plan says the requested epidural steroid injection does 
not meet the Medicare LCD coverage criteria. 
 
The Plan follows Medicare rules. 
 
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 an epidural steroid injection. Our 
reviewer says that the requested epidural steroid injection is not considered medically necessary in this case. 
Our physician reviewer found that in this case, the epidural injection performed on January 31, 2023, 
immediately provided 100% relief of pain for a duration of two days. The relief then fell to 50% and has 
remained at that level. Unless the enrollee had at least 50% reduction in pain on May 1, 2023, the enrollee does 
not meet the Medicare LCD coverage criteria for a repeat ESI injection. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an epidural steroid injection.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician services provided on August 22, 2022, by an 
OON provider. 
 
You asked the Plan to pay for the physician services. You say that you are requesting reconsideration of the 
denied claim. The Plan denied your request. The Plan says that these services are not covered when received 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 physician services are not covered when received by an out-of-network provider. 
 
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 
item/service 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 physician services provided on August 22, 
2022, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and the intraoral-
complete series of radiographic images (D0210) provided on October 27, 2022. 
 
You asked the Plan to pay for these dental 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 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 dental services from an out-of-network provider. Though the Plan offers a 
dental benefit in excess of Medicare coverage, the services provided 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 comprehensive oral evaluation (D0150) and 
the intraoral-complete series of radiographic images (D0210) provided on October 27, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service December 
31, 2022. 
 You asked the Plan to pay for procedure code 70450. You say that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for code 
70496. 
 
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 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. 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 code 70450 billed for date of service December 31, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical placement of implant body: endosteal implant 
(D6010) provided on July 21, 2022. 
 
You asked the Plan to pay for dental services. You say that the original quote from the provider showed the 
billed service would be 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. Surgical placement of implant 
body: endosteal implant (D6010) is not covered under the Plans dental benefits. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D6010 is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for surgical 
placement of implant body: endosteal implant (D6010) provided on July 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance (D4910) provided on December 5, 
2022. 
 
You asked the Plan to pay for the dental services. You say that you previously had two gum grafts from this 
provider. You also say that it was recommended by the dental providers office that you have a periodontal 
cleaning once a year and two additional cleanings per year due to gum recession. 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 periodontal maintenance (D4910) provided on December 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prophylaxis - adult (D1110) provided on December 22, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial and would like the 
Plan to reconsider. 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 prophylaxis - adult (D1110) provided on December 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prophylaxis - adult (D1110), and periodic oral evaluation - 
established patient (D0120) provided on December 20, 2022. 
 
You asked the Plan to pay for the dental services. You say that you believe your policy covers two cleaning per 
year and you did not receive a notice from the Plan  that you had reached your limit. You also say that you 
would have waited 10 days and had the cleaning in January. The Plan denied your request. The Plan says your 
benefit for the prophylaxis - adult (D1110) and periodic oral evaluation $1,000 dollar limit was met at time of 
service for the 2022 Calendar year. 
 
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 prophylaxis - adult and periodic oral evaluation $1,000 dollar limit was exhausted 
on date of service December 20, 2022. Therefore, we decided that the Plan does not have to pay for 
prophylaxis - adult (D1110), and periodic oral evaluation - established patient (D0120) provided on December 
20, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service October 18, 
2022. 
 You asked the Plan to pay for procedure code 76641. You say that the member had multiple exams done on 
this date of service. The Plan denied your request. The Plan says the number of units billed exceeds the 
maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
Based on this information, we decided that Medicare rules for coverage of procedure code 76641 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 76641 billed for date of 
service October 18, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation miles. 
 
You asked the Plan to pre-approve the additional miles. You say that you have attempted to search for 
providers close to your home but there are none within 50 miles. The Plan denied your request. The Plan says 
the requested transportation in each direction has exceeded the mileage limit. 
 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 routine transportation for each one-way trip and it must not exceed 50 miles of driving 
distance per trip.  
 
We looked at the file and Medicare rules. You are requesting a trip of 62 miles. Based on this information, we 
decided that Medicare rules for coverage of the additional mileage have not been met. Therefore, we decided 
that the Plan does not have to pre-approve additional routine transportation miles.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and the intraoral 
complete series of radiographic images (D0210) provided on November 17, 2022. 
 
You asked the Plan to pay for the dental services. You say that you never heard from the provider after the 
appointment and would like the Plan to take care of the bill. The Plan denied your request. The Plan says your 
benefit for the requested items or services 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 items or services was exhausted on the date of service of March 8, 2021. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and the 
intraoral complete series of radiographic images (D0210) provided on November 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for limited oral evaluation - problem focused (D0140), intraoral 
- periapical first radiographic image (D0220) and crown - porcelain/ceramic (D2740) provided on December 
27, 2022. 
 
You asked the Plan to pay for dental services. You say that you were not told the provider was out-of-network, 
all you were told was insurance would cover approximately $300. The Plan denied your request. The Plan says 
these services are not covered under your Plan under any circumstance. 
  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. Limited oral evaluation - 
problem focused (D0140), intraoral - periapical first radiographic image (D0220) and crown - porcelain/ 
ceramic (D2740) are not covered under the Plans dental benefits. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D0140, D0220 and 
D2740 are not among those covered under this benefit under any circumstance. Therefore, we decided that the 
Plan does not have to pay for limited oral evaluation - problem focused (D0140), intraoral - periapical first 
radiographic image (D0220) and crown - porcelain/ceramic (D2740) provided on December 27, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit provided on March 12, 2021. 
 
You asked the Plan to pay for the emergency department visit. You say that the claim was filed timely. The 
Plan denied your request. The Plan says the timely filing period for both paper and electronic Medicare claims 
is 12 months, or one calendar year, after the date of service. 
 
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 the emergency department visit was not filed until December 8, 2022. 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 an emergency department visit provided on  
March 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on September 9, 2022. 
 
You asked the Plan to pay for the physician's services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says there is no authorization on file. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for physician's services provided on September 9, 2022.
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 would like to request 
reconsideration of the denied authorization. The Plan denied your request. The Plan says the inpatient 
rehabilitation facility (IRF) services you are requesting do not meet the requirements for approval. 
 
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 an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care. The enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. Medically necessary care can be provided in a different level of care.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hearing aids to be rendered by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says hearing aids from an out-of-network provider are not  
covered. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when purchased from an in-network vendor.  
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically, the hearing aids in this case were requested to be 
purchased from an out-of-network provider. Hearing aid providers must be in the designated vendors network. 
Therefore, we decided that the Plan does not have to pre-approve hearing aids to be rendered by an out-of-
network (OON) provider.