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

 
We decided that the Plan does not have to pre-approve porcelain or ceramic retainer crowns (D6740), ceramic 
or porcelain pontics (D6245), a mandibular implant or abutment (D6115), semi-precision abutment placements 
(D6191), semi-precision abutment placements (D6192), and a mandibular implant or abutment supported 
removable denture. 
 
  You asked the Plan to pre-approve porcelain or ceramic retainer crowns (D6740), ceramic or porcelain pontics 
(D6245), a mandibular implant or abutment (D6115), semi-precision abutment placements (D6191), semi-
precision abutment placements (D6192), and a mandibular implant or abutment supported removable denture. 
You say that you say that you spoke with two representatives at the Plan, and both suggested that due to your 
circumstances, your company might consider using your $2,000 dental coverage in conjunction with your 
Medicare to help you get this done. 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 pre-approve 
porcelain or ceramic retainer crowns (D6740), ceramic or porcelain pontics (D6245), a mandibular implant or 
abutment (D6115), semi-precision abutment placements (D6191), semi-precision abutment placements 
(D6192), and a mandibular implant or abutment supported removable denture.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each IV therapy service provided on June 
23, 2023, to June 29, 2023. 
 
You asked the Plan to waive the copayment for each IV therapy service. You say that you say that the services 
were medically necessary. 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 $300 
copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and 
ambulatory surgical centers. 
 
You have been asked to pay a $300 copayment for each IV therapy service. This item/service falls within the outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical 
centers 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. 
The total you owe is $2,100 ($300 copayment x 7 visits = $2,100). Therefore, we decided that the Plan does not 
have to waive the copayment for each IV therapy service provided on June 23, 2023, to June 29, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs this level of care. The Plan denied 
your request. The Plan says the enrollees medical condition does not require IRF services, and care can be 
provided in another setting.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's medical, rehabilitation, and nursing needs does not 
require IRF care with an interdisciplinary approach to rehabilitative care. While the medical records support a 
need for physical or occupational therapy, there is no documented need for intensive rehabilitation services. 
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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the second deep sedation/general anesthesia for each 
subsequent 15 minute increment. 
 
You asked the Plan to pre-approve the second deep sedation/general anesthesia for each subsequent 15 minute 
increment. You say that you are appealing with supporting records. The Plan denied your request. The Plan 
says according to what is indicated, the first 15 minutes are covered, and a single additional increment of 15 
minutes for a maximum of 30 minutes. The Plan also says that for this reason, the additional increase of 15 
minutes was denied. 
 
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 the 
second deep sedation/general anesthesia for each subsequent 15 minute increment.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gauze provided on May 04, 2023. 
 
You asked the Plan to pay for gauze. 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 gauze provided on May 
04, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intracept procedure. 
 
You asked the Plan to pre-approve the intracept procedure. You say that the enrollee has tried and failed 
conservative treatments without relief. You say that the intracept procedure is medically reasonable and 
necessary to treat the enrollee's chronic low back pain. The Plan denied your request. The Plan says the 
intracept procedure is considered investigational and 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 the intracept procedure. Our reviewer 
says that the intracept procedure is not medically necessary. Our physician reviewer found that there is no 
magnetic resonance imaging (MRI) showing only modic changes without facet degenerative disease or 
stenosis. Also, the cause of pain is not clear. Therefore, the request is not medically reasonable and 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 the intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the intracept procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on June 13, 2023. 
 
You asked the Plan to pay for the office visit. You say that you are requesting reconsideration of the denied 
claim. 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 provided 
on June 13, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for in-network diagnostic eye testing provided 
on March 22, 2023. 
 
You asked the Plan to waive the deductible for eye testing. You say that you don't understand why the Plan 
didn't cover more. 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. Your 
contract with the Plan says that there is a $1500 deductible which applies to outpatient diagnostic tests and 
related services and supplies. You have been asked to pay $164 towards this deductible. 
 
The item or service you asked the Plan to waive the deductible for falls within the outpatient diagnostic tests 
and related services and supplies benefit category. The Plan has followed Medicare rules by clearly disclosing 
in the contract that there is a $1500 deductible which applies to outpatient diagnostic tests and related services 
and supplies. This cost sharing is a contractual obligation that had not been met at the time eye testing was 
received on March 22, 2023. Therefore, we decided that the Plan does not have to waive the deductible for in-
network diagnostic eye testing provided on March 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 0391U provided on August 8, 2023. 
 
You asked the Plan to pay for procedure code 0391U. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the claim for this molecular pathology testing 
did not include the required unique identifier. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of procedure code 0391U 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 0391U 
provided on August 8, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a deductible in-network psychological 
visits provided on June 12, 2023, and August 3, 2023. 
 
You asked the Plan to waive the copayment for a deductible psychological visits. You say that you thought this 
would be covered in full. 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. Your 
contract with the Plan says that there is a $750 deductible which applies to Physician/Practitioner services, 
including doctor's office visits.  
 
You have been asked to pay $245.86 towards the $750 deductible for 2023.   
 
The item or service you asked the Plan to waive the copayment for a deductible falls within the 
Physician/Practitioner services, including doctor's office visits benefit category. The Plan has followed 
Medicare rules by clearly disclosing in the contract that there is a $750 deductible which applies to 
Physician/Practitioner services, including doctor's office visits.  This cost sharing is a contractual obligation that had not been met at the time psychological visits was received 
on June 12, 2023, to August 3, 2023. Therefore, we decided that the Plan does not have to waive the copayment 
for a deductible in-network psychological visits provided on June 12, 2023, and August 3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a respiratory syncytial virus (RSV) vaccine. 
 
You asked the Plan to pre-approve an RSV vaccine. You say that the services are necessary. The Plan denied 
your request. The Plan says the requested services are not covered. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide an RSV vaccine. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to an RSV vaccine. 
Therefore, we decided that the Plan does not have to pre-approve a respiratory syncytial virus (RSV) vaccine.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for x-rays, laryngoscopy and an office visit on 
May 22, 2023. 
 
You asked the Plan to waive the copayment for x-rays, laryngoscopy and an office visit. You say that you want 
to appeal the amount being charged. 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 $30 
copayment for provider and professional services at a specialist's office. You must pay a $30 copayment for 
diagnostic procedures and tests at a specialist's office. The provider billed in the amount of $118 and the 
allowed amount is $29.58. This is less than the copayment amount. There were four services done (4 x $30 = 
$120). For all services it's, $120 + $29.58 = $149.58. Therefore, results in the total cost sharing amount of 
$149.58. 
 
You have been asked to pay a $30 copayment for each x-rays, laryngoscopy and a $29.58 copayment which is 
less than the copayment for office visit. This item/service falls within the outpatient diagnostic tests and 
therapeutic services and supplies 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 x-
rays, laryngoscopy and an office visit on May 22, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for lab testing provided on July 10, 2023. 
 
You asked the Plan to waive the copayment for lab testing. You say that you thought the lab work would be 
100% covered. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $40 copayment for lab testing. This item/service falls within the outpatient 
diagnostic tests and therapeutic services and supplies 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. However, since the allowed amount is less than the standard copayment, you only owe $27.85. Therefore, we decided that the Plan does not have to waive the copayment 
for lab testing provided on July 10, 2023.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes 11606, 13121, and 13122 provided on December 21, 
2022. 
 
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 that the denied codes cannot be reimbursed. 
 
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 
the denied codes is: 
 
CPT 11606: 
 
Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter over 4.0 cm 
 
CPT 13121: 
 
Repair, complex, scalp, arms, and/or legs; 2.6 cm to 7.5 cm 
 
CPT 13122: 
 
Repair, complex, scalp, arms, and/or legs; each additional 5 cm or less (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 supported by the medical records. Our reviewer found that in terms of CPT 11606, the procedure 
report describes excision of melanoma right upper arm; therefore, this procedure should be covered, as 
complex repair was supported in the operative report, which is separately reported. 
 
In terms of CPT 13121 and 13122, the documentation supports complex closure. Undermining to create flap 
for closure would not be reported with adjacent tissue transfer. A complex wound repair code includes the 
repair of a wound requiring more than a layered closure (e.g., scar revision or debridement), extensive 
undermining, stents, or retention sutures. It may also include debridement and repair of complicated lacerations 
or avulsions. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
procedure codes 11606, 13121, and 13122 provided on December 21, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient surgery provided on April 
05, 2022, to April 14, 2022. 
 
You asked the Plan to waive the copayment for the outpatient surgery. You say that you say that you are not 
willing to pay any more money. 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 outpatient surgery and other medical services provided at hospital outpatient facilities and 
ambulatory surgical centers.  
You have been asked to pay a $250 copayment for the outpatient surgery. This item/service falls within the 
outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical 
centers 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 the outpatient surgery provided 
on April 05, 2022, to April 14, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee will clearly benefit from acute 
rehabilitation to optimize their level of functioning prior to returning home. The Plan denied your request. The 
Plan says the enrollee does not meet Medicare guidelines for services in an inpatient rehabilitation facility.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical conditions appear improved on stable medications with no issues that appear to require a physician's 
evaluation three or more times per week in a hospital setting. The enrollee does require physical therapy and 
occupational therapy services, but the medical records provided do not clarify why they require an intensive 
inpatient rehabilitation therapy program. Provided medical records do not support that the intensive inpatient 
rehabilitation therapy program is necessary and that therapy at a lower level of care such as in a skilled nursing 
facility is not appropriate for the enrollee. The enrollee would be expected to participate in and benefit from the 
intensive rehabilitation therapy program provided in an inpatient rehabilitation facility; however, the medical 
records do not support a complexity of needs to require an acute inpatient rehabilitation facility over a skilled 
nursing facility.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.