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

 
We decided that the Plan does not have to pay more for a comprehensive oral evaluation (D0150) and the 
panoramic radiographic image (D0330) provided by an out-of-network provider on February 9, 2023. 
  You asked the Plan to pay more for the dental services. You say that you have not reached your annual 
maximum and the procedure were performed on 2 different dates. The Plan denied your request. The Plan says 
you are responsible for any charged amount above the Plans cost-sharing amount when your services are 
received from an out-of-network provider.  
 
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 total amount billed for the comprehensive oral evaluation was $230 and the allowed amount was $53 
leaving a difference of $177 ($230 billed - $53 allowed). The total amount billed for the panoramic 
radiographic image was $232 and the allowed amount was $88 leaving a difference of $144 ($232 billed - $88 
allowed). The total difference amount for the dental services was $321 ($177 difference + $144 difference). 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for a comprehensive oral evaluation (D0150) 
and the panoramic radiographic image (D0330) provided by an out-of-network provider on February 9, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a CT scan of the head or brain provided on October 18, 2022. 
 You asked the Plan to pay for a CT scan of the head or brain. You say that the claim should be reprocessed. 
The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for a CT scan of the head or brain provided on October 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the core buildup (D2950) for tooth #31. 
 
You asked the Plan to pre-approve the dental service. You say that you cannot afford to pay for the core 
buildup, and it is necessary to get with the crown. The Plan denied your request. The Plan says the denial of 
authorization for this service is correct, because the core buildup is not covered by the 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 item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
core buildup (D2950) for tooth #31.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removal of torus mandibularis (D7473). 
 
You asked the Plan to pre-approve removal of torus mandibularis. You say that this should be covered. The 
Plan denied your request. The Plan says this is not a covered service. 
 
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 
removal of torus mandibularis (D7473).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary and mandibular denture 
(D5110/D5120) 
 
You asked the Plan to pre-approve the dental services. You say that you would like approval for these dentures. 
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 November 26, 2019. Therefore, we decided that the Plan does not have to pre-approve a complete maxillary and mandibular denture 
(D5110/D5120)
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6530. 
 
You asked the Plan to pre-approve the compression stockings. You say that you are requesting a 
reconsideration of the Plan's denial. The Plan denied your request. The Plan says the requested stockings are 
not a covered benefit.  
  
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6530.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve extraspinal chiropractic manipulative treatments 
(98943). 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says the requested services are not a covered benefit.  
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pre-approve extraspinal chiropractic manipulative treatments (98943).
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 we will not preauthorize a referral to a non-Plan vendor for 
hearing services and utilization of a hearing aid allowance. 
 
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 at issue in this appeal. We found no exception that would require the Plan 
to pre-approve these items. Therefore, we decided that the Plan does not have to pre-approve hearing aids to be 
rendered by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Favorable

 
We decided that the Plan has to pre-approve partial hospitalization program. 
 
You asked the Plan to pre-approve partial hospitalization program. You say that the main purpose is to avoid 
deterioration of symptoms and in turn, avoid an acute hospitalization. The Plan denied your request. The Plan 
says that currently, the patient does not present acute symptoms or psychosocial factors that represent imminent 
or potential imminent risk to her, others, or her property. Documented clinical findings do not justify the level 
of care requested  
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve partial hospitalization program. Our 
reviewer says that the requested partial hospitalization program is considered medically reasonable and 
necessary in this case. Our physician reviewer found that based upon review the records provided, this enrollee 
was not showing any dangerousness to self or others although she has been exhibiting severe psychological or 
psychiatric impairment including feelings of sadness, emptiness, hopelessness and thoughts of death, 
discouragement, low self-esteem, social isolation, alterations in sleep pattern, difficulty concentrating, frequent 
forgetfulness, thought blocking. It did appear medically necessary and reasonable to have psychiatric care 
provided at the partial hospitalization level of care rather than a lower level of care as she has shown depressive 
symptomatology as well as hopelessness and thoughts of death. This enrollee did appear to require partial 
hospitalization treatment. The enrollee was showing any severity of psychological or psychiatric illness. Based 
upon review the records provided, this enrollee does meet the criteria for treatment at partial hospitalization 
level of care and could not have been treated in a lesser restrictive setting as she was showing hopelessness, 
despair, thoughts of death. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of partial hospitalization program  have been met. Therefore, we decided that the 
Plan has to pre-approve partial hospitalization program.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an MRI of the lower extremity. 
 
You asked the Plan to pre-approve an MRI of the lower extremity. You say that you are having trouble with 
walking, and you feel cracking in your ankle each time you stand up. The Plan denied your request. The Plan 
says an MRI of the lower extremity is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an MRI of the lower extremity. Our 
reviewer says that an MRI of the lower extremity is not medically necessary. Our physician reviewer found that 
you have been diagnosed with left peroneal tendinitis for which plain films have been negative. While the plan 
was for a 6-week course and then a reevaluation you only went to 3 sessions. Although the last podiatry visit 
was before the commencement of the incomplete physical therapy program on April 19, 2023, the notes do not 
show any completion of the prescribed therapy. Therefore, the medical necessity of the requested MRI of the 
left ankle and foot has not been established in the submitted records. 
 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 MRI of the lower extremity have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an MRI of the lower extremity.
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 you are requesting reconsideration for the denial of 
an IRF admission. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria 
for admission to an IRF. 
 
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. While the 
medical record supports 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee suffers from a medically complex case 
requiring the level of care that can only be provided at an IRF. You also say this combination of conditions 
makes care at a skilled nursing facility inappropriate. The Plan denied your request. The Plan says the enrollee 
does not meet Medicare guidelines for services in an IRF.  
 
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 that the complexity of the enrollee's nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical 
therapy and/or occupational therapy, there is no documented need for intensive rehabilitation services. 
Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that 
the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. 
 
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 an IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation. 
 
You asked the Plan to pre-approve radiofrequency ablation. You say that sacral lateral branch radiofrequency 
ablation has an established success rate in patients with pain originating from the sacroiliac joint complex.  The 
Plan denied your request. The Plan says radiofrequency ablation is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve radiofrequency ablation. Our reviewer 
says that that the requested radiofrequency ablation is not medically necessary. Our physician reviewer found 
that the enrollee is diagnosed with sacroiliitis. Although the provider is requesting coverage for the enrollee to 
undergo a sacroiliac joint radiofrequency ablation procedure, the clinical value and effectiveness of 
radiofrequency ablation to the sacroiliac joint in the setting of sacroiliitis have not been demonstrated. Also, the 
use of radiofrequency ablation for pain management related to sacroiliitis has not been shown to provide a clear 
long-term benefit over standard treatment for chronic sacroiliac joint pain. Therefore, the radiofrequency 
ablation not considered 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 radiofrequency ablation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve radiofrequency ablation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on February 3, 2023. 
 
You asked the Plan to pay for the dental services. You say that your provider is cheating you. 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 January 21, 2021. 
Therefore, we decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on 
February 3, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the myocardial perfusion imaging provided 
on November 2, 2022. 
 
You asked the Plan to waive the copayment for the myocardial perfusion imaging. You say that you were 
unaware you had a 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). Your contract with the Plan clearly says that you must pay a $200 
copayment for diagnostic and nuclear medicine radiological services.  

You have been asked to pay a $200 copayment for the myocardial perfusion imaging. 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 the myocardial perfusion imaging provided on November 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93042 billed for February 10, 2023, to 
February 11, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 93042 is not supported. 
 
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 93042 is rhythm ECG, 1-3 leads; interpretation and 
report only. 
 
We find that CPT code 93042 is not supported in the medical record. Specifically, there is no documentation of 
an interpretation and report of a rhythm ECG with 1-3 leads. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 93042 billed for February 10, 2023, to February 11, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve myocardial perfusion imaging/Single-Photon Emission 
Computerized Tomography (SPECT) (78452), Thallium (A9505), Technetium (A9502), injection, regadenoson 
(J2785). 
 
You asked the Plan to pre-approve myocardial perfusion imaging/Single-Photon Emission Computerized 
Tomography (SPECT), Thallium, Technetium, injection, regadenoson. You say that this is medically 
necessary. The Plan denied your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve myocardial perfusion imaging/Single-
Photon Emission Computerized Tomography (SPECT), Thallium, Technetium, injection, regadenoson. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there is no documentation that the ECG shows an uninterpretable pattern or 
that the enrollee is unable to exercise. There is no evidence provided that would support the need for 
radionuclide stress testing at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of myocardial perfusion imaging/Single-Photon Emission Computerized 
Tomography (SPECT), Thallium, Technetium, injection, regadenoson have not been met. Therefore, we 
decided that the Plan does not have to pre-approve myocardial perfusion imaging/Single-Photon Emission 
Computerized Tomography (SPECT) (78452), Thallium (A9505), Technetium (A9502), injection, regadenoson 
(J2785).