Persius/hicric huggingface dataset:
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 is failing at a lower level of care and 
requires daily medical monitoring. The Plan denied your request. The Plan says the enrollee does not meet the 
requirements for an IRF admission. 
 
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 enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. There is not a reasonable expectation that this enrollee will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. 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 pay for a diagnostic consultation (D9310) provided on February 15, 
2023. 
 
You asked the Plan to pay for a diagnostic consultation (D9310). You say that you feel this fee should be paid. 
The Plan denied your request. The Plan says this service is not a covered expense under your dental plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a 
diagnostic consultation (D9310) provided on February 15, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81479 provided on February 2, 2021. 
 
You asked the Plan to pay for procedure code 81479. 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 81479 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 81479 
provided on February 2, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an evaluation of wheezing provided on December 13, 2022. 
 You asked the Plan to pay for the evaluation. You say that the enrollee was not on hospice on this date. 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 an evaluation of wheezing provided on December 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the periodic oral evaluation (D0120), 
intraoral-periapical first radiographic image (D0220), intraoral-periapical additional radiographic image 
(D0230), bitewing x-rays-four radiographic images (D0274), and the dental cleaning (D1110) provided on 
March 23, 2023. 
 
You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's 
denial for payment. 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 20% 
coinsurance for preventive and comprehensive dental services rendered by an out-of-network provider.  
 
You have been asked to pay $57.60 (Plans allowed amount of $288 x 20% coinsurance) for the preventive and 
comprehensive dental services rendered by an out-of-network provider. 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 coinsurance for the periodic oral evaluation (D0120), intraoral-periapical first radiographic image (D0220), 
intraoral-periapical additional radiographic image (D0230), bitewing x-rays-four radiographic images (D0274), 
and the dental cleaning (D1110) provided on March 23, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hearing aids (V5253) provided on February 13, 2023. 
 
You asked the Plan to pay for hearing aids (V5253). You say that you are requesting reimbursement for hearing 
aids purchased on February 13, 2023. The Plan denied your request. The Plan says they have researched your 
case information and did find a contact to the Plan in reference to reimbursement for hearing aids, however the 
records confirm that you called after you already purchased the hearing aids. 
 
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 through the Plan vendor.  
 
 
  We looked at the file, and the Plan's rules. The Plan rules state that coverage will not be provided for hearing 
aids purchased from a non-participating provider. The record shows that the hearing aids were purchased from 
a non-Plan vendor. The record also shows that contact was not made with the Plan until after the hearing aids 
had been purchased. Based on this information, we decided that the Plan's rules for coverage of hearing aids 
(V5253) have not been met. Therefore, we decided that the Plan does not have to pay for hearing aids (V5253) 
provided on February 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete upper denture (D5110) and a complete lower 
denture (D5120) provided on February 22, 2023. 
 
You asked the Plan to pay for the dental services. You say that the provider pulled up a benefit sheet and it said 
you were covered 1 procedure per calendar year for $2,500. The Plan denied your request. The Plan says the 
denial of payment for these services is correct because the complete upper denture and the complete lower 
denture are not covered by the Plan. Also, it was verified that you were given the proper benefits along with a 
copy of the proper benefit sheet prior to the date of 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 pay for a 
complete upper denture (D5110) and a complete lower denture (D5120) provided on February 22, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the complete upper denture (D5110) 
provided on February 22, 2023. 
 
You asked the Plan to waive the coinsurance for this dental item. You say that you are requesting a 
reconsideration of the Plan's denial for payment. 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 50% 
coinsurance for a complete upper denture. 
 
You have been asked to pay $350 (Plans allowed amount of $700 x 50% coinsurance) for the complete upper 
denture provided.   
 
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 coinsurance for the complete upper denture (D5110) provided on  
February 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99203 billed for date of service January 5, 
2022.  
 You asked the Plan to pay for procedure code 99203. You say that you would like the Plan to reconsider their 
denial of payment. 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 cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 99203 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 99203 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 99203 billed for date of service January 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vision supply provided on March 16, 2023.  
You asked the Plan to pay for the vision supply . You say that the optometrist checked your insurance and that 
at least the frames would be covered. The Plan denied your request. The Plan says the service is not a covered 
benefit. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan only covers a routine eye exam every 12 months. 
 
We looked at the file and the Plan's rules. Specifically, eyewear is not a supplemental covered benefit. Based 
on this information, we decided that the Plan's rules for coverage of the vision supply have not been met. 
Therefore, we decided that the Plan does not have to pay for the vision supply provided on March 16, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of an implantable loop recorder (ILR) (33285). 
 You asked the Plan to pre-approve insertion of an ILR. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that cardiac event monitors are covered when specific 
criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve insertion of an ILR. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found a recent randomized clinical trial 
found that continuous monitoring for atrial fibrillation with an ILR (followed by treatment with oral 
anticoagulation if atrial fibrillation was detected) was not superior to usual care in reducing stroke or systemic 
embolism among patients at high risk of stroke but without a known prior history of atrial fibrillation. At this 
time, insertion of an ILR would not be considered medically appropriate and necessary in this enrollees 
clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of insertion of an ILR have not been met. Therefore, we decided that the Plan does 
not have to pre-approve insertion of an implantable loop recorder (ILR) (33285).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on March 
21, 2023. 
 
You asked the Plan to pay for the dental service. You say that you needed a second opinion and the provider 
needed to do the exam. 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 comprehensive oral examination on January 25, 2023; therefore, your benefit for the 
requested item or service was exhausted on the date of service of January 25, 2023. Therefore, we decided that 
the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on March 21, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the guided tissue regeneration (D4266) provided on 
December 29, 2022. 
 
You asked the Plan to pay for the dental services. You say that this is a covered benefit once per lifetime. The 
Plan denied your request. The Plan says this service is not a covered benefit under your dental plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
guided tissue regeneration (D4266) provided on December 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on August 1, 2022. 
 
You asked the Plan to pay for the dental services. You say that these services should be covered. The Plan 
denied your request. The Plan says your annual dental allowance maximum amount of $1,250 was exhausted 
on the date of service in question. 
 
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 August 1, 2022. 
Therefore, we decided that the Plan does not have to pay for the remaining dental services provided on August 
1, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided from March 22, 2023, to 
March 23, 2023. 
 
You asked the Plan to pay for the medication. You say that you were admitted to the hospital and any drugs 
given were under the direction of the doctors. The Plan denied your request. The Plan says the medication is 
not covered as a medical benefit under the Plan. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs provided 
from March 22, 2023, to March 23, 2023.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve partial mastectomy. 
 
You asked the Plan to pre-approve partial mastectomy. You say that the services are necessary. The Plan 
denied your request. The Plan says that medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 mastectomy. Our reviewer says 
that the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the record provided establishes the medical necessity and reasonableness, as defined by 
Medicare rules, of the requested service. The elements of the coverage criteria are satisfied. The requested 
service is recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of partial mastectomy have been met. Therefore, we decided that the Plan has to 
pre-approve partial mastectomy.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drugs or medicaments dispensed in the office for home 
use (D9630 x 2), periodontal scaling and root planing-one to three teeth per quadrant (D4342 x 4), bitewing x-
rays-four radiographic images (D0274), periodontal scaling and root planing-four or more teeth per quadrant 
(D4341 x 4), lower partial denture (D5212), upper partial denture (D5211), and the gingival irrigation-per 
quadrant (D4921 x 4) provided on January 19, 2023.   
 
 
  
 
 
 
You asked the Plan to pay for the dental items/services. You say that you are requesting a reconsideration of 
the Plan's denial for payment. The Plan denied your request. The Plan says the dental items/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 items/services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, dental items/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 drugs or medicaments dispensed in the office for home use (D9630 x 2), periodontal scaling and root 
planing-one to three teeth per quadrant (D4342 x 4), bitewing x-rays-four radiographic images (D0274), 
periodontal scaling and root planing-four or more teeth per quadrant (D4341 x 4), lower partial denture 
(D5212), upper partial denture (D5211), and gingival irrigation-per quadrant (D4921 x 4) provided on  
January 19, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cone beam (D0364) provided on March 3, 2023. 
 
You asked the Plan to pay for the dental service. You say that it was medically necessary for the dentist to do 
the imaging to identify what tooth was causing pain. The Plan denied your request. The Plan says the denial of 
payment for this service is correct, because the cone beam 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 pay for a cone 
beam (D0364) provided on March 3, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on November 10, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that a separate 
ambulance for the same date of service from a second call did pay. You also say that the claim that paid is a 
separate claim number from this reconsideration. The Plan denied your request. The Plan says these services 
are not a covered benefit.  
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on November 10, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on November 10, 2022.