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

 
We decided that the Plan does not have to pay for a panoramic radiographic image (D0330), and gingival 
irrigation  per quadrant (D4921) provided on March 15, 2023. 
 
You asked the Plan to pay for the panoramic radiographic image and gingival irrigation  per quadrant. The 
Plan denied your request. The Plan says your benefit for the panoramic radiographic image has already been 
exhausted. The Plan also says that gingival irrigation  per quadrant is 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, certain limitations apply. The record 
shows your benefit for the panoramic radiographic image was exhausted on date of service March 15, 2023 as 
you received an additional frequency of full mouth panoramic x-rays (D0210) on the appealed claim.  
Therefore, we decided that the Plan does not have to pay for a panoramic radiographic image (D0330) provided 
on March 15, 2023.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the gingival irrigation  per quadrant is 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
gingival irrigation  per quadrant provided on March 15, 2023 
 
Your complaint about your dissatisfaction with the provider is not a valid appeal for medical coverage. This 
part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility provided on January 01, 2023, to 
January 02, 2023. 
 
You asked the Plan to pay for skilled nursing facility. You say that you would like a 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 skilled nursing facility 
provided on January 01, 2023, to January 02, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical placement of the implant body (D6010) and the 
radiographic/surgical implant index (D6190) provided on April 6, 2023. 
 
You asked the Plan to pay for the dental services. You say that the providers office verified your coverage at 
the appointment and when you checked your policy it stated implants were covered with a 50% coinsurance. 
The Plan denied your request. The Plan says the denial of payment for these services is correct because services 
related to implants including implant removal, repair, restoration or placement are not covered by the Plan. 
Also, it was verified that there was no contact with the Plan prior to or on the date of service to verify benefits. Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
surgical placement of the implant body (D6010) and the radiographic/surgical implant index (D6190) provided 
on April 6, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing provided on February 17, 2023. 
 
You asked the Plan to pay for the panel testing. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that a test panel is a single test with multiple 
components and is characterized by a single unit of service (UOS =1). A panel cannot be unbundled and billed 
as individual components regardless of the fact that the test reports multiple individual pathogens and/or 
targets.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the panel testing have not been met. Specifically, the service at issue is a test panel which was unbundled and billed as individual components. Therefore, we decided that the Plan does not have to pay for 
the panel testing provided on February 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the panoramic radiographic image (D0330), a cleaning 
(D1110), and to pay for the full mouth debridement (D4355) provided by an out-of-network provider on 
February 16, 2023, and March 14, 2023. 
 
You asked the Plan to pay more for the dental services. You say that there are no in-network dental providers, 
and you would like the Plan to cover the full amount. 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. The full mouth debridement is not covered by the Plan. Also, it was verified 
that there is many in-network provider within your service area. 
 
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. For the panoramic radiographic image the total amount billed was $127 and the total allowed amount was $59 
leaving a difference of $68 ($127 billed - $59 allowed). The total billed amount for the cleaning was $120 and 
the total allowed amount was $40 leaving a difference of $80 ($120 billed - $40 allowed). The total difference 
amount for both dental services was $148 ($68 difference + $80 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. The full 
mouth debridement is not covered under the Plans dental benefit. Therefore, we decided that the Plan does not 
have to pay more for the panoramic radiographic image (D0330), a cleaning (D1110), and to pay for the full 
mouth debridement (D4355) provided by an out-of-network provider on February 16, 2023, and March 14, 
2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services billed with diagnosis codes R52 and 
G89.29 provided on March 2, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 The Plan must follow Medicare rules. The rules say that health plans, physicians, hospitals, and other health 
care providers must comply with the Official International Classification of Disease, 10th Edition, Clinical 
Modification (ICD-10-CM) Coding Guidelines. 
 
We looked at the file and Medicare rules. In this case, coding guidelines state that a type 1 Excludes note is a 
pure excludes note. It means "Not Coded Here!" An Excludes1 note indicates that the code excluded should 
never be used at the same time as the code above the Excludes1 note. An Excludes1 is used when two 
conditions cannot occur together, such as a congenital form versus an acquired form of the same condition. 
Diagnosis codes R52 and G8.29 should not be reported together. Therefore, we decided that the Plan does not 
have to pay for the laboratory services billed with diagnosis codes R52 and G89.29 provided on March 2, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on March 8, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that the services should be covered. The Plan 
denied your request. The Plan says there was insufficient documentation submitted. 
 
The Plan must follow Medicare rules. Medicare rules say that, upon request, the entity that submitted the claim 
(e.g., the laboratory) must provide documentation of the order for the service billed as well as diagnostic or 
other medical information that the entity received from the ordering physician. If a laboratory bills for a 
diagnostic laboratory test and documentation to support the medical necessity of the test is not submitted, the 
claim is denied.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay 
for the laboratory services provided on March 8, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the external defibrillator (k0606). 
 
You asked the Plan to pay for the external defibrillator. You say that the item should be covered. The Plan 
denied your request. The Plan says the claim was filed untimely. 
 
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 external defibrillator was not filed until September 19, 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 the external defibrillator (k0606).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit provided on April 3, 2023, by an OON 
provider.  
 
You asked the Plan to pay for the home visit. You say that you are appealing with supporting documentation. 
The Plan denied your request. The Plan says this service was 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 Plan's POS benefit only applies to limited covered services 
in Puerto Rico. 
 
The records show you are 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 home visit provided on April 3, 2023, by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the eighteen indwelling catheters (A4338). 
 
You asked the Plan to pre-approve the eighteen indwelling catheters. You say that the items are medically 
necessary. The Plan denied your request. The Plan says the health plan has approved 12 catheters for 180 days 
based on the physicians documented rationale for catheter change every two weeks. There is no 
documentation of medical necessity for a total of 30 catheters for 180 days. 
 
The Plan must follow Medicare rules. Medicare rules say that no more than one catheter per month is covered 
for routine catheter maintenance. Non-routine catheter changes are covered when documentation substantiates 
medical necessity, such as for the following indications: 
1. Catheter is accidentally removed (e.g., pulled out by beneficiary) 
2. Malfunction of catheter (e.g., balloon does not stay inflated, hole in catheter) 
3. Catheter is obstructed by encrustation, mucous plug, or blood clot 4. History of recurrent obstruction or urinary tract infection for which it has been established that an acute 
event is prevented by a scheduled change frequency of more than once per month. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the eighteen indwelling catheters have not been met. Specifically, the Plan already approved 
twelve catheters, an additional eighteen is not medically necessary. Therefore, we decided that the Plan does 
not have to pre-approve the eighteen indwelling catheters (A4338).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve C5-C6 anterior cervical discectomy and fusion (ACDF) 
procedure (22551, 22845, 22853). 
 
You asked the Plan to pre-approve C5-C6 anterior cervical discectomy and fusion (ACDF) procedure. You say 
that this is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet 
criteria. 
 
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 C5-C6 anterior cervical discectomy and 
fusion (ACDF) procedure. 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 recent imaging study showing 
specific neural impingement that matches physical exam.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of C5-C6 anterior cervical discectomy and fusion (ACDF) procedure have not 
been met. Therefore, we decided that the Plan does not have to pre-approve C5-C6 anterior cervical discectomy 
and fusion (ACDF) procedure (22551, 22845, 22853).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a chemotherapy drug injection provided on 
November 15, 2022.  
 
You asked the Plan to reduce the copayment for a chemotherapy drug injection. You say that you feel the cost 
share should be reduced because the current cost is too much. 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 20% 
coinsurance for Medicare Part B chemotherapy prescription drugs.  You have been asked to pay $1,781.96 for chemotherapy drug injection. This total is less than the standard 
coinsurance for chemotherapy drugs because your maximum out-of-pocket was met with the processing of this 
claim. This item/service falls within the Medicare Part B prescription drugs 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 reduce the copayment for a chemotherapy drug injection provided on November 15, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found there is no magnetic resonance imaging 
(MRI) showing only modic changes without facet degenerative joint disease or foraminal stenosis. The cause 
of the enrollee's pain is not clear. The records do not support that the Intracept procedure is reasonable or 
medically necessary 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an Intracept procedure.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on February 2, 2023. 
 
You asked the Plan to pay for the psychotherapy. You say that you are an in-network provider based off a 
contract from April 2019 and therefore the member should not need a referral to be seen. The Plan denied your 
request. The Plan says 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 Plan says that the Plan has also determined 
that these services are not urgent or emergent, nor were they approved in advance. 
 
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 psychotherapy provided on February 2, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each physical therapy (PT) visit provided 
on April 04, 2023, to May 19, 2023. 
 
You asked the Plan to waive the copayment for each physical therapy (PT) visit. You say that you should not 
have to pay these copayments when you go to physical therapy. 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 rehabilitation services. 
 
You have been asked to pay a $40 copayment for each physical therapy (PT) visit. This item/service falls 
within the outpatient rehabilitation services 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 $240 for the PT visits ($40 per visit x 6 visits = $240). 
Therefore, we decided that the Plan does not have to waive the copayment for each physical therapy (PT) visit 
provided on April 04, 2023, to May 19, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the brain. 
 
You asked the Plan to pre-approve the MRI. You say that you feel your memory has declined and your last 
MRI was in 2020. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
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 the MRI. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found you report that your memory is worsening. A 
neuro psych evaluation was scheduled for June 7, but no results are in the chart. There is no objective evidence 
of cognitive decline since 2020 such as mini-mental state examination (MMSE) or other testing data to justify 
repeat MRI. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve magnetic resonance imaging (MRI) of the brain.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the lumbar injection provided on May 24, 
2023. 
 
You asked the Plan to waive the copayment for the lumbar injection. You say that you disagree with the 
copayment. 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, including services provided at hospital outpatient facilities. 
 
You have been asked to pay a $300 copayment for the lumbar injection. This item/service falls within the 
outpatient surgery, including services provided at hospital outpatient facilities 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 lumbar injection provided on May 24, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drugs, self-administered. 
 
You asked the Plan to pay for the medication. 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 the drugs, self-administered.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gingival irrigation with a medicinal agent (D4921 x 2). 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing with supporting records. 
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 pre-approve 
gingival irrigation with a medicinal agent (D4921 x 2).