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

 
We decided that the Plan does not have to pay for periodontal maintenance (D4910) provided on March 28, 
2023. 
 
You asked the Plan to pay for the periodontal maintenance. You say that this service was not done and you 
were only in the chair for 15 minutes. You also say that the provider submitted the wrong dental code. The Plan 
denied your request. The Plan says your benefit for the periodontal maintenance 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 periodontal maintenance was exhausted on dates of service September 20, 2022, and 
December 21, 2022. Therefore, we decided that the Plan does not have to pay for periodontal maintenance 
(D4910) provided on March 28, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the head or brain. 
 
You asked the Plan to pre-approve the CT scan. You say that your primary care provider (PCP) recommended 
the scan for a possible vertigo diagnosis. 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 CT scans 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 CT scan. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the enrollee has a likely diagnosis of 
orthostatic hypotension related to BP meds.  However, there is a request for an e-neuro consult, which is not in 
the records submitted.  Furthermore, A CT without contrast would not be the appropriate test for symptoms. 
 
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 CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a computed tomography (CT) scan of the head or brain.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a flex-walk system (L5981) and a multi-axial rotation unit (L5986) 
for a lower-limb prosthesis. 
 
You asked the Plan to pre-approve a flex-walk system and a multi-axial rotation unit. You say that the 
requested items are a medical necessity for the enrollee. The Plan denied your request. The Plan says that the 
requested items are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a determination of the medical necessity for certain 
components/additions to the prosthesis is based on the beneficiarys potential functional abilities. 
 
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 a flex-walk system and a multi-axial 
rotation unit. Our reviewer says that the requested prosthesis components are medically reasonable and 
necessary in this case. Our physician reviewer found that the Plans denial letter sets more stringent 
requirements than does Medicare. The enrollee's medical needs are closely tied to functional ambulation, which 
the enrollee could attain with the right components. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a flex-walk system and a multi-axial rotation unit have been met. Therefore, we 
decided that the Plan has to pre-approve a flex-walk system (L5981) and a multi-axial rotation unit (L5986) for 
a lower-limb prosthesis.  
 
  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 waive the copayment for a magnetic resonance image (MRI) 
provided on December 24, 2022. 
 
You asked the Plan to waive the copayment for a magnetic resonance image (MRI). You say that you were 
advised by your provider that there would be no copayment for the MRI. 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 $325 
copayment for outpatient diagnostic test. 
 
You have been asked to pay a $325 copayment for a magnetic resonance image (MRI). This item/service falls 
within the outpatient diagnostic test 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 a 
magnetic resonance image (MRI) provided on December 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an endosteal implant, custom fabricated abutment, and 
abutment supported porcelain/ceramic crown (D6057, D6058, D6010). 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they do 
not fall within your dental 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 pre-approve an 
endosteal implant, custom fabricated abutment, and abutment supported porcelain/ceramic crown (D6057, 
D6058, D6010).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee precludes from lower level 
of care and requires complex wound care to multiple wounds, daily physician intervention/monitoring, daily 
laboratory tests, and aggressive rehabilitation therapies. The Plan denied your request. The Plan says the 
enrollee does not meet all the requirements for admission to the LTACH.  
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the record indicates the enrollee is improving but still requires acute care 
services before transitioning to a lower level of care. The enrollee continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that they 
are not currently receiving but that would be available at the LTACH facility. The elements of the coverage 
rules are not satisfied.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for culture, typing; identification by nucleic acid (DNA or RNA) 
probe, amplified probe technique, per culture or isolate, each organism probed (87150-59) provided on August 
19, 2022. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the medical records do not contain documentation to support coding criteria for code 87150-59 
for 12 unit  
 
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 87150 is culture, typing; identification by nucleic acid 
(DNA or RNA) probe, amplified probe technique, per culture or isolate, each organism probed. 
 
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 service. Our reviewer found there is no documentation 
that support the CPT code 87150-59 for 12 units. Provided records in this case do not document culture, typing; 
identification by nucleic acid (DNA or RNA) probe as required for code 87150.  
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pay for culture, typing; identification by nucleic acid (DNA or RNA) probe, amplified probe technique, 
per culture or isolate, each organism probed (87150-59) provided on August 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a resin-based composite - one surface, anterior (D2330) 
provided on January 23, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were unaware that there were no out-of-
network benefits. The Plan denied your request. The Plan says the dental services were received from an out-
of-network provider and are not covered by your supplemental benefits.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
 
 The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a resin-based composite - one surface, anterior (D2330) provided on January 23, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 2D oral imaging (D0350), cone beam CT capture (D0367), 
unspecified periodontal procedure (D4999), and oral hygiene instructions (D1330), provided on January 19, 
2023, to January 27, 2023. 
 
You asked the Plan to pay for D0350, D0367, D4999, and D1330. You say that this dental work was all 
medically necessary. The Plan denied your request. The Plan says the denied services are not covered 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. D4921 has been assessed a $65 copayment. Therefore, we decided that 
the Plan does not have to pay for 2D oral imaging (D0350), cone beam CT capture (D0367), unspecified periodontal procedure (D4999), and oral hygiene instructions (D1330), provided on January 19, 2023, to 
January 27, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for occupational therapy provided on December 30, 2022, to 
December 31, 2022. 
 
You asked the Plan to pay for occupational therapy. You say that you are appealing the claim payment denial. 
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 occupational therapy 
provided on December 30, 2022, to December 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for implants and associated services provided on January 11, 
2023. 
 
You asked the Plan to pay for implants and associated services. 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 pay for implants 
and associated services provided on January 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the infusion therapies, injections, 
chemotherapy administration, injection administration, and the injection drugs provided from December 2, 
2022, to December 21, 2022. You asked the Plan to waive the cost share for the infusion therapies, injections, chemotherapy administration, 
injection administration, and the injection drugs. You say that you disagree with the charges. 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 $345 
copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital. Your 
contract with the Plan also clearly says that you must pay 20% coinsurance for each Medicare-covered 
chemotherapy drug and the administration of that drug. Your contract with the Plan also clearly says that you 
must pay 20% coinsurance for all other Medicare-covered Part B drugs. 
 
You have been asked to pay a $75.01, which is less than the standard copayment for each infusion therapy 
(96367) provided on December 2, 2022, and December 19, 2022. You have also been asked to pay $145.26, 
which is less than the standard copayment for each injection (96375) provided on December 2, 2022, and 
December 19, 2022. These items/services fall within the outpatient surgery and other medical 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.  
 
You have also been asked to pay 20% coinsurance of the allowed amount for each chemotherapy 
administration and each injection administration You have also been asked to pay 20% coinsurance of the 
allowed amount for each injection drug. These items/services fall within the Medicare Part B prescription drugs 
benefit category. 
 
Date of Service Code Allowed Amount 20% Coinsurance 
December 2, 2022 96416 $385.78 $77.16 
December 19, 2022 96416 $385.78 $77.16 
December 2, 2022 96413 $385.78 $77.16 
December 19, 2022 96413 $385.78 $77.16 
December 2, 2022 96415 $75.01 $15.00 
December 19, 2022 96415 $75.01 $15.00 
December 2, 2022 96417 $75.01 $15.00 
December 19, 2022 96417 $75.01 $15.00 
December 4, 2022 Q5108 $1,693.37 $338.67 
December 21, 2022 J2506 $1,576.97 $315.39 
 
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 cost share for the infusion therapies, injections, chemotherapy 
administration, injection administration, and the injection drugs provided from December 2, 2022, to December 
21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve push handles (K0108), arm rests (K0108), leg rest 
assembly (K0108), electronic connection between wheelchair controller and one power seating system motor 
(E2310), harness (E2313), expandable controller (E2377).  

You asked the Plan to pre-approve push handles, arm rests, leg rest assembly, electronic connection, harness, 
and expandable controller. You say that the items in question are not an integral part of the base, thus a split 
decision should be possible. The Plan denied your request. The Plan says leg rests and arm rests are already 
included with approved E1002 power tilt. The Plan says push handles do not serve a medical purpose and 
cannot be covered. The Plan also says there is not a medical need to control this power options through the 
joystick. 
 
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 push handles, arm rests, leg rest 
assembly, electronic connection, harness, and expandable controller. Our reviewer says that the requested 
items/services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the requested electrical accessories are not medically necessary as the enrollee does have use of the 
upper extremity and can operate and control the power options using the switches that are included in the basic 
wheelchair. Additionally, the documentation does not indicate the enrollee has a medical condition that would 
require push handles or duplicate arm rests. Our reviewer also found that the requested accessories are not 
medically 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 push handles, arm rests, leg rest assembly, electronic connection, harness, and 
expandable controller have not been met. Therefore, we decided that the Plan does not have to pre-approve 
push handles (K0108), arm rests (K0108), leg rest assembly (K0108), electronic connection between 
wheelchair controller and one power seating system motor (E2310), harness (E2313), expandable controller 
(E2377).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for hepatobiliary system imaging provided on 
January 13, 2023. 
 
You asked the Plan to waive the copayment for hepatobiliary system imaging. You say that this was a follow-
up sevice, and you were not aware there would be a 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 $245 
copayment for outpatient hospital services. 
 
You have been asked to pay a $245 copayment for hepatobiliary system imaging. This item/service falls within 
the outpatient hospital 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. Therefore, we decided that the Plan does not have to waive the copayment for 
hepatobiliary system imaging provided on January 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) and a partial lower denture 
(D5214) provided by an out-of-network provider on January 17, 2023. 
  You asked the Plan to pay for the dental services. You say that there are no in-network providers that is close to 
the enrollee. The Plan denied your request. The Plan says the dental services were received from an out-of-
network provider and are not covered by your supplemental benefits. Also, there are multiple in-network 
provider that are within the enrollee's 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. 
 
The record shows the enrollee received the requested dental services from an out-of-network provider. Though 
the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered 
under this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not 
have to pay for a limited oral evaluation (D0140) and a partial lower denture (D5214) provided by an out-of-
network provider on January 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary complete denture (D5110) and mandibular 
partial denture (D5214). 
 
You asked the Plan to pre-approve the dental services. You say that you have a wound on your gums and 
cannot find your 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 August 18, 2021. 
Therefore, we decided that the Plan does not have to pre-approve a maxillary complete denture (D5110) and 
mandibular partial denture (D5214).