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

 
We decided that the Plan does not have to pay more for the comprehensive oral evaluation (D0150), the 
intraoral radiographic images (D0220 and D0230), and a cleaning (D1110) provided by an out-of-network 
provider on February 22, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you had no choice to see an out-of-
network provider because you were outside your service area, and you would like the Plan to pay more for the 
dental services. 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 (D0150) was $110 and the allowed amount was 
$40 leaving a difference of $70 ($110 billed - $40 allowed). The total amount billed for the intraoral 
radiographic image (D0220) was $33 and the total allowed amount was $9 leaving a difference of $24 ($33 
billed - $9 allowed). The total amount billed for each additional intraoral radiographic image (D0230) was $28 
and the total allowed amount was $5 leaving a difference of $23 ($28 billed - $5 allowed). The total difference 
for the 5 additional intraoral radiographic images (D0230) was $115 ($23 difference x 5 images). The total 
amount billed for the cleaning (D1110) was $109 and the total allowed amount was $64 leaving a difference of 
$45 ($109 billed - $45 allowed). The total amount you owe for the difference is $254 ($70 difference + $24 
difference + $115 difference + $45 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 the comprehensive oral evaluation (D0150), 
the intraoral radiographic images (D0220 and D0230), and a cleaning (D1110) provided by an out-of-network 
provider on February 22, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the boxing club membership provided on January 1, 2022. 
 
You asked the Plan to pay for the boxing club membership. You say that the boxing club should be covered. 
You say that this a total body, no contact exercise and a national chain. The Plan denied your request. The Plan 
says the service is not a covered benefit. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers gym benefits 
when the membership is to a qualified health club or fitness facility. 
 
The Plans rules for coverage of gym benefits have not been met because the boxing club membership is not 
considered a qualified health club or fitness facility. Therefore, we decided that the Plan does not have to pay 
for the boxing club membership provided on January 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core buildup, including any pins when required (D2950) 
provided on February 14, 2023. 
 
You asked the Plan to pay for the core buildup, including any pins when required. You say that the services 
were needed in order to replace your two front teeth. The Plan denied your request. The Plan says there is no 
coverage for D2950 - core buildup, including any pins when required. 
 
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 core 
buildup, including any pins when required (D2950) provided on February 14, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an immediate partial maxillary denture (D5221) 
provided on March 9, 2023. 
 
You asked the Plan to pre-approve the dental services. You say that you thought partials were covered. 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 April 6, 2021. Therefore, we decided that the Plan does not have to pre-approve an immediate partial maxillary denture (D5221) 
provided on March 9, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic radiographic image (D0330), intraoral - 
periapical first radiographic image (D0220), and each additional radiographic image (D0230) provided on 
March 8, 2023. 
 
You asked the Plan to pay for the panoramic radiographic image, intraoral - periapical first radiographic image 
and each additional radiographic image. You say that x-rays are covered at 55% but the claim was denied. The 
Plan denied your request. The Plan says these services are not covered 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 
panoramic radiographic image (D0330), intraoral - periapical first radiographic image (D0220), and each 
additional radiographic image (D0230) provided on March 8, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation, bitewing x-rays, and 
panoramic x-rays (D0150, D0274, D0330) provided on April 18, 2023. 
 
You asked the Plan to pay for 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 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 comprehensive oral evaluation, bitewing x-rays, and panoramic x-rays (D0150, D0274, D0330) 
provided on April 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cone beam CT capture and interpretation (D0365) and 
endodontic therapy (D3220 x 2) provided on March 28, 2023. 
 
You asked the Plan to pay for the dental services. You say that you assumed that these were covered 
procedures because you were using an in-network provider. The Plan denied your request. The Plan says these 
services are not covered under the Plan's 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 pay for the cone 
beam CT capture and interpretation (D0365) and endodontic therapy (D3220 x 2) provided on March 28, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that ongoing skilled care can be provided in an 
alternative setting. The Plan denied your request. The Plan says the enrollee would benefit from 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 the enrollee does not require treatment by multiple therapies. 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (81455) provided on January 19, 2023. 
 
You asked the Plan to pay for the genetic testing. You say that this service was medically necessary. The Plan 
denied your request. The Plan says this service is non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that Comprehensive Genomic Profile (CGP) Next-
Generation Sequence (NGS) testing is covered when the test has Food & Drug Administration (FDA) approval 
or clearance as a companion in vitro diagnostic; and an FDA-approved or cleared indication for use for the 
patients cancer. 
 
We looked at the file and Medicare rules. The Tempus xF test does not have FDA approval. Based on this 
information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, 
we decided that the Plan does not have to pay for genetic testing (81455) provided on January 19, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Optune Lua (E0766). 
 
You asked the Plan to pre-approve the Optune Lua. You say that the item is medically necessary. The Plan 
denied your request. The Plan says this is considered experimental for the enrollee's diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Optune Lua. Our reviewer says that 
the requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found this is considered experimental for the enrollee's diagnosis. 
 
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 Optune Lua have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Optune Lua (E0766).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Magnetic resonance (eg, proton) imaging, spinal 
canal, and contents, without contrast material (72156). 
 
You asked the Plan to pre-approve a Magnetic resonance imaging. You say that the enrollee's symptoms 
worsening. Still with right side numbness, now having pain and numbness in left leg, tarted in toes, now up to 
mid shin. Also pain in right leg and sometimes waking up at night from pain. The Plan denied your request. 
The Plan says services are 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 a Magnetic resonance imaging. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found detailed documentation 
regarding a trial and failure of recent, reasonable, comprehensive, less invasive conservative care measures is 
not evident, an MRI is not medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Magnetic resonance imaging have not been met. Therefore, we decided that the Plan does not have to pre-approve a Magnetic resonance (eg, proton) imaging, spinal canal, and contents, 
without contrast material (72156).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an oral evaluation, cleaning, and fluoride application 
(D0120, D1110, D1206) provided on December 15, 2022. 
 
You asked the Plan to pay for 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 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 an oral evaluation, cleaning, and fluoride application (D0120, D1110, D1206) provided on December 
15, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 6 physical therapy (PT) visits. 
 
You asked the Plan to pre-approve the PT visits. You say that the services are needed to focus on improving 
balance and gait efficiency and facilitate caregiver training in order to increase independence and move to a 
home program. The Plan denied your request. The Plan says the services are not medically necessary.  
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 PT visits. Our reviewer says that skilled 
services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. 
Our physician reviewer found the goals of therapy have been to increase endurance. The enrollee can perform a 
home exercise program. Endurance training is repetitive exercise and does not require input from a skilled 
therapist. Aquatic therapy is no longer indicated for the enrollee. Per chapter 7 as unique input from a skilled 
therapist is 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 PT visits have not been met. Therefore, we decided that the Plan does not have 
to pre-approve 6 physical therapy (PT) visits.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an MRI and a stress test provided on 
January 12, 2023. 
 
You asked the Plan to waive the copayment for an MRI and a stress test. You say that you did not know the 
tests would cost so much and it is a financial hardship. 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 radiology services and a $30 copayment for a stress test.  
 
 You have been asked to pay a $230 copayment for an MRI and a stress test. This item/service falls within the 
Outpatient Diagnostic Tests 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 an MRI and 
a stress test provided on January 12, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care. 
 
You asked the Plan to pre-approve inpatient psychiatric care. You say that the services at issue were medically 
necessary. The Plan denied your request. The Plan says the services at issue were not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
   
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 inpatient psychiatric care. Our reviewer 
says that the enrollee does not meet the criteria for treatment in an acute inpatient mental health treatment. Our 
physician reviewer found the enrollee did not require inpatient mental health treatment as he was not a danger 
to himself or others and was cooperative and compliant. The enrollee did not have any delusions, auditory or 
visual hallucinations. It did not appear that active treatment was taking place. It did not appear that the services 
were reasonably expected or medically necessary to improve the enrollees condition or for the purpose of 
diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve inpatient psychiatric care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87652, 87481, 87798, 87640) provided on 
November 30, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed services. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 87652, 87481, 87798, & 87640 are not supported in the medical record. Specifically, 
lab results were not provided for the billed codes. Based on this information, we decided that Medicare rules 
for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for 
lab services (87652, 87481, 87798, 87640) provided on November 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A4550 billed for date of service January 27, 
2023. 
 
You asked the Plan to pay for procedure code A4550. You say that this service was medically necessary. The 
Plan denied your request. The Plan says procedure code A4550 is considered bundled and not separately 
payable.  
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code A4550 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code A4550 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code A4550 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code A4550 billed for date of service January 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a specialist office visit to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve a specialist office visit. You say that the services is medically necessary. 
The Plan denied your request. The Plan says there are in-network providers that can perform this service. 
 
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/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a specialist office visit to be provided by an out-of-network (OON) provider.
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 services are necessary for the enrollee to return to 
their prior level of function. The Plan denied your request. The Plan says the enrollee does not meet the 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 enrollee does not require treatment by multiple therapies. 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.