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

 
We decided that the Plan does not have to pay for an intraoral - complete series of radiographic images 
(D0210), and full mouth debridement to enable a comprehensive oral evaluation and diagnosis on a subsequent 
visit (D4355) provided on March 21, 2023. 
 
You asked the Plan to pay for the intraoral - complete series of radiographic images and full mouth 
debridement. You say that you were not told that the services would not be covered even though you scheduled 
an initial evaluation and x-ray with an in-network provider. The Plan denied your request. The Plan says these 
services are 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, the requested services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an intraoral - 
complete series of radiographic images (D0210), and full mouth debridement to enable a comprehensive oral 
evaluation and diagnosis on a subsequent visit (D4355) provided on March 21, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient behavioral health services provided from 
August 1, 2021, through September 29, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not payable as the provider 
is not enrolled in the Medicare program.  
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
A review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the outpatient behavioral health services 
provided from August 1, 2021, through September 29, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT) scan of leg. 
 
You asked the Plan to pre-approve the CT scan. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the records do not show a treatment plan or follow up have occurred.  
 
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 
CT scan is not medically necessary. Our physician reviewer found the enrollee has bilateral foot pain. The x-
rays show some degenerative joint disease. There is no conservative treatment plan documented. There is no 
clinical need for a Ct 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 the CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve computed tomography (CT) scan of leg.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility services provided from February 19, 
2023, to February 22, 2023. 
 
You asked the Plan to pay for skilled nursing facility services. You say that the services required during the 
period in question are coverable under the Medicare Act. The Plan denied your request. The Plan says rules for 
SNF care have not been met. 
  The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that you received 100 days of SNF care during the benefit period from October 6, 2022, to May 
23, 2023. The Plan has covered 100 days of SNF care prior to the processing of these dates of service. 
 
Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. You will be eligible for a new benefit period when you have not been 
receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the 
Plan does not have to pay for skilled nursing facility services provided from February 19, 2023, to February 22, 
2023.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve revascularization procedures (37221, 37224, 37225, 37226, 37227, 
37228, 37229, 37230, 37231). 
 
You asked the Plan to pre-approve revascularization procedures. 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 revascularization procedures. Our 
reviewer says that medical necessity has not been established. Therefore, coverage criteria have not been met. 
Our physician reviewer found the documentation meets coverage criteria and supports conditional approval of 
lower extremity arterial intervention. The enrollee has documentation of ischemic rest pain and non-healing 
ulcers, consistent with limb threatening ischemia. There is objective documentation of lower extremity arterial 
occlusive disease. The plan of diagnostic angiography with possible intervention is appropriate and medically 
necessary. It is not possible to anticipate pre-procedure what specific interventions will be needed. Therefore, 
diagnostic angiography and conditional approval of requested intervention codes (the specifics to be 
determined at the time of angiography) without delay is necessary as the enrollees condition is limb threatening. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of revascularization procedures have been met. Therefore, we decided that the 
Plan has to pre-approve revascularization procedures (37221, 37224, 37225, 37226, 37227, 37228, 37229, 
37230, 37231).  
 
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 a limited oral evaluation - problem focused (D0140), 
intraoral - periapical first radiographic image (D0220), and endodontic therapy, anterior tooth (excluding final 
restoration) (D3310) provided on March 22, 2023. 
 
You asked the Plan to pay for the limited oral evaluation - problem focused, intraoral - periapical first 
radiographic image, and endodontic therapy, anterior tooth. You say that these claims were the result of a 
traumatic fall that occurred.  
 You also say that they should be processed under the medical benefits portion of your coverage rather than the 
limited coverage of your dental benefits. The Plan denied your request. The Plan says your benefit for the 
requested services $2,000 dollar limit was met 
 
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. Your benefit 
for dental services is limited to $2,000 annually. The record shows your annual benefit allowance for the dental 
services provided in 2023 had already been exhausted when the claim was submitted for the limited oral 
evaluation - problem focused, intraoral - periapical first radiographic image, and endodontic therapy, anterior 
tooth in dispute. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation - 
problem focused (D0140), intraoral - periapical first radiographic image (D0220), and endodontic therapy, 
anterior tooth (excluding final restoration) (D3310) provided on March 22, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (87633) provided on October 19, 
2022. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says insufficient 
information was submitted for review. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the laboratory services have been met. 
In this case medical records were not provided to review the claim. Without this information we are unable to 
review whether coverage criteria are met. Therefore, we decided that the Plan does not have to pay for the 
laboratory services (87633) provided on October 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on March 13, 2023, by an 
OON provider.  
 
You asked the Plan to pay for the laboratory services. You say that you are requesting reconsideration of the 
denied claim. 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 requested provider in this case is 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 laboratory services provided on March 13, 
2023, by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for CT scans provided on October 8, 2022. 
 
You asked the Plan to waive the copayment for CT scans. You say that you have already paid $140.47 but 
would like a refund because the facility advised they would rebill the Plan. 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 
copayment for Medicare-covered radiological diagnostic services, not including x-rays.  
 
 
  You have been asked to pay a $140.47 copayment for CT scans. This total includes a $100 copayment for two 
CT scans performed and $40.47 for a third CT scan performed, which is less than the standard copayment. 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 CT scans provided on October 8, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility provided on January 
24, 2023, to February 24, 2023. 
 
You asked the Plan to waive the copayment for skilled nursing facility. You say that the enrollee was held at 
the facility an additional two weeks for no medical reasons as her was cleared to return home. 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 $275 
copayment for skilled nursing facility care. 
 
You have been asked to pay a $275 copayment for skilled nursing facility. This item/service falls within the 
skilled nursing facility care 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 skilled 
nursing facility provided on January 24, 2023, to February 24, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan 
provided on November 04, 2022. 
 
You asked the Plan to waive the copayment for a computed tomography (CT) scan. You say that you do not 
understand why the copayment is so high and you are unable to afford to pay it on a fixed income. 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 $125 
copayment for outpatient diagnostic tests. 
 
You have been asked to pay a $125 copayment for a computed tomography (CT) scan. 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. The total you owe is $102.30, which is less than the standard copayment for a 
CT scan. Therefore, we decided that the Plan does not have to waive the copayment for a computed 
tomography (CT) scan provided on November 04, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional miles for routine transportation beyond the 
Plan's 100-mile limit. 
 
You asked the Plan to pre-approve additional mileage. You say that you need evaluation for a broken wrist. 
The Plan denied your request. The Plan says the requested transportation exceeds your mileage limit. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when each one-way trip does not exceed 100 miles.  
 
We looked at your request, the records in the case file, and the rules. In this case the requested trip is greater 
than 100 miles of driving distance. Based on this information, we decided that the Plans rules for coverage of 
routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve 
additional miles for routine transportation beyond the Plan's 100-mile limit.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bone replacement graft for ridge preservation-per site 
(D7953) and the guided tissue regeneration, natural teeth-resorbable barrier, per site (D4266) provided on 
March 30, 2023. 
 
You asked the Plan to pay for the dental 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 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 services from an out-of-network provider. Though the Plan offers a 
dental benefit in excess of Medicare coverage, the services provided 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 
bone replacement graft for ridge preservation-per site (D7953) and the guided tissue regeneration, natural teeth-
resorbable barrier, per site (D4266) provided on March 30, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an immediate upper denture (D5130) and an immediate 
lower denture (D5140) provided on November 29, 2022. 
 
You asked the Plan to pay for the dental services. You say that you have coverage for dentures, and they should 
be covered. The Plan denied your request. The Plan says the denial of payment for these services is correct, 
because the immediate dentures are 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an 
immediate upper denture (D5130) and an immediate lower denture (D5140) provided on November 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Infectious agent detection by nucleic acid (DNA or RNA); 
respiratory virus, includes multiplex reverse transcription, when performed, and multiplex amplified probe 
technique, multiple types or subtypes, 12-25 targets (87633) provided on October 24, 2022. 
 
You asked the Plan to pay for the respiratory pathogen panel, 12-25 targets. The Plan denied your request. The 
Plan says this test should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 We looked at the file and Medicare rules. This test was not billed with a single panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the respiratory pathogen panel, 12-25 
targets have not been met. Therefore, we decided that the Plan does not have to pay for Infectious agent 
detection by nucleic acid (DNA or RNA); respiratory virus, includes multiplex reverse transcription, when 
performed, and multiplex amplified probe technique, multiple types or subtypes, 12-25 targets (87633) 
provided on October 24, 2022.
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. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical status does not currently require intensive rehabilitation physician or nursing oversight in an IRF. The 
enrollee's functional level does not require treatment by multiple therapies including physical or occupational 
therapy in an intensive rehabilitation program in an IRF. While the enrollee may benefit from additional 
therapy the documentation does not support that the therapy program needs to be on an intensive level such as 
is provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an endosteal implant for teeth #30 and #31 (D6011). 
 
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 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 May 1, 2023. Therefore, 
we decided that the Plan does not have to pre-approve an endosteal implant for teeth #30 and #31 (D6011).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrocardiogram provided on November 8, 2022, by an 
OON provider.  
 
You asked the Plan to pay for the electrocardiogram. You say that you are requesting reconsideration of the 
denied claim. 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 enrollee's POS benefit does not apply to an out-of-network 
electrocardiogram. 
 
The requested provider in this case is 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 electrocardiogram provided on November 8, 
2022, by an OON provider.