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

 
We decided that the Plan does not have to pay more for the intravenous moderate (conscious) 
sedation/analgesia- first 15 minutes (D9239), each subsequent 15 minute increment (D9243), biologic materials 
to aid in soft and osseous tissue regeneration, per site (D4265), and extraction, erupted tooth requiring removal 
of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210) provided 
on October 4, 2022. 
 
You asked the Plan to pay more for the dental services represented by codes D9239, D9243, D4265, and 
D7210. You say that you are appealing the reimbursement amount applied for the dental services. The Plan 
denied your request. The Plan says this cost sharing was charged correctly. 
 
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 services represented by codes 
D9239, D9243, D4265 are not among those covered under this benefit. Therefore, we decided that the Plan 
does not have to pay more for the dental service represented by codes D9239, D9243, D4265. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $100 deductible which applies to yearly in and out-of-network 
covered dental services. 
 
The extraction, erupted tooth requiring removal of bone and/or sectioning of tooth you asked the Plan to pay 
more for falls within the oral surgery benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $100 deductible which applies to yearly in and out-of-network covered 
dental services, and that you must pay a 20% coinsurance for oral surgery, subject to the annual plan deductible 
for each visit for out-of-network covered oral surgery services. This cost sharing is a contractual obligation that 
had not been met at the time the dental services represented by D7210 that was received on October 4, 2022.  
 
Therefore, we decided that the Plan does not have to pay more for the intravenous moderate (conscious) 
sedation/analgesia- first 15 minutes (D9239), each subsequent 15 minute increment (D9243), biologic materials 
to aid in soft and osseous tissue regeneration, per site (D4265), and extraction, erupted tooth requiring removal 
of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210) provided 
on October 4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Fungal Polymerase Chain Reaction (PCR) Panel testing 
provided on December 28, 2022. 
 
You asked the Plan to pay for the Fungal PCR Panel testing. You say that the Fungal PCR Panel testing 
provided on December 28, 2022, was medically necessary. The Plan denied your request. The Plan says the 
Fungal PCR Panel testing provided on December 28, 2022, was 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 pay for the Fungal PCR Panel testing. Our reviewer 
says that the Fungal PCR Panel testing provided on December 28, 2022, was not medically necessary. Our 
physician reviewer found the PCR testing of the specimen collected was not medically reasonable or necessary. 
Current standard of care for investigation of tinea in skin or toenail is to perform a potassium hydroxide (KOH) 
and or fungal culture on the specimen. These lab tests are inexpensive, sensitive, and specific. It is unclear as to 
why this enrollee's specimen required PCR testing when other less expensive and efficacious lab tests (KOH 
and fungal culture) are available. Therefore, the PCR testing of this enrollee's skin specimen was not medically 
reasonable or 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 the Fungal PCR Panel testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the Fungal Polymerase Chain Reaction (PCR) Panel testing provided on 
December 28, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from September 8, 2022 
to October 7, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that this service was medically 
necessary. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from September 8, 2022 to 
October 7, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services (G0153, G0495, G0496, Q5001) 
provided on June 20, 2021 to July 19, 2021. 
 
You asked the Plan to pay for the home health services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
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 G0153, G0495, G0496, & Q5001 are not supported in the medical record. Specifically, 
a Request for Anticipated Payment (RAP) claim was not submitted for these service dates. Based on this 
information, we decided that Medicare rules for coverage of the home health services have not been met. 
Therefore, we decided that the Plan does not have to pay for home health services (G0153, G0495, G0496, 
Q5001) provided on June 20, 2021 to July 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for resin-based composite - three surfaces, posterior (D23930 
and resin-based composite - four or more surfaces, posterior (D2394) provided on August 11, 2021. 
 
 
You asked the Plan to pay for resin-based composites. You say that this should be covered. The Plan denied 
your request. The Plan says the enrollee is enrolled in the $500 maximum plan, and this is not a covered benefit 
under that 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 resin-
based composite - three surfaces, posterior (D23930 and resin-based composite - four or more surfaces, 
posterior (D2394) provided on August 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation and cleaning (D0120, D1110) 
provided on November 21, 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 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 February 7, 2022, and 
May 26, 2022. Therefore, we decided that the Plan does not have to pay for a periodic oral evaluation and 
cleaning (D0120, D1110) provided on November 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraspinal chiropractic manipulative treatment (98943) 
provided on December 5, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the extraspinal chiropractic manipulative treatment (98943) provided on 
December 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sailing club membership. 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says the requested 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 Plans rules for coverage of gym benefits have not been met because the requested membership is not for a 
qualified health club or fitness facility. This benefit does not cover fees for sports clubs or sports activities. 
Therefore, we decided that the Plan does not have to pre-approve a sailing club membership.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist office visit provided on 
December 02, 2022. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that you saw a nurse on this 
date of service. 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 $35 
copayment for in-network specialist physician/practitioner services. 
 
You have been asked to pay a $35 copayment for the specialist office visit. This item/service falls within the 
in-network specialist physician/practitioner 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 records show you were seen by a specialist on December 2, 
2022. Therefore, we decided that the Plan does not have to waive the copayment for the specialist office visit 
provided on December 02, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle continuous glucose monitor (CGM) and 
supplies. 
 
You asked the Plan to pre-approve the CGM and supplies. You say that your doctor sent all the evidence and 
proof that everything was well detailed to the medical plan. You also say you are appealing the denial. The 
Plan denied your request. The Plan says according to the clinical and medical information received the CGM 
and supplies do not meet medical criteria. 
 The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the CGM and supplies. Our reviewer 
says that per the criteria coverage has not been met. Our physician reviewer found the enrollee only takes 
insulin 1 time a day so criteria is not met. The criteria provided here and the date of the prescription likely 
suggest that the old criteria should be used for this case and hence, criteria has not been met. 
 
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 CGM and supplies have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a FreeStyle continuous glucose monitor (CGM) and supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic care provided on October 31, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for chiropractic care. You say that this is supported in the records. The Plan denied 
your request. The Plan says this 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 chiropractic care provided on October 31, 2022, 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chiropractic care to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve chiropractic care. You say that this is supported in the records. The Plan 
denied your request. The Plan says this 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 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 
chiropractic care to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the dental cleaning (D1110) provided on June 6, 2022. 
 
You asked the Plan to pay more for this dental service. You say that you are requesting a reconsideration of the 
Plan's denial for payment. 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. 
 
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 dental cleaning (D1110) provided on 
June 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic radiographic image (D0330) provided on 
December 14, 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 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 October 26, 2022. 
Therefore, we decided that the Plan does not have to pay for a panoramic radiographic image (D0330) provided 
on December 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. You say that you would like your eligibility to be 
reconsidered. The Plan denied your request. The Plan says the criteria for eligibility have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a 
documented chronic condition that is life threatening or significantly limits the health or function of the 
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.   
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have an 
eligible condition that meets all the required criteria. Therefore, we decided that the Plan does not have to pre-
approve special supplemental benefits for the chronically ill (SSBCI).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental anesthesia (to be put to sleep for dental 
procedures) (D9222). 
 
You asked the Plan to pre-approve dental anesthesia. You say that you are requesting the removal of the 
impacted wisdom tooth on the right bottom because it is partially broken through and is causing infections. The 
Plan denied your request. The Plan says medical necessity not met, you do not meet policy criteria for dental 
anesthesia because there is no documentation you will have extensive extractions, whether simple multiple 
extractions or extractions of impacted teeth. 
 
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 Plan covers dental 
anesthesia when the services are medically necessary and reasonable.  
 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 dental anesthesia. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the documentation provided does not 
meet the criteria for coverage for deep sedation/general anesthesia (D9222) in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of dental anesthesia have not been met. Therefore, we decided that the Plan does 
not have to pre-approve dental anesthesia (to be put to sleep for dental procedures) (D9222).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on January 5, 2023. 
 
You asked the Plan to pay for the psychotherapy. The Plan denied your request. The Plan says the records show 
an approved authorization number, 151517827 exists, however, this date of service does not match what was 
approved on the authorization. 
 
The Plan contract says some of the services listed in the Medical Benefits Chart are covered only if your doctor 
or other network provider gets approval in advance (sometimes called "prior authorization") from us.  
 
We looked at the file and the Plans rules. The file shows that this date of services was not authorized by the 
Plan. Based on this information, we decided that Medicare rules for coverage of the psychotherapy have not 
been met. Therefore, we decided that the Plan does not have to pay for psychotherapy provided on 
January 5, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power operated vehicle (K0801). 
 
You asked the Plan to pre-approve a power operated vehicle. You say that a heavy-duty power chair is 
medically necessary. The Plan denied your request. The Plan says that the coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 power operated vehicle. Our reviewer 
says that the coverage criteria has not been met. Our physician reviewer found that the record indicates you do 
not require a power device to complete your activities of daily living. 
 
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 power operated vehicle have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a power operated vehicle (K0801).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the podiatry office visit provided on 
November 07, 2022. 
 
You asked the Plan to waive the copayment for the podiatry office visit. You say that you have never seen a 
podiatrist before. 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 $25 
copayment for in-network podiatry services. 
 
You have been asked to pay a $25 copayment for the podiatry office visit. This item/service falls within the in-
network podiatry 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 medical records show you were seen by a podiatrist on November 7, 2022. Therefore, 
we decided that the Plan does not have to waive the copayment for the podiatry office visit provided on 
November 07, 2022.