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

 
We decided that the Plan does not have to pay for full mouth debridement to enable comprehensive periodontal 
evaluation and diagnosis (D4355) provided on April 4, 2023.  
 
You asked the Plan to pay for the dental services. You say that this should be 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 February 22, 2022. 
Therefore, we decided that the Plan does not have to pay for full mouth debridement to enable comprehensive 
periodontal evaluation and diagnosis (D4355) provided on April 4, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on April 20, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says your $4,000 annual maximum 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. Therefore, we decided that the Plan does 
not have to pay for dental services provided on April 20, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Behavioral Health inpatient level of care. 
 
You asked the Plan to pre-approve the Behavioral Health inpatient level of care. You say that the service is 
medically necessary. The Plan denied your request. The Plan says the service is 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 the Behavioral Health inpatient level of 
care. Our reviewer says that the service is not medically necessary. Our physician reviewer found the enrollee 
can be treated in a lesser restrictive setting. 
 
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 Behavioral Health inpatient level of care have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the Behavioral Health inpatient level of care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the genicular nerve block. 
 
You asked the Plan to pre-approve the genicular nerve block. You say that you are in pain and need the 
injection to provide you relief. The Plan denied your request. The Plan says the genicular nerve block is 
considered experimental and investigational.  
 
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 genicular nerve block. Our reviewer 
says that the genicular nerve block is considered experimental and investigational. Our physician reviewer 
found that the genicular nerve block is the subject of ongoing clinical trials and is considered an experimental 
and investigational procedure. 
 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 genicular nerve block have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the genicular nerve block.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids (V5298) purchased on 
April 26, 2023. 
 
You asked the Plan to issue reimbursement for these items. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says these items are not payable as 
they were purchased from an out-of-network provider. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when purchased from the Plans select hearing aid provider.  
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically, the Plans contract states that hearing aids are only 
covered when purchased from the Plans select hearing aid provider. However, the hearing aids in this case 
were purchased from an out-of-network provider. Therefore, we decided that the Plan does not have to issue 
reimbursement for the hearing aids (V5298) purchased on April 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network mental health visits provided 
from October 25, 2021, to March 13, 2023. 
 
You asked the Plan to waive the copayment for an in-network mental health visit. You say that your husband 
has not been in alcohol rehab in years this was just for mental health. The Plan denied your request. The Plan 
says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for mental health services.  
 You had 13 visits each had a $40 copayment, resulting in a $520 total copayment due for the above dates (13 
visits x $40 = $520) 
  
You have been asked to pay a $520 total copayment for an in-network mental health visit. This item/service 
falls within the mental health 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 
an in-network mental health visits provided from October 25, 2021, to March 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on March 23, 
2023. 
 
You asked the Plan to pay for the dental service. You say that you had to see a specialist for the pain that you 
were having in your jaw. 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 the Plan paid for a limited oral evaluation (D0140) on February 1, 2023, and March 16, 2023; therefore, 
your benefit for the requested item or service was exhausted on the date of service of March 16, 2023. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on 
March 23, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous implantations of neurostimulator electrode 
array; peripheral nerve (excludes sacral nerve) (StimQ neurostimulator) (64555 x 2). 
 
You asked the Plan to pre-approve StimQ neurostimulator. You say that this treatment is not the same as PNS. 
You say that this is approved by the Food and Drug Administration (FDA). You also say that this device 
enhances therapy effectiveness for treating chronic pain. The Plan denied your request. The Plan says this 
device is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve StimQ neurostimulator. Our reviewer 
says that the requested StimQ neurostimulator is not considered medically reasonable and necessary in this 
case. Our physician reviewer found there are two clinical trials evaluating the use of this device in chronic knee pain. The enrollee is not enrolled in a clinical trial. Therefore, the requested StimQ neurostimulator is not 
medically reasonable and necessary as it is investigational 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 StimQ neurostimulator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve percutaneous implantations of neurostimulator electrode array; peripheral nerve 
(excludes sacral nerve) (StimQ neurostimulator) (64555 x 2).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an external ambulatory infusion pump for insulin (E0784).  
You asked the Plan to pay for an external ambulatory infusion pump for insulin. You say that your sugar now 
runs very low. You also say that you have had this for years and feel it is medically necessary. The Plan denied 
your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity. Medicare 
rules also say if the supplier bills for an item addressed without first receiving a completed SWO, the claim 
shall be denied as not reasonable and necessary. 
 
The record does not contain a valid physician order. There is also no documentation showing you are an 
established patient with the treating provider. The record shows that the Plan attempted to obtain the necessary 
documentation without success. Therefore, we decided that the Plan does not have to pay for an external 
ambulatory infusion pump for insulin (E0784).  
 
Please Note: The record shows that you have been approved for supplies for 1 month until you can establish 
care with your Provider and orders can be obtained.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided on August 
11, 2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for SNF. You say that the records provided support these services. The Plan denied 
your request. The Plan says these services can be provided by an in-network provider. 
 
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 skilled nursing facility (SNF) services provided on 
August 11, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral complete series of radiographic images (D0210) 
provided on May 11, 2023. 
 
You asked the Plan to pay for the dental service. You say that you were unaware of the frequency limits and 
your new dentist needed x-rays done. 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 the Plan paid for the intraoral complete series of radiographic images (D0210) on April 15, 2022; 
therefore, your benefit for the requested item or service was exhausted on the date of service of April 15, 2022. 
Therefore, we decided that the Plan does not have to pay for the intraoral complete series of radiographic 
images (D0210) provided on May 11, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility provided on May 22, 2023. 
 
You asked the Plan to pay for skilled nursing facility. You say that you are requesting review of the denied 
claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for skilled nursing facility 
provided on May 22, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 81342, 85025, and 88377 billed for date of 
service March 27, 2023. 
 
You asked the Plan to pay for the billed services. You say that the distinct nature of the analytes is well 
documented. The Plan denied your request. The Plan says the billed codes are not supported. 
 
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 code 85025 is not supported in the medical records. The records do not show that this test was 
ordered by the enrollees treating physician.  
 
We find that CPT codes 81342 and 88377 are not supported in the medical record. There are insufficient 
records to show how this testing is expected to influence the treatment of the enrollees condition. Based on 
this information, we decided that Medicare rules for coverage of the billed services have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes 81342, 85025, and 88377 billed 
for date of service March 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vision supply provided on March 8, 2023. 
 
You asked the Plan to pay for the vision supply . You say that you needed new reading and distance glasses 
because you could not pass your drivers test.  The Plan denied your request. The Plan says the vision supply is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and 
eyewear.  
 
The services you asked the Plan to pay for are considered routine vision services or eyewear. Therefore, we 
decided that the Plan does not have to pay for the vision supply provided on March 8, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve abraxane, carboplatin and dexamethasone sodium 
phosphate. 
 You asked the Plan to pre-approve the drugs. The Plan denied your request. The Plan says that the step therapy 
requirements have not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 drugs. Our reviewer says that 
abraxane, carboplatin and dexamethasone sodium phosphate is not medically necessary. Our physician 
reviewer found that the enrollee has not tried and failed the Plan's required drugs taxol and taxotere. Also, there 
is no indication that the Plan's required drugs would likely be less effective or likely have adverse effects for 
the enrollee. 
 
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 drugs have not been met. Therefore, we decided that the Plan does not have 
to pre-approve abraxane, carboplatin and dexamethasone sodium phosphate.
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 is in need of daily physician 
assessments, 6+ hours of daily nursing care and monitoring. The Plan denied your request. The Plan says that 
the enrollee does not meet all of the requirements. 
 
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 enrollee is receiving appropriate care in the current acute care setting as 
provided by the Plan. Documentation does not support that LTACH services are medically appropriate 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the application of fluoride (D1208) and the periodontal 
maintenance (D4910) provided by an out-of-network provider on March 10, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you have been a patient at the dentist 
office for over 10 years and you would like the Plan to pay the remaining balance. 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 billed amount for the application of fluoride (D1208) was $55 and the total allowed amount was $19 
leaving a difference of $36 ($55 billed - $19 allowed). The total billed amount for the periodontal maintenance 
(D4910) was $165 and the total allowed amount was $67 leaving a difference of $98 ($165 billed - $67 
allowed). 
 
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 application of fluoride (D1208) and the 
periodontal maintenance (D4910) provided by an out-of-network provider on March 10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral radiographic image (D0220) and a cone beam 
(D0380) provided by n out-of-network provider on March 3, 2023. 
 
You asked the Plan to pay for the dental services. You say that the service was for an emergency with an 
endodontist, and you were not aware that the provider was not in the program. 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 the intraoral radiographic image (D0220) and a cone beam (D0380) provided by n out-of-network 
provider on March 3, 2023.