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

 
We decided that the Plan does not have to pre-approve retainer crowns (D6751) for teeth # 3 and 5, and a 
pontic (D6241) for tooth # 4. 
 
You asked the Plan to pre-approve the dental services. You say that it is recommended the enrollee have a 
bridge instead of a denture. You say that a denture would cover the enrollee's palate which would limit her 
ability to taste food and determine temperature. You say that that it would trap food. You also say that the 
enrollee has a history of root canals and extractions. You also say that a bridge is recommended to restore form 
and function of the upper arch. The Plan denied your request. The Plan says the submitted narrative fails to 
indicate or support any specific physical or psychological condition(s) that precludes the use of a removable 
prosthesis. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. The Plan covers the dental 
services 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 the dental services. Our reviewer says 
that the bridge is not medically necessary. Our physician reviewer found a fixed bridge would be considered 
for coverage only if there is documented psychological or neurological condition which would preclude the use 
of a removable prosthesis. The reviewer found there was no documentation to support this. Therefore, the 
reviewer found that the documentation provided did not preclude the use of a removable prosthesis. 
 
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 the dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve retainer crowns (D6751) for teeth # 3 and 5, and a pontic (D6241) for tooth # 4.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair and raised toilet seat. 
 
You asked the Plan to pre-approve a shower chair and raised toilet seat. The Plan denied your request. The Plan 
says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair and raised toilet seat.  
 
The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered because they 
are not primarily medical in nature.  
 
While a raised toilet seat may be appropriate for, neither the Plan nor Medicare offers coverage of this item.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Crestor tablet, 10 mg. 
 
You asked the Plan to pre-approve Crestor. You say that the enrollee has been taking Crestor since September 
2012. You say that the enrollee has had adverse effects in the past with Lipitor and Simvastiatin-Zetia. You 
also say that the continuation of this medication is necessary to continue to lower her LDL. The Plan denied 
your request. The Plan says the requested drug is considered self-administered. The Plan says self-administered 
drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the requested drug is not 
covered under Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Crestor tablet, 10 mg.  
 
Benefits for Crestor may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a transcutaneous electrical nerve stimulation (TENS) device 
rented for March 19 - September 19, 2020. 
 
You asked the Plan to pay for the rented TENS device. You say that the documentation provided supports the 
denied charges. The Plan denied your request. The Plan says Medicare rules for payment of this claim have not 
been met. 
 
The Plan must follow Medicare rules. Medicare rules say that coverage for a TENS unit is limited to a 30-day 
rental for acute post-operative pain. Medicare rules say that coverage for the rental of a TENS unit is limited to 
two months for the treatment of chronic pain.  
 
We looked at the file and Medicare rules. The records show that the Plan paid for a TENS unit rental for 
January 19 and February 19, 2020. Based on this information, we decided that Medicare rules for coverage of 
the rented TENS device have not been met. Therefore, we decided that the Plan does not have to pay for a 
transcutaneous electrical nerve stimulation (TENS) device rented for March 19 - September 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone replacement graft for ridge preservation. 
 
You asked the Plan to pre-approve the bone replacement graft. The Plan denied your request. The Plan says 
this service is not covered under the enrollee's contract or the Medicare program. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
bone replacement graft for ridge preservation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the special detailed evaluation (D0160), the 
panoramic x-ray (D0330), and the surgical extractions (D7210 x 2) provided on July 28, 2020. 
 
You asked the Plan to reimburse you for the dental services. You say that you had emergency services due to a 
dreadful toothache. You say that you had to have 2 teeth extracted. You say that you are on a fixed monthly 
income. You also say that you would like a refund for the services that you paid for out of pocket. The Plan 
denied your request. The Plan says the provider in this case is out of network. The Plan says that dental 
services that you receive out of network are not covered. The Plan also says that the services you received were 
not emergent in nature and could have been performed in network. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, dental services that you receive out of 
network are not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
reimburse you for the special detailed evaluation (D0160), the panoramic x-ray (D0330), and the surgical 
extractions (D7210 x 2) provided on July 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a partial lower 
denture (D5214). 
 
You asked the Plan to pre-approve the dental items. You say that the enrollee needs dentures. The Plan denied 
your request. The Plan says dentures are not covered items. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
complete upper denture (D5110) and a partial lower denture (D5214).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine 
(72158). 
 
You asked the Plan to pre-approve MRI lumbar spine. You say that the services are medically necessary. The 
Plan denied your request. The Plan says the services are not medically necessary. 
 
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 Medicare rules for 
coverage of MRI lumbar spine have not been met. Specifically, it is the responsibility of the requestor to 
provide sufficient information to determine whether payment is due. In this case, insufficient medical records 
were submitted, and therefore, could not be reviewed for medical necessity. Therefore, we decided that the 
Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine (72158).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the manual wheelchair accessory (E2231). 
 
You asked the Plan to pay for the manual wheelchair. You say that you would like reconsideration because this 
equipment is medically necessary. The Plan denied your request. The Plan says E2231 is meant for use with 
manual wheelchairs and is included in the allowance for the power wheelchair. 
 
The Plan must follow Medicare rules. Medicare rules say that a solid support base is included in the allowance 
for the power wheelchair codes. There should be no separate billing with power wheelchairs. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the manual wheelchair have not been met. The record indicates that the Plan has approved a power 
wheelchair. The requested support base is included in the allowance for the power wheelchair codes.  Therefore, 
we decided that the Plan does not have to pay for the manual wheelchair accessory (E2231).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on September 10, 2020 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for outpatient hospital visit. You say that there is no doubt that this service was 
medically necessary. The Plan denied your request. The Plan says the denial of payment for this service is 
correct, because this provider is out-of-network with the Plan and authorization was not obtained. 
 
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 medical services provided on September 10, 
2020 by an out of network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy and the mental health service plan 
development services provided from September 13, 2019 to December 18, 2019 by an out of network (OON) 
provider. 
 
You asked the Plan to pay for the psychotherapy and the mental health service plan development services. You 
say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the 
services received are not a covered benefit. 
 
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 psychotherapy and the mental health service 
plan development services provided from September 13, 2019 to December 18, 2019 by an out of network 
(OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for portable x-ray services (71045-TC, Q0092, R007) provided 
on February 1, 2020. 
 
You asked the Plan to pay for portable x-ray services. You say that these codes are payable. The Plan denied 
your request. The Plan says these codes are not separately payable because they were provider during a skilled 
nursing facility stay. 
 
The Plan must follow Medicare rules. Medicare rules say that SNF resident receives a portable x-ray service 
during the course of a Medicare-covered stay in the SNF, only the service's professional component 
(representing the physician's interpretation of the test results) is a separately billable physician service under 
Part B. By contrast, the technical component representing the procedure itself, including any associated 
transportation and setup costs, would be subject to consolidated billing and must be included on the SNF's Part 
A bill for the resident's covered stay rather than being billed separately under Part B.  
 
We looked at the file and Medicare rules. The record shows that the services at issue were provided during an 
SNF stay and cannot be billed separately. Based on this information, we decided that Medicare rules for 
coverage of portable x-ray services have not been met. Therefore, we decided that the Plan does not have to 
pay for portable x-ray services (71045-TC, Q0092, R007) provided on February 1, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion of a Superion interspinous stabilization 
device (22869). 
 
You asked the Plan to pre-approve this service. You say that this service is medically necessary for the 
enrollee. The Plan denied your request. The Plan says this service 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 this service. Our reviewer says that the 
requested service is not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the device is experimental. More research is needed to show safety and efficacy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the insertion of a Superion interspinous stabilization device (22869).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing services provided on August 17, 2020 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for skilled nursing services. You say that you would like this claim reprocessed and 
paid. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the 
member's skilled nursing facility is also out-of-network. 
 
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 services provided on August 17, 
2020 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 adjunctive pre-diagnostic test (D0431), the localized 
delivery of microbial agents (D4381 x 8), the gingival irrigation (D4921 x 2), and the drugs or medicaments 
(D9630 x 2) provided on September 24, 2020. 
 
You asked the Plan to pay for the dental services. You say that the services were necessary. The Plan denied 
your request. The Plan says the pre-diagnostic test, gingival irrigation and drugs or medicaments are not listed 
as covered services. The Plan also says that the localized delivery of microbial agents cannot be performed on 
the same day as periodontal scaling and root planing. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the pre-diagnostic test, gingival 
irrigation and drugs or medicaments are not among those covered under this benefit. Although the localized 
delivery of microbial agents is listed as a covered service, it cannot be performed on the same day as 
periodontal scaling and root planing. The record shows that you received scaling and root planing on this date 
of service. Therefore, we decided that the Plan does not have to pay for the adjunctive pre-diagnostic test 
(D0431), the localized delivery of microbial agents (D4381 x 8), the gingival irrigation (D4921 x 2), and the 
drugs or medicaments (D9630 x 2) provided on September 24, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion of a Vertiflex Superion spacer device 
(22869, 22870). 
 
You asked the Plan to pre-approve the insertion of a Vertiflex Superion spacer device. You say that this is 
medically necessary. The Plan denied your request. The Plan says this is experimental. 
 
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 insertion of a Vertiflex Superion 
spacer device. Our reviewer says that the requested services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the spacer is experimental. More research is needed to 
show safety and efficacy. 
 
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 insertion of a Vertiflex Superion spacer device have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the insertion of a Vertiflex Superion spacer 
device (22869, 22870).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on June 11, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation. 
 
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 the laboratory services are not supported in the medical record. Specifically, the submitted claim 
form indicates the laboratory specimen was obtained in a laboratory, place of service 81; however, the 
submitted medical documentation and/or claim history indicates that the specimen was obtained in an office 
setting place of service 11. Based on this information, we decided that Medicare rules for coverage of the 
laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the 
laboratory services provided on June 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CPAP cleaner. 
 
You asked the Plan to pre-approve the CPAP cleaner. You say that you are currently battling Leukemia, are 
receiving chemotherapy, and had a biopsy of the fungus in your leg. You say that the requested device should 
be covered to help combat any infections that you may get through the CPAP usage. You say that, with the 
COVID-19 virus and your having to go to the hospital, you are at high risk. You say that your cousin has this 
CPAP cleaner and he no longer gets sore throats. The Plan denied your request. The Plan says the requested 
device is not considered medically reasonable and necessary. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a CPAP cleaner.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an out-of-network referral for inpatient admission and 
bariatric surgery. 
 
You asked the Plan to pre-approve the referral. You say that the services are medically necessary. The Plan 
denied your request. The Plan says there are network providers available. 
 
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 
an out-of-network referral for inpatient admission and bariatric surgery.