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

 
We decided that the Plan does not have to pre-approve a partial maxillary and mandibular denture (D5213 and 
D5214) to be provided by a participating provider. 
 
You asked the Plan to pre-approve a partial maxillary and mandibular denture. You say that you would like the 
Plan to approve these dentures. The Plan denied your request. The Plan says the benefit limit for D5213 and 
D5214 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. The Plan covers a partial 
maxillary and mandibular denture when the services once every five years.  
 
We looked at the file and Medicare rules. Evidence was provided to show that this benefit was exhausted on 
March 24, 2022. Based on this information, we decided that the Plan's rules for coverage of a partial maxillary 
and mandibular denture have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
partial maxillary and mandibular denture (D5213 and D5214) to be provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the overdenture  complete mandibular (D5865). 
 
You asked the Plan to pre-approve the complete lower overdenture. You say that this service is necessary for 
your denture to fit. The Plan denied your request. The Plan says this service is not covered under your benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
overdenture  complete mandibular (D5865).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the four surgical extractions (D7210 x4) and deep 
sedation/general anesthesia (D9222 and D9223) provided on November 19, 2021 by a Medicare opt out 
provider. 
 
You asked the Plan to pay for the surgical extractions and deep sedation/general anesthesia. You say that your 
dentist referred you to this treating provider. You also say that you were told that although this treating 
provider was not in-network, you would be reimbursed. The Plan denied your request. The Plan says you 
received these services from a provider who chose not to receive Medicare funds. 
 
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 
covered when they are rendered by a provider who has opted out of Medicare. Therefore, we decided that the 
Plan does not have to pay for the four surgical extractions (D7210 x4) and deep sedation/general anesthesia 
(D9222 and D9223) provided on November 19, 2021 by a Medicare opt out provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the custom fabricated abutment (D6057) provided 
on January 24, 2022. 
 
You asked the Plan to reimburse you for the dental service. You say that your providers advised that the service 
is an integral and necessary component in a dental implant procedure. You say that you were advised when you 
added the enhanced dental and vision package that implants were covered at 50%. You also say that you should 
be reimbursed for 50% of the $363 that you paid. The Plan denied your request. The Plan says the claim was 
processed correctly. 
 
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 custom fabricated abutment is not 
among those covered under this benefit.  
 
Therefore, we decided that the Plan does not have to reimburse you for the custom fabricated abutment 
(D6057) provided on January 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150) to be provided 
by an oral surgeon. 
 
You asked the Plan to pre-approve a comprehensive oral evaluation. You say that you were referred to the oral 
surgeon so you can get partial dentures and extractions. You say that you need these extractions as soon as 
possible. The Plan denied your request. The Plan says services must be provided by a participating general 
dentist. 
 
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 a 
comprehensive oral evaluation when the services are a participating general dentist.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of a comprehensive oral evaluation have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a comprehensive oral evaluation (D0150) to be provided by an oral surgeon.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical extraction (D7210) provided on February 15, 2022. 
 
You asked the Plan to pay for the surgical extraction. You say that you cannot afford this bill. The Plan denied 
your request. The Plan says this service is not covered under your dental plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 pay for the 
surgical extraction (D7210) provided on February 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Dexcom G6 device. 
 You asked the Plan to pre-approve the Dexcom G6 device. You say that the item is medically necessary. The 
Plan denied your request. The Plan says the member does not use insulin with at least three daily injections. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
the Dexcom G6 device have not been met. Therefore, we decided that the Plan does not have to pre-approve 
the Dexcom G6 device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an epidural injection provided on December 6, 2021. 
 
You asked the Plan to pay for an epidural injection. The Plan denied your request. The Plan says despite 
multiple outreaches by the Health Plan, this provider has not submitted any clinical records to support the 
medical necessity of the services. 
 
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 an epidural injection provided on 
December 6, 2021 have been met. Therefore, we decided that the Plan does not have to pay for an epidural 
injection provided on December 6, 2021.
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 enrollee does not require the intensity of services provided at an IRF. 
Specifically, the enrollee is not shown to be able to tolerate fifteen hours per week of rehabilitative services with regular physician evaluation. The enrollees care needs can be met at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the telehealth office visit (99203) provided 
on December 8, 2021. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
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 $30 
copayment for each telehealth specialist visit.  
 
You have been asked to pay a $30 copayment for the telehealth specialist visit provided. 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 the telehealth office visit (99203) provided on 
December 8, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the face for the 
enrollee. 
 
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no information on how the requested test would change medical treatment. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the MRI. Our reviewer says that the 
requested MRI is not medically reasonable or necessary. Our physician reviewer found the medical necessity of 
this request has not been explained in the records. The enrollee has had the ptosis for at least two years. MRI of 
the brain on 3/24/21 failed to show an orbital or retro orbital mass. There is no subdural hematoma. The patient 
apparently may have myasthenia gravis but the rationale for the requested MRI of the orbits has not been 
explained as to medical decision making or change in treatment. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve magnetic resonance imaging (MRI) of the face for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapy services provided to the enrollee on December 29, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the provider did not bill as required by Medicare coding regulations. 
 
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 code 97010 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 97010 is not separately payable. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for therapy services 
provided to the enrollee on December 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that  The Plan denied your request. The Plan says 
this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that the pain you're experiencing is because 
ligaments and tendons can no longer sustain your weight. The Plan denied your request. The Plan says this item 
is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on August 17, 2021. 
 
You asked the Plan to pay for the lab services. You say that you billed these services correctly. The Plan denied 
your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on August 17, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on September 25, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says an appropriate modifier was not billed with this code edit. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for imaging services provided to the enrollee on September 25, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture services provided from August 2, 2021, to 
August 30, 2021. 
 
You asked the Plan to pay for the acupuncture services. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says the services must be provided by a legally 
qualified physician practicing within the scope of their license. 
 The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements.  
 
We looked at the file and Medicare rules. The records do not show that the acupuncture services were furnished 
under the supervision of a physician, PA, NP, or CNS. Based on this information, we decided that the rules for 
coverage of the acupuncture services have not been met. Therefore, we decided that the Plan does not have to 
pay for the acupuncture services provided from August 2, 2021, to August 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prosthetic leg with an advanced foot, ankle feature, 
and other parts for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says a request for a K3 foot does not meet Medicare criteria as reasonable and 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 the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found while the physician states that there is K3 ambulatory potential, the notes specifically state that the 
enrollee is expected to require use of a cane for ambulation. Furthermore, the enrollee required use of a cane 
prior to ambulation. The review has determined that the enrollee is not a K3 ambulator. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a prosthetic leg with an advanced foot, ankle feature, and other parts for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chemotherapy services (J8540) provided to the enrollee on 
November 4, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says this code is not eligible for reimbursement. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code J8540 is "Dexamethasone, oral, 0.25 mg."  
We find that procedure code J8540 is not supported in the medical record for multiple reasons. Specifically, 
this code has a status indicator of "E" which means that it is excluded from the Physician Fee Schedule by 
regulation. No payment may be made for these codes. Additionally, the Medically Unlikely Edits (MUE) for 
this code for practitioners is 0, which means it is not eligible for reimbursement. Based on this information, we 
decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan 
does not have to pay for chemotherapy services (J8540) provided to the enrollee on November 4, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for infusion services provided to the enrollee on October 8, 2021. 
 
You asked the Plan to pay for . You say that Medicare said that the patient is covered by the contractor. The 
Plan denied your request. The Plan says that Medicare payment for COVID vaccinations administered during 
calendar years 2020 
and 2021 to Medicare Advantage beneficiaries will be made through the Medicare Fee For Service program. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The definition of the procedure code at issue in this case (M0243) is 
"Intravenous infusion or subcutaneous injection, casirivimab and imdevimab includes infusion or injection, and 
post administration monitoring." This is not a code for the COVID-19 vaccine, it is a code for infusion 
services. The enrollee's primary diagnosis is U071.1 which is the diagnosis code for COVID-19 itself. The plan 
has not substantiated their denial in this case, as the services at issue in this case were clearly for the treatment 
of COVID-19 itself, not the vaccine for COVID-19. Therefore, we decided that the Plan has to pay for infusion 
services provided to the enrollee on October 8, 2021.  
 
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.