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

 
We decided that the Plan does not have to pay for prophylaxis (D1110), periodic oral evaluation (D0120), and 
bitewings (D0274), provided by an out-of-network provider on August 22, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for this. 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 prophylaxis (D1110), periodic oral evaluation (D0120), and bitewings (D0274), provided by an out-
of-network provider on August 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction of erupted tooth or exposed root (D7140), an 
intraoral - complete services (D0210), unspecified orthodontic procedure (D9999), and a limited oral 
evaluation - problem focused (D0140) provided from July 28, 2021, to October 12, 2021. 
 
  You asked the Plan to pay for the extraction of erupted tooth or exposed root (D7140), an intraoral - complete 
services (D0210), unspecified orthodontic procedure (D9999), and a limited oral evaluation - problem focused 
(D0140). You say that you were told these would be covered if this was a medical necessity. The Plan denied 
your request. The Plan says according to Centers of Medicare & Medicaid Services (CMS), Medicare Dental 
Coverage guidelines indicate that Medicare will not make payments for dental treatment preceding kidney 
transplantation or heart valve replacement. Upon additional review by the Plan's Medical Director, 
this service did not meet these guidelines outlined by CMS. 
 
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 the 
extraction of erupted tooth or exposed root (D7140), an intraoral - complete services (D0210), unspecified 
orthodontic procedure (D9999), and a limited oral evaluation - problem focused (D0140) provided from July 
28, 2021, to October 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a prefabricated abutment (D6056) and an abutment 
supported crown (D6059) provided by an out-of-network provider on June 21, 2022. 
 
You asked the Plan to pay for a prefabricated abutment and an abutment supported crown. You say that you 
would like the Plan to pay for this. The Plan denied your request. The Plan says the rendered dental services are 
not covered 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 pay for a 
prefabricated abutment (D6056) and an abutment supported crown (D6059) provided by an out-of-network 
provider on June 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a resin-based composite (D2393) and intraoral - periapical 
first radiographic image (D0220) provided on May 12, 2022. 
 
You asked the Plan to pay for the dental services. You say that each time you went to the dental provider, they 
informed you these services would be covered by your Plan. You also say that at no time were your informed 
that these services would exhaust your benefit. 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 April 8, 2022. Therefore, 
we decided that the Plan does not have to pay for a resin-based composite (D2393) and intraoral - periapical 
first radiographic image (D0220) provided on May 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for procedure codes 97010, 97026 and 97140 billed for date of 
service February 22, 2022. 
 
You asked the Plan to pay for procedure codes 97010, 97026 and 97140. You say that this service was 
medically necessary. The Plan denied your request. The Plan says the codes billed cannot be paid. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 97010 has a status indicator of B on the Physician Fee Schedule. Code 97140 has 
a bundled relationship with code 97012 and is not separately payable. Code 97026 was billed or infrared 
therapy which is a non-covered service under Medicare rules. Therefore, we decided that the Plan does not 
have to pay for procedure codes 97010, 97026 and 97140 billed for date of service February 22, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan of the thorax provided 
on September 13, 2021. 
 
You asked the Plan to pay for the CT scan of the thorax. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says this claim must be billed to Original 
Medicare. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the computed tomography (CT) scan of the thorax provided 
on September 13, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is a medical necessity for the enrollee. The 
Plan denied your request. The Plan says rules for IRF care have 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 that the complexity of the enrollee's nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical and/or occupational therapy, there is no documented need for 
intensive rehabilitation services. There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Lupron. 
 
You asked the Plan to pre-approve Lupron. You say that Lupron is clinically indicated and appropriate, not 
Eligard. The Plan denied your request. The Plan says the Plan requires a trial of Eligard before it will approve 
Lupron. 
 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 Lupron. Our reviewer says that the 
enrollee does not meet the criteria for a step therapy exception for Lupron. Our physician reviewer found the 
enrollee has not tried and failed Eligard. The record does not show that this drug would likely be less effective 
and/or 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 Lupron have not been met. Therefore, we decided that the Plan does not have to 
pre-approve use of Lupron.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for standard frames (V2020), photochromic tint (V2744) anti-
reflective coating (V2750), progressive lenses (V2781), and polycarbonate lenses (V2784) provided on July 15, 
2022. 
 
You asked the Plan to pay for standard frames (V2020), photochromic tint (V2744) anti-reflective coating 
(V2750), progressive lenses (V2781), and polycarbonate lenses (V2784). You say that your eye exam 
determined that your prescription had changed from our last eye examination, and you needed new glasses. The 
Plan denied your request. The Plan says the plan coverage is limited to one pair of standard lenses and frames 
every two years. The Plan also says they issued payment for the first eyewear purchased on March 29, 2021. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers one pair of standard lenses and frames every two years. 
 
We looked at the file and the Plan's rules. The Plan rules say they cover one pair of standard lenses and frames 
every two years. The record shows that the Plan covered a pair of eyeglasses on July 15, 2022, therefore, the 
benefit has been exhausted. Based on this information, we decided that the Plan's rules for coverage of standard 
frames (V2020), photochromic tint (V2744) anti-reflective coating (V2750), progressive lenses (V2781), and 
polycarbonate lenses (V2784) have not been met. Therefore, we decided that the Plan does not have to pay for 
standard frames (V2020), photochromic tint (V2744) anti-reflective coating (V2750), progressive lenses 
(V2781), and polycarbonate lenses (V2784) provided on July 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an extraction of the erupted tooth or exposed root (D7140) 
for tooth number 26, and adding a tooth to an existing partial denture (D5650) for tooth number 26 provided on 
December 3, 2021. 
 
You asked the Plan to pay for an extraction of the erupted tooth or exposed root (D7140) for tooth number 26, 
and adding a tooth to an existing partial denture (D5650). You say that you are on a limited income. You also 
say that you pay for this coverage, and you expect it to be paid. The Plan denied your request. The Plan says 
the service is not covered under the member's contract under any normal circumstances. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an 
extraction of the erupted tooth or exposed root (D7140) for tooth number 26, and adding a tooth to an existing 
partial denture (D5650) for tooth number 26 provided on December 3, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for diagnostic colonoscopy provided on August 
12, 2022. 
 
You asked the Plan to waive the cost share for diagnostic colonoscopy. You say that you are disputing the 
share cost. 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 10% 
coinsurance for outpatient hospital services. You have been asked to pay 220.78 deductible. The allowed 
amount of this diagnostic colonoscopy total $600.05, resulting in a total coinsurance amount of $60.05. The 
final cost is $280.83.  
 
You have been asked to pay 10% coinsurance for diagnostic colonoscopy. This item/service falls within the 
outpatient hospital 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 cost share for diagnostic 
colonoscopy provided on August 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral complete series of radiographic images (D0210) 
provided on July 21, 2022. 
 
You asked the Plan to pay for intraoral complete series of radiographic images (D0210). You say that  The Plan 
denied your request. The Plan says there is no coverage for intraoral complete series of radiographic images 
(D0210). 
 
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 intraoral 
complete series of radiographic images (D0210) provided on July 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve excision or destruction (e.g., laser), intranasal lesion; 
internal approach and Nasal endoscopy, diagnostic, unilateral or bilateral (separate procedure) - [nasal 
cryotherapy (vidian neurectomy)]. 
 
You asked the Plan to pre-approve excision or destruction (e.g., laser), intranasal lesion; internal approach and 
Nasal endoscopy, diagnostic, unilateral or bilateral (separate procedure) - [nasal cryotherapy (vidian 
neurectomy)]. You say that excision or destruction (e.g., laser), intranasal lesion; internal approach and Nasal 
endoscopy, diagnostic, unilateral or bilateral (separate procedure) - [nasal cryotherapy (vidian neurectomy)] is 
medically necessary. The Plan denied your request. The Plan says a review of the current medical literature 
indicates that this service is considered experimental and investigational as it is not identified as widely used 
and generally accepted for the proposed use as reported in nationally recognized peer-reviewed medical 
literature published in the English language. 
 
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 excision or destruction (e.g., laser), 
intranasal lesion; internal approach and Nasal endoscopy, diagnostic, unilateral or bilateral (separate procedure) 
- [nasal cryotherapy (vidian neurectomy)]. Our reviewer says that the requested excision or destruction (e.g., 
laser), intranasal lesion; internal approach and Nasal endoscopy, diagnostic, unilateral or bilateral (separate 
procedure) - [nasal cryotherapy (vidian neurectomy)] is not considered medically reasonable and necessary. 
Our physician reviewer found that in this case, the record indicates that the enrollee has chronic rhinitis. There 
is insufficient literature to support the safety and efficacy of the requested procedure for the enrollee's clinical 
condition. The record provided does not establish the medical necessity and reasonableness, as defined by 
Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of excision or destruction (e.g., laser), intranasal lesion; internal approach and 
Nasal endoscopy, diagnostic, unilateral or bilateral (separate procedure) - [nasal cryotherapy (vidian 
neurectomy)] have not been met. Therefore, we decided that the Plan does not have to pre-approve excision or 
destruction (e.g., laser), intranasal lesion; internal approach and Nasal endoscopy, diagnostic, unilateral or 
bilateral (separate procedure) - [nasal cryotherapy (vidian neurectomy)].
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs (A9270) provided from July 13, 
2022, through July 14, 2022. 
 
You asked the Plan to pay 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 a covered benefit. 
 
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 provided are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
(A9270) provided from July 13, 2022, through July 14, 2022.  
 Benefits for these items 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hearing aid (V5298) provided on June 13, 2022. 
 
You asked the Plan to pay for a hearing aid (V5298). You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says the hearing benefit is not covered if the services are not registered 
in advance. 
 
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 ordered through the Plan hearing providers.  
 
We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of a hearing aid (V5298) have not been met. Therefore, we decided that the Plan does not have to pay 
for a hearing aid (V5298) provided on June 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service July 9, 2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 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 procedure code 70450 billed for date of service July 9, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS procedure. 
 
You asked the Plan to pre-approve CardioMEMS. You say that this device will help keep the enrollee out of 
the hospital. The Plan denied your request. The Plan says there is not enough evidence showing this would 
improve the enrollee's condition. 
 
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 CardioMEMS. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there remains a dearth of randomized, blinded clinical studies examining long-term clinical 
outcomes establishing the value of CardioMEMS in patient management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CardioMEMS have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the CardioMEMS procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral imaging (D0210) provided by a participating 
provider on July 5, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were having pain. 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 July 2, 2021. Therefore, 
we decided that the Plan does not have to pay for intraoral imaging (D0210) provided by a participating 
provider on July 5, 2022.