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

 
We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided May 4, 2022. 
 
You asked the Plan to pay for the periodontal maintenance. You say that you feel the service performed was no 
different than a regular cleaning. 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 pay for the 
periodontal maintenance (D4910) provided May 4, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an integrated upgraded electronic system for a power 
wheelchair.  
You asked the Plan to pre-approve an upgraded electronic system. You say that this equipment is medically 
necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
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 an upgraded electronic system. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there is no medical necessity for integrated electronics allowing the 
enrollee to operate motors from one location. She has decreased strength but does not have paralysis or limited 
to no use of one of her upper extremties or hands. The requested equipment is not medically reasonable and 
necessary per Medicare coverage rules. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an upgraded electronic system have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an integrated upgraded electronic system for a power wheelchair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), intraoral x-rays (D0210), 
fluoride treatment (D1208), resin-based composite filling on tooth #25 (D2331), and prophylaxis (D1110) 
provided on July 22, 2020. 
 
You asked the Plan to pay for the dental services. You say that you were told you had a $1,000 allowance for 
dental services. The Plan denied your request. The Plan says that your dental allowance has been exhausted.  
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 have a $1,000 
allowance for supplemental preventive and comprehensive dental services 
 
The record shows your dental allowance has been exhausted on previous dental claims. You have been asked to 
pay a total of $536 for the dental services received on July 22, 2020. The dental services fall within the Dental 
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 pay for a periodic oral evaluation (D0120), intraoral 
x-rays (D0210), fluoride treatment (D1208), resin-based composite filling on tooth #25 (D2331), and 
prophylaxis (D1110) provided on July 22, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve all lower extremity prostheses, flex-walk system or equal (L5981) 
and all lower extremity prostheses, multiaxial rotation unit (L5986). 
 
You asked the Plan to pre-approve prosthetics. You say that you do more than simple walking. You have no 
prosthetic limb, this being your first and this is needed for daily activities. The Plan denied your request. The 
Plan says that the request for a K3 foot exceeds your need and does not meet the Medicare criteria of 
reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 prosthetics. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found clinical documentation shows that you are a K3 level ambulator with variable cadences on 
different terrain with capacity and activities that are more complex than ambulation solely. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of prosthetics have been met. Therefore, we decided that the Plan has to pre-
approve all lower extremity prostheses, flex-walk system or equal (L5981) and all lower extremity prostheses, 
multiaxial rotation unit (L5986).  
 
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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the expandable controller with joystick (E2377, E2313, 
E2311, K0108). 
 
You asked the Plan to pre-approve the expandable controller. You say that this equipment is medically 
necessary for the enrollee to operate the power wheelchair. The Plan denied your request. The Plan says there 
is no medical need for the enrollee to control the power wheelchair through the joystick. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules say the criteria for an expandable controller is listed in the Medicare rules 
section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the expandable controller. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this is a request for an expandable controller accessory to a power wheelchair. The 
enrollee has a progressive form of multiple sclerosis and has been non-ambulatory for at least 10 years. She is 
dependent in all activities of daily living. The medical record from the face-to-face with her physician clearly 
states she has a normal grip. Her functional deficits are primarily in her lower extremity. In this case, the 
enrollee has normal hand strength that does not prohibit her from operating the power wheelchair. The 
requested accessory is not medically necessary as it exceeds what the enrollee requires to meet her needs for 
mobility associated activities of daily living. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the expandable controller have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the expandable controller with joystick (E2377, E2313, E2311, K0108).
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for all the dental services provided from June 2, 2021, to October 13, 2021.
  
You asked the Plan to pay for the dental services. You say that you needed emergency dental care. The Plan 
denied your request. The Plan says that this provider has opted out of Medicare and is not eligible for payment. 
 
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 Plan did not provide enough information allowing us to confirm the 
providers address location. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare plans may not pay for services given 
by a physician or other practitioner who has opted out of Medicare. The rules also say that a Medicare plan 
must pay for emergency or urgently needed services given by a physician or practitioner who has not signed a 
private contract with the enrollee.  
 
We are unable to confirm if the provider you received services from has opted out of Medicare, as the address 
location provided in the record is different than the one listed on the Medicare opt out website. Therefore, we 
decided that the Plan has to pay for all the dental services provided from June 2, 2021, to October 13, 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.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for procedure code 17250 billed for date of service January 25, 
2022. 
 
You asked the Plan to pay for procedure code 17250. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says payment for code 17250 is bundled into 
payment for code 11042. 
 
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 17250 
is a column II code to column I code 11042. 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 17250 billed for date of service January 25, 
2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no off-label use supported in the Centers for Medicare & Medicaid Services 
(CMS) accepted compendia or medical literature for this enrollee's condition. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found that the record indicates 
that the enrollee has a diagnosis of retroperitoneal leiomyosarcoma. The Food and Drug Administration has not 
stated that the requested drug is indicated for the enrollee's condition. The Medicare approved cancer drug 
compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical 
situation. No literature from Medicare approved cancer journals were submitted for review. 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 the drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 7, 2021, billed with 
codes four units of 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that this is a medically necessary test that 
assists in diagnosis/treatment of irritable bowel syndrome. The Plan denied your request. The Plan says all 
codes aside from 81479 were approved for payment. The claim did not provide the required narrative 
information to validate the use of the code 81479. 
 The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
June 7, 2021, billed with codes four units of 81479.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for urgent care visit provided on December 15, 
2021. 
 
You asked the Plan to waive the copayment for urgent care visit. You say that you were told there would be no 
charge. The Plan denied your request. The Plan says the copayment applied is correct. 
 
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 $65 
copayment for Medicare covered urgently needed care services.  
 
You have been asked to pay $65 copayment for urgent care visit. Urgent care visits fall within the Urgently 
Needed 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 urgent care visit 
provided on December 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildup (D2950), gingivectomy (D4212), and core 
in addition to crown (D2952) for tooth #8. 
 
You asked the Plan to pre-approve core buildup, gingivectomy, and core in addition to crown. You say that you 
need these procedures done and would like for the Plan to pay for it. The Plan denied your request. The Plan 
says the denial of authorization for these services is correct, because core buildup, gingivectomy, and core in 
addition to crown are not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve core 
buildup (D2950), gingivectomy (D4212), and core in addition to crown (D2952) for tooth #8.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visit provided on February 
23, 2022. 
 
You asked the Plan to waive the copayment for specialist office visit. You say that you received this visit while 
you were in the hospital so it should be covered. The Plan denied your request. The Plan says the copayment 
applied is correct. 
 
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 $35 
copayment per visit to a specialist.  
 
You have been asked to pay $35 copayment for specialist office visit. Specialist office visits fall within the 
Physician/Practitioner Services, Including Doctors Office Visits 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 specialist office visit provided on February 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for medical eye exam provided on February 
16, 2022. 
 
You asked the Plan to waive the copayment for medical eye exam. You say that this was supposed to be a 
routine eye exam not a medical one. The Plan denied your request. The Plan says the copayment applied is 
correct. 
 
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 $20 
copayment for a medical eye exam.  
 
You have been asked to pay $20 copayment for medical eye exam. Medical eye exams fall within the Vision 
Care 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 medical eye exam provided on 
February 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a specialist office visit on April 5, 2022. 
 
You asked the Plan to reduce the copayment for a specialist office visit. You say that you should only be 
responsible to pay the copayment for a primary care provider visit. The Plan denied your request. The Plan says 
you must pay a $40 copayment for each specialist visit or telehealth visit for Medicare-covered benefits. 
 
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 $40 for a 
specialist visit.  
 
You have been asked to pay $40 for a specialist office visit. A specialist office visit falls within the 
Physician/Practitioner Services, Including Doctors Office Visits 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 reduce the copayment for a specialist office visit on April 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a dental screening (D0190) and a partial mandibular denture 
(D5212) provided on March 31, 2022, and a dental screening (D0190) and a partial mandibular denture 
(D5212) provided on June 6, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services 
The Plan denied your request. The Plan says your annual dental maximum has been exhausted. The Plan also 
says that a dental screening (D0190) is not covered by your dental benefits. 
 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 this benefit includes only 
the items and services listed in the Dental Services benefit category but only up to $1,000 for comprehensive 
denial services. 
 
The record shows your annual maximum for comprehensive dental services was exhausted on March 11, 2022. 
Therefore, you are responsible for any charges above the maximum amount. A screening and dentures fall 
within the Dental 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.  
 
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, a dental screening is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for a dental screening 
(D0190) and a partial mandibular denture (D5212) provided on March 31, 2022, and a dental screening 
(D0190) and a partial mandibular denture (D5212) provided on June 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bitewing x-rays (D0274) provided by a network provider 
on March 22, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are appealing this claim and you do not 
know why the claim denied. 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 20, 2021. Therefore, 
we decided that the Plan does not have to pay for the bitewing x-rays (D0274) provided by a network provider 
on March 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial ostectomy/sequestrectomy, or the removal of 
dead bone (D7550). 
 
You asked the Plan to pre-approve the dental services. You say that you received a dental bone graft in 2021 
and you need the requested services to remove bone growth. The Plan denied your request. The Plan says 
coverage of the requested service was denied appropriately. The Plan says removal of dead bone is not a 
covered benefit included in the supplemental benefit offered to you. 
 
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 service is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a partial 
ostectomy/sequestrectomy, or the removal of dead bone (D7550).