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

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on July 
20, 2022. 
 
You asked the Plan to pay for the comprehensive oral evaluation. You say that you went to the dentist and were 
told you needed to see a surgeon to have your teeth removed. You also say that you had to be evaluated by the 
surgeon for surgery. 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 14, 2022. Therefore, 
we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on July 
20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) 
provided on August 11, 2022. 
 
You asked the Plan to pay for the problem focused limited oral evaluation. You say that you did not have a root 
canal because the tooth was infected, but you were charged $200 for the office visit. 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 August 9, 2022. 
Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation 
(D0140) provided on August 11, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve laparoscopy, surgical, gastric restrictive procedure; 
longitudinal gastrectomy (43775), and laparoscopy, surgical, gastric restrictive procedure; removal of 
adjustable gastric restrictive device and subcutaneous port components (43774). 
 
You asked the Plan to pre-approve the gastric surgical services. You say that you need this procedure done. 
You say that you have diabetes. You also say that you want to get off your blood pressure medication. The Plan 
denied your request. The Plan says the requested procedure is not medically necessary. 
 The Plan follows Medicare rules. Medicare rules say that the surgical management for the treatment of morbid 
obesity is considered reasonable and necessary for all nationally covered bariatric surgical procedures and 
Laproscopic sleeve gastrectomy when all of the conditions are met and recorded in the medical record. 
 
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 gastric surgical services. Our 
reviewer says that the requested gastric surgical services is not medically necessary. Our physician reviewer 
found the provided documentation does not indicate that you have a body mass index of at least 35. The 
reviewer found that the record indicates that you are prescribed psychotropic medications. The documentation 
does not include documentation of current psychological evaluation. Therefore, the reviewer found that the 
requested services are not medically necessary. 
 
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 gastric surgical services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve laparoscopy, surgical, gastric restrictive procedure; longitudinal gastrectomy 
(43775), and laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric restrictive device 
and subcutaneous port components (43774).
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 enrollee needs intense speech therapy and 
physical therapy. The Plan denied your request. The Plan says based the enrollee does not require the intensity 
of services provided at an IRF.  
 
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 mobility issues can now be managed at a lower level of care. There is no documented need for an intensive, multi-disciplinary rehabilitation program. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) 
provided on August 2, 2022. 
 
You asked the Plan to pay for the problem focused limited oral evaluation. You say that the provider you saw 
on this date of service did not help you. You also say that you are living on social security, and if you had 
known your dentist was out of town at the time, you would not have gone in. The Plan denied your request. 
The Plan says this service is not a covered expense under your dental plan. The Plan also says that you did not 
contact the Plan prior to the date of service to verify benefits and provider eligibility. 
 
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 
problem focused limited oral evaluation (D0140) provided on August 2, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a positron emission tomography (pet) scan. 
 
You asked the Plan to pay for a positron emission tomography (pet) scan. You say that you would like to 
request reconsideration of the denied authorization. The Plan denied your request. The Plan says the service is 
not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans 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 pay for a positron emission tomography (pet) scan. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found a PSMA PET/CT 
is not a covered scan for a patient without the diagnosis of prostate cancer. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a positron emission tomography (pet) scan have not been met. Therefore, we 
decided that the Plan does not have to pay for a positron emission tomography (pet) scan.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cone beam computed tomography (CT) capture and 
interpretation (D0367) provided on July 5, 2022. 
 
You asked the Plan to pay for the cone beam CT capture and interpretation. You say that you thought the x-ray 
was a covered procedure. The Plan denied your request. The Plan says this service is not a covered benefit 
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 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 cone 
beam computed tomography (CT) capture and interpretation (D0367) provided on July 5, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (80307, G0480) provided on April 7, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services were necessary and are supported as 
billed. 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, for 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 (80307, G0480) provided on April 7, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9500 billed for date of service April 1, 2022 
to April 4, 2022. 
 
You asked the Plan to pay for procedure code S9500. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
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 S9500 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9500 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure code S9500 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9500 billed for date of service April 1, 2022 to April 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids (V5261) purchased on July 15, 2022. 
 
You asked the Plan to pay for the hearing aids. You say that you were assured the Plan would cover up to $500 
for hearing aids. The Plan denied your request. The Plan says hearing aids must be ordered through the Plan's 
hearing aid vendor. 
 
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 they are purchased from the Plan's approved hearing aid vendor.  
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for 
the hearing aids (V5261) purchased on July 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the maxillary tissue conditioning (D5850) and reline of a 
complete mandibular denture (D5751) provided on February 9, 2022, and July 26, 2022. 
 
You asked the Plan to pay for the maxillary tissue conditioning and reline of a complete mandibular denture. 
You say that you went to the dentist in good faith that you were going to come out of the procedure with 
wearable dentures. You also say that both you and the Plan paid a lot of money to result in a failed service. The 
Plan denied your request. The Plan says the maxillary tissue conditioning is not covered if performed within six 
months of initial denture replacement. The Plan also says that your benefits for the reline of a complete 
mandibular denture have been satisfied and the frequency limitation has been exceeded. 
 
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, denture adjustments are not covered if 
provided within six months of initial placement. The record shows that the initial denture placement was 
provided on November 3, 2021, and this adjustment was provided within six months of the initial placement, 
and is not covered. The Plan contract also says denture relines are limited to one procedure code per calendar 
year. The record shows that you received a reline of a complete maxillary denture (D5750) on July 26, 2022, 
which was covered by the Plan, and your denture relines benefit has been exhausted. Therefore, we decided 
that the Plan does not have to pay for the maxillary tissue conditioning (D5850) and reline of a complete 
mandibular denture (D5751) provided on February 9, 2022, and July 26, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee would benefit from IRF services. The 
Plan denied your request. The Plan says the request is not medically necessary. 
 
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 enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
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 IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the removal of torus mandibularis (D7473) provided on June 
1, 2022. 
 
You asked the Plan to pay for the removal of torus mandibularis. You say that you would like this claim to be 
reconsidered for coverage because you paid out of pocket for this service, and you are on a disability income. 
The Plan denied your request. The Plan says this service is not covered under your 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 pay for the 
removal of torus mandibularis (D7473) provided on June 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the visit provided on June 23, 2022. 
 
You asked the Plan to pay for the visit. The Plan denied your request. The Plan says this was not a new patient 
visit. 
 
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 99205 is "Office or other outpatient visit for the 
evaluation and management of a new patient, which requires a medically appropriate history and/or 
examination and high level of medical decision making. When using time for code selection, 60-74 minutes of 
total time is spent on the date of the encounter."  
We find that CPT code 99205 is not supported in the medical record. Specifically, the records show that the 
enrollee was seen by this provider on April 6, 2022. The requested visit was provided within three years of the 
visit on April 6, 2022. As such, the requested visit is not considered a new patient visit. Based on this 
information, we decided that Medicare rules for coverage of the visit have not been met. Therefore, we decided 
that the Plan does not have to pay for the visit provided on June 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued care with the out-of-network neurosurgeon. 
 
You asked the Plan to pre-approve continued care with the out-of-network neurosurgeon. You say that 
continued care with the out-of-network neurosurgeon is medically necessary. The Plan denied your request. 
The Plan says continued care with the out-of-network neurosurgeon is not medically necessary. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet the enrollees needs. The enrollees contract with the Plan says that, with few 
exceptions, enrollees must use contract providers for care.  
 
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 continued care with the out-of-network 
neurosurgeon. Our reviewer says that continued care with the out-of-network neurosurgeon is not medically 
necessary. Our physician reviewer found the record indicates that the enrollee has previously undergone spinal 
fusion in 2008. The record indicates that the enrollee has been seen by the requested provider who has 
recommended non-surgical treatment. The record does not indicate that the enrollee is receiving active care 
such that transferring her care and medical management to another provider would be medically inappropriate 
and/or contraindicated at this time. The plan has indicated that plan providers are capable and available of 
providing the needed services. The elements of the coverage criteria are not satisfied. The requested service is 
not recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued care with the out-of-network neurosurgeon have not been met. 
Therefore, we decided that the Plan does not have to pre-approve continued care with the out-of-network 
neurosurgeon.
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 you need an acute rehabilitation stay to return home 
at the highest level possible. The Plan denied your request. The Plan says criteria for admission to the IRF 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 the clinical documentation shows you have complex functional impairments 
however, there are no active medical comorbidities specified that would require continued inpatient 
hospitalization during rehabilitation. The complexity of your nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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 IRF admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a gastric emptying study. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the record indicates that the enrollee 
has a type III paraoesophageal hernia without reflux and underwent an upper gastrointestinal contrast study that 
did not reveal any obstruction. The test is being requested to screen for gastroparesis, for which the enrollee is 
symptomatic. The requested gastric emptying study is not reasonable or medically necessary based on the 
submitted documentation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a gastric emptying study.