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

 
We decided that the Plan does not have to pre-approve desensitizing medicament (D9910), occlusal 
adjustments (D9951, D9952), post and core in addition to crown (D2952) for teeth #22, #27 and #28, 
porcelain/ceramic crowns (D2740) for teeth #22 and #28, and prefabricated post and core in addition to crown 
(D2954) for tooth #21. 
 
You asked the Plan to pre-approve the dental services. You say that these services are necessary, and you 
expected more to be covered by your benefit. The Plan denied your request. The Plan says these services are 
not medically necessary, and some of these services are not covered by the Plan's dental benefit. 
 
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 the dental 
services which are listed in the Schedule of Benefits when the services are medically necessary and reasonable.  Though the Plan offers a supplemental benefit in excess of Medicare coverage, the requested desensitizing 
medicament and occlusal adjustments are not among those covered under this benefit. 
 
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 post and core services and the 
crowns. Our reviewer says that the requested services are not medically necessary in this case. Our physician 
reviewer found that post and core treatments are done only on teeth that have had root canals. Teeth #27, #28 
and #21 have not had root canals. Teeth #22, #27 and #28 currently have crowns in place which appear 
adequate. There was no narrative indicating why these crowns need to be replaced. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve desensitizing medicament (D9910), occlusal adjustments (D9951, D9952), post and 
core in addition to crown (D2952) for teeth #22, #27 and #28, porcelain/ceramic crowns (D2740) for teeth #22 
and #28, and prefabricated post and core in addition to crown (D2954) for tooth #21.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unspecified preventative procedure (D1999) provided on 
April 23, 2021. 
 
You asked the Plan to pay for the unspecified preventative procedure. You say that you did not know these 
services would not be covered. The Plan denied your request. The Plan says they have agreed to pay for the 
filling; however, the unspecified preventative procedure is not a covered service under your dental benefit. 
 
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 
unspecified preventative procedure (D1999) provided on April 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gingival irrigation (D4921). 
 
You asked the Plan to pre-approve gingival irrigation. You say that this service is necessary. The Plan denied 
your request. The Plan says this service is not covered by your dental benefit. 
 
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 
gingival irrigation (D4921).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vivigen allograft (20931). 
 
You asked the Plan to pre-approve Vivigen allograft. You say that the requested service is medically necessary. 
The Plan denied your request. The Plan says the service at issue is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Vivigen allograft. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is limited published, large-scale, long-term peer-reviewed literature that shows 
this request to be an effective and/or safe treatment for the noted pathology. There is no compelling rationale 
presented or extenuating circumstances noted to support the medical necessity of this request as an exception to 
guidelines.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vivigen allograft have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Vivigen allograft (20931).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on October 11, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says these services are 
not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the lab services provided on October 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 power wheelchair (K0843) power seating 
system, combination tilt and recline, with mechanical shear reduction (E1007) center mount power elevating 
leg rest/platform, complete system (E1012) group 24 sealed lead acid battery (E2363) expandable controller 
(E2377) electronic connection between wheelchair controller and two or more power seating system motors 
(E2311) harness (E2313). 
 
You asked the Plan to pre-approve power wheelchair with associated accessories. You say that the medical 
records provided will show proof of medical necessity. The Plan denied your request. The Plan says the records 
do not support that the enrollee meets the Medicare criteria. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 power wheelchair with associated 
accessories. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found based on the medical records provided it is not clear from 
the telehealth visit that a necessary physical examination could be adequately performed to meet all of the 
criteria required by the LCD for the power wheelchair and the requested accessories. Elements of this 
examination in question include gait assessment, edema assessment, ability to perform a functional weight shift 
and a skin assessment. There is no documentation that the physician who performed the telehealth face to face 
visit has been involved in the enrollee's care other than this one encounter. Provided records do not support the 
requested expandable controller, harness and electronic connection as it is documented that the enrollee has 3-
/5 upper extremity strength and is independent with feeding and hydration thus indicating she has adequate 
upper extremity strength and function to operate the wheelchairs power options with their own switches 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of power wheelchair with associated accessories have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a group 2 power wheelchair (K0843) power seating system, 
combination tilt and recline, with mechanical shear reduction (E1007) center mount power elevating leg 
rest/platform, complete system (E1012) group 24 sealed lead acid battery (E2363) expandable controller 
(E2377) electronic connection between wheelchair controller and two or more power seating system motors 
(E2311) harness (E2313).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) provided 
on September 14, 2021 by a Medicare opt out provider. 
 
You asked the Plan to pay for the comprehensive periodontal evaluation. You say that the treating provider was 
in-network in May 2020, but after June 2020 the provider was out-of-network, and you were not aware of this. 
The Plan denied your request. The Plan says you received this service from a provider who chose not to receive 
Medicare funds. The Plan also says that the treating provider opted out of Medicare effective June 20, 2016, to 
June 20, 2022. 
 
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 received by a provider who has opted out of Medicare. Therefore, we decided that the 
Plan does not have to pay for the comprehensive periodontal evaluation (D0180) provided on September 14, 
2021 by a Medicare opt out provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an opt-out provider on October 
8, 2020. 
 
You asked the Plan to pay for dental services. You say that you would like the Plan to pay for this. The Plan 
denied your request. The Plan says this provider has opted out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program until July 15, 2022. Therefore, we decided that the Plan does not have 
to pay for dental services provided by an opt-out provider on October 8, 2020.
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 the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
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 is medically stable and does not need physical Medicine and 
Rehabilitation (PM&R) physician close supervision three (3) times per week (at a minimum) for the ongoing 
management of any active or acute exacerbations of chronic medical conditions. No rehabilitation nursing 
needs identified or documented in the record. At the current functional level, the enrollee does not need three 
(3) hours a day five days a week of IRF therapies with interdisciplinary management and the needs can be met in an alternate and lower setting such as in a skilled nursing facility (SNF). IRF admission is not medically 
necessary based on medical stability, lack of medical complexity, and lack of rehabilitation nursing needs. 
Documentation does not support the necessity for admission to an IRF. While the enrollee may benefit from 
physical therapy (PT), and occupational therapy (OT), the enrollee's rehabilitation can be safely provided at a 
lower intensity and alternate setting such as in an SNF with intermittent therapies. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction, erupted tooth requiring removal of bone 
and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210) and 
alveoloplasty in conjunction with extractions (D7310) provided October 13, 2021. 
 
You asked the Plan to pay for the tooth extractions and alveoloplasty. You say that these extractions were 
necessary prior to having heart surgery. The Plan denied your request. The Plan says tooth extractions are 
covered as a dental service however you have used your full dental allowance. The alveoloplasty 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 Plan's coverage rules apply in this case.  
Though the Plan offers dental benefits in excess of Medicare coverage, the extraction of erupted teeth (D7210) 
and alveoloplasty are not among those covered services. Therefore, we decided that the Plan does not have to 
pay for the extraction, erupted tooth requiring removal of bone and/or sectioning of tooth and including 
elevation of mucoperiosteal flap if indicated (D7210) and alveoloplasty in conjunction with extractions 
(D7310) provided October 13, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex Superion spacer. 
 
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 Food and Drug Administration 
(FDA) indications include implantation of the Superion device at one or two adjacent lumbar levels in patients 
with moderate spinal stenosis in whom operative treatment is indicated at no more than two levels, from L1 to 
L5. This enrollee has multiple degrees of spinal stenosis, many not at FDA indicated levels of moderate 
spinal stenosis. There is no compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception to guidelines. Therefore, the request for Vertiflex Superion 
interspinous device at L2-3 and L3-4 is not medically reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Vertiflex Superion spacer.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gingival irrigations (D4921) for the upper right quadrant 
and lower right quadrant. 
 
You asked the Plan to pre-approve the gingival irrigations. You say that gingival irrigation was recommended 
for the enrollee because it is an effective way to flush the debris and bacteria out of the periodontal pocket that 
has been broken down with the scaling and planing. You also say that the antimicrobial irrigation will aid in 
further eliminating the harmful bacteria that has cause the enrollee's gum infection. The Plan denied your 
request. The Plan says this service is not covered under the enrollee's benefit 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 
gingival irrigations (D4921) for the upper right quadrant and lower right quadrant.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), prophylaxis (D1110), 
bitewing x-rays (D0274), first intraoral periapical x-ray (D0220), crown (D2740), endodontic therapy (D3320), 
and prefabricated post and core in addition to crown (D2954) provided on September 30, 2021, and December 
7, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the periodic oral evaluation, prophylaxis, bitewing x-rays, first intraoral 
periapical x-ray, crown, endodontic therapy, and prefabricated post and core. You say that the treating provider 
is in-network, and there was never any reference to your insurance card being OON. The Plan denied your 
request. The Plan says services performed by an OON provider are not covered because your healthcare plan 
does not have OON benefits. The Plan also says that the prefabricated post and core is not a covered expense 
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, prefabricated post and core in addition 
to crown (D2954) is not among those covered under this benefit. You are also responsible for 100% of the cost 
for dental services rendered by an OON provider. Therefore, we decided that the Plan does not have to pay for 
the periodic oral evaluation (D0120), prophylaxis (D1110), bitewing x-rays (D0274), first intraoral periapical 
x-ray (D0220), crown (D2740), endodontic therapy (D3320), and prefabricated post and core in addition to 
crown (D2954) provided on September 30, 2021, and December 7, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

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

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on January 8, 
2022. 
 
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. 
 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 January 8, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service November 3, 
2021. 
 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 November 3, 
2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Repatha. 
 
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 self-administered drugs are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Repatha.  
 
 
 Benefits for these services 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on August 9, 2021. 
 
You asked the Plan to pay for the lab services. You say that this is a Medicare-covered service. 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 9, 2021.