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

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140), and endodontic therapy 
(D3332) provided by a participating provider on August 17, 2021. 
 
You asked the Plan to pay for a limited oral evaluation and endodontic therapy. You say that you would like 
the Plan to pay for this. The Plan denied your request. The Plan says this claim has been processed correctly. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers one limited 
oral evaluation every plan year. The Plan does not cover endodontic therapy. 
 
We looked at the file and Medicare rules. Evidence was provided to show that D0140 was previously provide 
on August 4, 2021. Based on this information, we decided that the Plan's rules for coverage of a limited oral 
evaluation have not been met. a limited oral evaluation (D0140). Endodontic therapy is not a covered dental benefit. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140), and 
endodontic therapy (D3332) provided by a participating provider on August 17, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee orthosis represented by code L1843, and a 
suspension sleeve addition represented by code L2397. 
 
You asked the Plan to pre-approve codes L1843 and L2397. You say that the enrollee will benefit from the 
requested bracing which is medically necessary. The Plan denied your request. The Plan says the requirements 
for approval have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that L1843 is covered for certain indications, and related 
additions are only covered when the base orthosis has been approved.  
 
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 codes L1843 and L2397. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the documentation does not 
reveal objective physical exam evidence of knee instability. There is no evidence of recent injury or surgery to 
the knees. The patient is documented to be ambulatory. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of codes L1843 and L2397 have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a knee orthosis represented by code L1843, and a suspension sleeve addition 
represented by code L2397.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the flow cytometry rendered on October 25, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable. 
 
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 88342 
is a column II code to column I code 88184. This claim has not been billed with an appropriate modifier to 
bypass the edit. The -XU modifier is not supported as a separate and distinct procedural service. Based on the 
claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have 
to pay for the flow cytometry rendered on October 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve osseous (D7952), and sinus augmentation (D7950) 
provided by a participating provider. 
 
You asked the Plan to pre-approve osseous and sinus augmentation. You say that you would like the Plan to 
approve these services. The Plan denied your request. The Plan says the requested 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 pre-approve 
osseous (D7952), and sinus augmentation (D7950) provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crowns (D2740), and core build-ups (D2950), provided 
by a participating provider. 
 
You asked the Plan to pre-approve crowns and core build-ups. You say that these services were medically 
necessary. The Plan denied your request. The Plan says the requested services have been processed correctly 
and denied. 
 
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, D2950 is not among those covered 
under this benefit. The benefit limit for D2740 has been exhausted due to pre-approval for D2740 for tooth #7. 
Therefore, we decided that the Plan does not have to pre-approve crowns (D2740), and core build-ups (D2950), 
provided by a participating provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visit provided on January 21, 2022. 
 
You asked the Plan to waive the copayment for office visits. You say that you do not have a copayment for 
wellness visits, and you paid the copayment for the regular office visit. The Plan denied your request. The Plan 
says coinsurance 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 $5 for 
each Medicare-covered visit with an in-network PCP.  
 
  You have been asked to pay $5 copayment for the office visit. The office visit falls within the 
Physician/Practitioner services, including doctor's 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 office visit provided on January 21, 2022.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pre-approve a breathing capacity testing (94010). 
 
You asked the Plan to pre-approve a breathing capacity testing. You say that the requested testing is medically 
necessary. The Plan denied your request. The Plan says that the requested testing does not meet criteria. 
 
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 a breathing capacity testing. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case. 
Our physician reviewer found you have moderate persistent asthma. Objective measures of lung function aid 
the clinician in assessing the status of asthma control.  You have had recent changes in medications, and 
spirometry was used at the March visit to help in making treatment decisions. It is reasonable to repeat 
spirometry at the 3-month follow up visit to see if improvements at the March visit have been maintained, 
especially given your poor memory and unreliable reporting of symptoms. 
 
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 breathing capacity testing have been met. Therefore, we decided that the Plan 
has to pre-approve a breathing capacity testing (94010).  
 
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 waive the coinsurance for the oscillation system provided on 
February 4, 2022. 
 
You asked the Plan to waive the coinsurance for the oscillation system. You say that you returned the 
equipment early so you shouldn't have to pay for the whole month. The Plan denied your request. The Plan says 
the coinsurance 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 5% 
coinsurance for in- network durable medical equipment (DME) and related supplies.  
 
 
 
 
 You have been asked to pay $45.16 which is 5% of the allowed amount for the oscillation system. (5% x 
903.29 = $45.16). The oscillation system falls within the durable medical equipment (DME) and related 
supplies 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 coinsurance for the oscillation system 
provided on February 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on 
December 15, 2021. 
 
You asked the Plan to pay for the comprehensive oral evaluation. You say that the Plan referred you to this 
provider. The Plan denied your request. The Plan says this service exceeds the maximum allowed per period. 
 
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, comprehensive oral evaluation 
(D0150) is limited to one procedure every three plan years. The record shows that you received a 
comprehensive oral evaluation (D0150) on June 11, 2021 and your comprehensive oral evaluation (D0150) 
benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive 
oral evaluation (D0150) provided on December 15, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laser surgery provided on February 7, 2022. 
 
You asked the Plan to waive the copayment for laser surgery. You say that were not advised the facility you 
went to was a hospital facility and that costs would exceed your expected copayment. The Plan denied your 
request. The Plan says coinsurance 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 $245 
copayment for in-network, ambulatory surgical center.  
 
  You have been asked to pay $215.04, which is less than the standard $245 copayment for laser surgery. The 
laser surgery falls within the Outpatient surgery, including services provided at hospital outpatient facilities 
and ambulatory surgical centers 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 
laser surgery provided on February 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve anti-slip socks. 
 
You asked the Plan to pre-approve the anti-slip socks. You say that the anti-slip socks are necessary. The Plan 
denied your request. The Plan says anti-slip socks are not primarily medical and nature and excluded by Health 
Plan and Original Medicare. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. 
This item is available to the general public and would be helpful even to those who are not sick or injured. 
Therefore, we decided that the Plan does not have to pre-approve anti-slip socks.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided by a 
participating provider on March 14, 2022. 
 
You asked the Plan to pay for a comprehensive oral evaluation. You say that you would like the Plan to pay for 
this. The Plan denied your request. The Plan says the benefit limit for D0150 has already been met and 
exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers one 
comprehensive oral evaluation every three plan years. 
 
We looked at the file and Medicare rules. Evidence was provided to show that D0150 was previously provided 
on November 9, 2021. Based on this information, we decided that the Plan's rules for coverage of a comprehensive oral evaluation have not been met. Therefore, we decided that the Plan does not have to pay for 
a comprehensive oral evaluation (D0150) provided by a participating provider on March 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bath/toilet chair equipment repairs. 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says bathtub seats and anything related to bath are not covered because they are for comfort 
or convenience, is a hygienic equipment, and is not primary medical in nature. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve bath/toilet chair equipment repairs.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chiropractic office visit services. 
 
You asked the Plan to pre-approve chiropractic office visit services. You say that additional chiropractic care is 
medically necessary. The Plan denied your request. The Plan says your supplemental chiropractic coverage for 
office visits has been exhausted. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. The records show that the 
service at issue is office visits with a chiropractor. The Plan's benefit for coverage of chiropractic office visits is 
limited to 12 visits per year. The records show that the Plan has covered 12 chiropractic office visits in the 
2022 calendar year. This means that the requested office visits exceed the benefit allowance. Therefore, we 
decided that the Plan does not have to pre-approve chiropractic office visit services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intradialytic parenteral nutrition. 
 
You asked the Plan to pre-approve the parenteral nutrition. You say that oral intake is meeting 100% of the 
enrollee's nutritional needs while balancing protein losses due to hemodialysis. The Plan denied your request. 
The Plan says the enrollee has a functioning gastrointestinal (GI) tract, no history of permanent impairments of 
small intestine, stomach absorption of nutrients or motility disorder that impairs ability of nutrients to be 
absorbed by GI system. 
 
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 parenteral nutrition. Our physician 
reviewer found the enrollee has a functioning GI tract, no history of permanent impairments of small intestine, 
stomach absorption of nutrients or motility disorder that impairs ability of nutrients to be absorbed by GI 
system. The review indicates that the medical records provided do not meet the requirements listed in the LCD 
for Medicare coverage. 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 parenteral nutrition have not been met. 
Therefore, we decided that the Plan does not have to pre-approve intradialytic parenteral nutrition.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the selective catheter placement (36246 and 36248) provided 
on July 8, 2021. 
  You asked the Plan to pay for the selective catheter placement (36246 and 36248). You say that the corrected 
medical records should be reviewed, and the claim reprocessed. The Plan denied your request. The Plan says 
procedure code 34812 was overturned. The plan also says procedure codes 36246 and 36248 remain denied as 
they were not billed with an appropriate modifier. 
 
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 36246 
and 36248 are column II codes to column I code 34718. 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 the selective catheter placement (36246 and 
36248) provided on July 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on July 14, 2021. 
 You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the testing is not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening 
purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan 
does not have to pay for the laboratory services rendered on July 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay the in network rate for the gingival irrigation (D4921 x 4) 
provided on February 3, 2022, by the out of network provider. 
 
You asked the Plan to pay the in network rate for the gingival irrigation. You say that the dentist in this case 
was present on a list of participating dentists on the plan's website. The Plan denied your request. The Plan says 
gingival irrigation is not listed as a covered service. 
 
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 gingival irrigation is not among those covered under this benefit regardless of the providers network status. Therefore, we decided that the 
Plan does not have to pay the in network rate for the gingival irrigation (D4921 x 4) provided on February 3, 
2022, by the out of network provider.
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
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 
enrollee does not meet criteria for IRF admission. Our physician reviewer found the enrollee is medically stable 
and does not need physical medicine and rehabilitation (PM&R) physician close supervision 3 times per week 
(at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. No acute nursing needs identified or documented. At the current functional level, the enrollee, does 
not require 3 hours a day five days a week of IRF therapies with interdisciplinary management. The complexity 
of the enrollee's medical and rehabilitation needs does not require an acute hospital inpatient rehab stay with an 
interdisciplinary approach to rehabilitation care. Document does not support the medical necessity for 
admission to 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay the in network rate for the gingival irrigation (D4921 x 4) 
provided on December 28, 2021. 
 
You asked the Plan to pay the in network rate for the gingival irrigation. You say that you would not have 
continued treatment in this facility had you known they were out of network. You also say that per your 
treatment plan the periodontal maintenance should be covered. The Plan denied your request. The Plan says 
gingival irrigation is not covered. 
 
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 gingival irrigation is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay the in network rate 
for the gingival irrigation (D4921 x 4) provided on December 28, 2021.