Persius/hicric huggingface dataset:
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 disagree with the denial for admission to an IRF. 
The Plan denied your request. The Plan says that the coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of IRF care have been met. The Plan 
made multiple requests for medical records. 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 an osseous graft (D7950) and apicoectomy (D3410) provided 
on January 25, 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 an osseous graft (D7950) and apicoectomy (D3410) are not 
covered by your dental 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 an 
osseous graft (D7950) and apicoectomy (D3410) provided on January 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), complete series 
of x-rays (D0210), and the cleaning (D1110) provided by an out-of-network provider on August 23, 2022. 
 
You asked the Plan to pay for the dental services. You say that you verified that the provider was in-network. 
You say you were not aware you had to check that each dentist's network status because the dental practice 
rotates their dentists. The Plan denied your request. The Plan says the dental services were received from an 
out-of-network provider and are not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for the comprehensive oral evaluation (D0150), complete series of x-rays (D0210), and the cleaning 
(D1110) provided by an out-of-network provider on August 23, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intracept procedure (CPT code 64628). 
 
You asked the Plan to pre-approve the intracept procedure. You say that the services are necessary. The Plan 
denied your request. The Plan says the services are unproven and not medically necessary due to insufficient 
evidence of efficacy. 
 
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 the intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the intracept procedure is experimental. More research is needed to show safety and 
efficacy. 
 
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 intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the intracept procedure (CPT code 64628).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the retainer for a crown (D6740) and the pontic (D6245) for 
tooth #9 and #10 provided on March 22, 2022. 
 
You asked the Plan to pay for the dental services. You say that the provider told you that the services would be 
covered but they never checked with the Plan. The Plan denied your request. The Plan says the denial of 
payment for these services is correct, because the retainer for a crown and the pontic are not covered by the 
Plan. Also, the Plan made one-time exception to allow two covered retainer crowns due to vague information 
of the EOC not adequately explaining services for retainer crowns are 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 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 
retainer for a crown (D6740) and the pontic (D6245) for tooth #9 and #10 provided on March 22, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Repatha. 
 
You asked the Plan to pre-approve Repatha. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for coverage for self-administered drugs have not 
been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drug requested here is not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Repatha.  
 
  Benefits for Repatha may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on June 1, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the service is not a covered 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 pay for the dental 
services on June 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre 2. 
 
You asked the Plan to pre-approve a FreeStyle Libre 2. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of a FreeStyle 
Libre 2 have not been met. Therefore, we decided that the Plan does not have to pre-approve a FreeStyle Libre 
2.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bone replacement graft for ridge preservation (D7953) and 
an extraction of an erupted tooth (D7210) provided on July 14, 2022. 
 
You asked the Plan to pay for a bone replacement graft for ridge preservation (D7953) and an extraction of an 
erupted tooth (D7210). You say that you have to have a bone graft due to an infection in your jaw. The Plan 
denied your request. The Plan says for the date of service billed, these services are not covered 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 a bone 
replacement graft for ridge preservation (D7953) and an extraction of an erupted tooth (D7210) provided on 
July 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Purewick Catheters. 
 
You asked the Plan to pre-approve Purewick Catheters. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that an item or service may be covered by a contractor 
LCD if certain criteria are met. 
 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 Purewick Catheters. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found claims for this type of bag will be 
denied as not reasonable and necessary. PureWickTM Female External Catheter and the PureWickTM Urine 
Collection System are unproven and not medically necessary for managing urinary incontinence due to 
insufficient evidence of efficacy. The review has determined that the Purewick product is not medically 
reasonable or necessary for you. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Purewick Catheters have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Purewick Catheters.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periapical x-rays (D0220, D0230), and gingival irrigation 
(D4921) provided on August 10, 2022. 
 
You asked the Plan to pay for the dental services. You say that you went for a second opinion for dentures. You 
say that you do not agree with the charges you have been given. You also say that you only had an x-ray done. 
The Plan denied your request. The Plan says your benefit for the periapical x-ray has already been exhausted. 
The Plan also says gingival irrigation is not 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, certain limitations apply. The record shows your benefit for the periapical x-rays was exhausted on date of service July 12, 2022. Additionally, 
gingival irrigation is not a covered benefit. Therefore, we decided that the Plan does not have to pay for the 
periapical x-rays (D0220, D0230), and gingival irrigation (D4921) provided on August 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for fluoride varnish (D1206), and prophylaxis (D1110) provided 
by an out-of-network provider on May 2, 2022. 
 
You asked the Plan to pay for the dental services. You say that you contacted the Plan for an in-network 
provider. The Plan denied your request. The Plan says the dental services were received from an out-of-
network provider and are not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for fluoride varnish (D1206), and prophylaxis (D1110) provided by an out-of-network provider on May 
2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injection services provided to the enrollee on June 17, 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 six units will not be reimbursed. 
 
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 the denied codes is: 
 
CPT 96372: 
 
Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular 
 
HCPCS J2357: 
 
Injection, omalizumab, 5 mg 
 
We asked our coder 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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the provider reported six units of 
CPT 96372; however, the medical records support three units. The additional units cannot be verified. In terms 
of J2357, the medical record does not include sufficient documentation of the injections given; therefore, the 
code cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for injection services provided to the enrollee on June 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prophylaxis (D1110) provided by an out-of-network provider 
on August 1, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for this. The Plan 
denied your request. The Plan says the dental services were received from an out-of-network provider and are 
not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for prophylaxis (D1110) provided by an out-of-network provider on August 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a consultation and multiple surgical extractions with an 
oral surgeon. 
 
You asked the Plan to pre-approve a consultation and multiple surgical extractions with an oral surgeon. You 
say that the services are necessary. The Plan denied your request. The Plan says based on the documentation 
provided, coverage criteria has not been met. 
 
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 says covered dental 
services must be performed by a participating general dentist.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of a consultation and multiple surgical extractions with an oral surgeon have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a consultation and multiple surgical extractions with an 
oral surgeon.
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. The Plan denied your request. The Plan says that the coverage 
criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that based on the medical records provided there is no support in the documentation 
that the enrollee requires the intensive medical care and the intensive rehabilitation therapy program provided 
in an inpatient rehabilitation facility. The medical records do not clarify that treatment in the home with home health services or at the skilled nursing facility level is not appropriate in this case.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the bone marrow aspirate (CPT code 20939). 
 
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says the clinical value and effectiveness of bone marrow aspirate in the setting of spinal 
fusion surgery have not been demonstrated in the peer-reviewed literature. 
 
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 the service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found bone marrow aspirate remains experimental in spine surgery and more research is needed. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the bone marrow aspirate (CPT code 20939).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an evaluation and dental extraction to be performed by 
an oral surgeon. 
 
You asked the Plan to pre-approve an evaluation and dental extraction to be performed by an oral surgeon. You 
say that the services are necessary. The Plan denied your request. The Plan says based on the documentation 
provided, coverage criteria has not been met. 
 
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 says covered dental 
services must be performed by a participating general dentist.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of an evaluation and dental extraction to be performed by an oral surgeon have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an evaluation and dental extraction to be 
performed by an oral surgeon.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services (83036, 80053, 85025, 36415) provided on July 6, 2022, by an out-of-network (OON) provider.

You asked the Plan to pay for the lab services. You say that these services should be covered. The Plan denied your request. The Plan says this service is not covered when provided OON.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the lab services (83036, 80053, 85025, 36415) provided on July 6, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), prophylaxis (D1110), 
bitewing x-rays (D0274), and periapical x-rays (D0220, D0230) provided on June 8, 2022. 
 
You asked the Plan to pay for the dental services. You say that you have had previous dental claims paid by 
this provider. The Plan denied your request. The Plan says the dental services were received from an out-of-
network provider and are not covered by your supplemental benefits. The Plan also says that bitewing x-rays 
(D0274) and periapical x-rays (D0220, D0230) are not covered by your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, a periodic oral evaluation and prophylaxis are not 
covered under this benefit when received from an out-of-network provider. Bitewing x-rays and periapical x-
rays are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a periodic oral evaluation (D0120), prophylaxis (D1110), bitewing x-rays (D0274), and periapical x-rays 
(D0220, D0230) provided on June 8, 2022.