Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office visits to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the office visits. You say that you need to see a rheumatologist to continue 
the care you received with your previous insurance. You say this provider's office is close to where you live. 
The Plan denied your request. The Plan says the provider is out-of-network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. The records provided for review do not show that the services at 
issue are urgent or emergent. 
 Therefore, we decided that the Plan does not have to pre-approve the office visits to be provided by an out-of-
network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral hygiene instructions (D1330), four periodontal 
scalings and root planings (D4341 x4), four gingival irrigations (D4921 x4), and four periodontal procedures 
(D4999 x4) provided on October 6, 2021. 
 
You asked the Plan to pay for the oral hygiene instructions, scalings and planings, gingival irrigations, and 
periodontal procedures. You say that you would like these services to be covered. The Plan denied your 
request. The Plan says these services are not covered benefits under your dental plan. The Plan also says that 
your plan offers a dental plan rider, but you did not enroll in this rider. 
 
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 oral 
hygiene instructions (D1330), four periodontal scalings and root planings (D4341 x4), four gingival irrigations 
(D4921 x4), and four periodontal procedures (D4999 x4) provided on October 6, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspirate (20939) for a spinal decompression and fusion procedure.
You asked the Plan to pre-approve bone marrow aspirate. You say that the requested service is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the requested procedure is experimental/investigational.
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 bone marrow aspirate. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that there is no specific indication provided to support the request for bone marrow aspirate for the approved surgery. There is no compelling rationale presented or extenuating circumstances
noted to support the medical necessity of bone marrow aspiration in conjunction with the lumbar surgery performed. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of bone marrow aspirate for this enrollee's medical condition. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of bone marrow aspirate have not been met. Therefore, we decided that the Plan does not have to pre-approve bone marrow aspirate (20939) for a spinal decompression and fusion procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prophylaxis (D1110), provided on October 11, 2021. 
 
You asked the Plan to pay for the prophylaxis. You say that the service was medically necessary. The Plan 
denied your request. The Plan says you have exceeded the maximum frequency allowed for this 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 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 
prophylaxis (D1110), provided on October 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for miscellaneous vision services (V2799) provided on October 
29, 2021. 
 
 
You asked the Plan to pay for miscellaneous vision services. You say that you had a prescription from your 
provider for new lenses. You also say the fitting for the lenses was the only service you received. You do not 
agree with the denial. The Plan denied your request. The Plan says the miscellaneous vision care service is not 
covered by your managed care benefits. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan does not cover miscellaneous vision services. 
 
We looked at the file and the Plan's rules. The EOC confirms that you are covered for one routine eye exam 
and up to $200 towards the purchase of eyeglasses or contact lenses. The records show that you received lenses 
and an anti-reflective coating and those were paid by the Plan. Specifically, the miscellaneous vision service is 
not covered by the Plan. Based on this information, we decided that the Plan's rules for coverage of 
miscellaneous vision services have not been met. Therefore, we decided that the Plan does not have to pay for 
miscellaneous vision services (V2799) provided on October 29, 2021.
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 (D0364) provided on October 20, 2021. 
 
You asked the Plan to pay for the cone beam CT capture and interpretation. You say that the Plan assured you 
that this service would be covered. The Plan denied your request. The Plan says this procedure is not a contract 
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 cone 
beam computed tomography (CT) capture and interpretation (D0364) provided on October 20, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for digital breast tomosynthesis (77061) provided April 26, 2021. 
 
You asked the Plan to pay for the diagnostic service. You say that the medical records support the level of 
service rendered Please review and have the claim reprocessed. The Plan denied your request. The Plan says 
the claim was billed with a non-covered code. 
 
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 find that CPT code 77061 is not supported in the medical record. Specifically, 77061 is not a Medicare approved code. Based on this information, we decided that Medicare rules for coverage of the 
diagnostic service have not been met. Therefore, we decided that the Plan does not have to pay for digital 
breast tomosynthesis (77061) provided April 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the custom fabricated abutment (D6057) and abutment 
supported porcelain fused to metal crown (D6059) provided on August 3, 2021. 
 
You asked the Plan to pay for the custom fabricated abutment and abutment supported porcelain fused to metal 
crown. You say that you feel that these services are considered to be major dental services and qualify for 50% 
coverage. The Plan denied your request. The Plan says these services are not covered benefits 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 
custom fabricated abutment (D6057) and abutment supported porcelain fused to metal crown (D6059) provided 
on August 3, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Mass spectrometry and tandem mass spectrometry 
(83789-59) provided on August 3, 2021. 
 
You asked the Plan to pay for code 83789-59. You say that the medical records support the use of modifier 59 
billed with code 83789. The Plan denied your request. The Plan says the medical records do not support the use 
of modifier 59 billed with code 83789. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   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 code 83789-59 Our reviewer says that the medical records do not support the use of modifier 59 billed with code 83789. Our physician reviewer found the review has determined that Current Procedural Terminology (CPT) code 83789-59 (1 Unit) remains not supported. This code is included in Healthcare Common Procedure Coding System (HCPCS) code G0480; 
therefore, it cannot be separately reimbursed. The documents received do not support that the procedure or 
service was distinct or independent from other services performed; therefore, the use of the 59 modifier is not 
supported. The review has determined that the medical records do not support the use of modifier 59 billed 
with code 83789. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 83789-59 have not been met. Therefore, we decided that the Plan does not 
have to pay for the Mass spectrometry and tandem mass spectrometry (83789-59) provided on August 3, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services (99053) provided on April 3, 2021. 
 
You asked the Plan to pay for code 99053. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered as 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. 
 
We looked at the file and Medicare rules. Code 99053 has a status code of "B" under the Medicare Physicians 
Fee Schedule Database (MPFSDB) and no separate payment is made for this code under the fee schedule as 
payment is bundled into the payment for the services to which this code is incident to. Therefore, we decided 
that the Plan does not have to pay for the medical services (99053) provided on April 3, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Renflexis. 
 
You asked the Plan to pre-approve Renflexis. You say that the enrollee has failed other treatments and 
Renflexis is not interchangeable with other drugs. The Plan denied your request. The Plan says the denial of 
authorization for this drug is correct, because the Plan requires a trial of Remicade or Inflectra before it 
approves Renflexis. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Renflexis. Our reviewer says that the 
enrollee does not meet the Medicare criteria for a step therapy exception for Renflexis. Our physician reviewer 
found the enrollee has not tried and failed the Plan's preferred drugs of Remicade or Inflectra. The record does 
not show that these drugs would likely be less effective and/or have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Renflexis have not been met. Therefore, we decided that the Plan does not have 
to pre-approve use of Renflexis.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the adjunctive pre-diagnostic test (D0431), provided on 
November 8, 2021. 
 
You asked the Plan to pay for the routine dental services. You say that the services should be covered The Plan 
denied your request. The Plan says this 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, 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 
adjunctive pre-diagnostic test (D0431), provided on November 8, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scans provided on October 
15, 2021 by an out-of-network (OON) provider. 
 
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 were rendered by an out-of-network provider without prior authorization. 
 
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 computed 
tomography (CT) scans provided on October 15, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete lower denture (D5120) provided on March 16, 2021. 
 
You asked the Plan to pay for the dental item. You say that the provider in this case was rude and disrespectful. 
You say that you have not received dentures before. You say that you are supposed to have $2,500 toward 
dentures. You say that you have not gotten anything for 2021. You also say that you need a top denture too. 
The Plan denied your request. The Plan says 1 complete lower denture is covered every 5 plan years. The Plan 
also says that the frequency limit 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 and 1 complete lower denture is 
covered every 5 plan years, the frequency limit has been exceeded. The record shows that the Plan paid for a 
complete lower denture that you received on October 11, 2019. Therefore, we decided that the Plan does not 
have to pay for the complete lower denture (D5120) provided on March 16, 2021.  
 
Your complaint about the provider being rude and disrespectful is not a valid appeal for medical coverage. This 
part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
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 October 19, 2021. 
 
You asked the Plan to pay for the problem focused limited oral evaluation. You say that the frequency was 
needed due to a broken tooth and cap coming off. You also say that you have limited resources to pay with. 
The Plan denied your request. The Plan says this service exceeds the frequency limitation in your benefit 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, problem focused limited oral 
evaluation (D0140) is limited to one procedure per plan year. The record shows that you received a problem 
focused limited oral evaluation (D0140) on February 9, 2021 and your problem focused limited oral evaluation 
(D0140) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the problem 
focused limited oral evaluation (D0140) provided on October 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids provided on January 14, 2021.
You asked the Plan to pay for the hearing aids. You say that you have a PPO plan, which has coverage for both in-network and out-of-network benefits. The Plan denied your request. The Plan says hearing aids ordered through providers other than the Plan's hearing vendor are not covered.
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 plan's coverage rules apply in this case. The Plan pays for hearing aids only when ordered through the Plan's hearing vendor. We looked at the file and the Plan's rules. The file shows that the hearing aids were not ordered through the Plan's hearing vendor. 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 hearing aids provided on January 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided the Plan does not have to pay for out of network services provided on August 5, 2021. 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care.  
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 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 out of network 
services provided to the enrollee on August 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the coronectomy (D7251), bone replacement graft for ridge preservation (D7953), deep sedation/general anesthesia (D9221 x2), and two adjunctive procedures (D9999 x2) provided on July 8, 2021.
You asked the Plan to pay for the coronectomy, bone replacement graft, deep sedation/general anesthesia, and adjunctive procedures. You say that you assumed oral surgery was considered to be dental and never considered calling to see if the provider was in or out-of-network. You also say that you would like to be reimbursed from the miscellaneous dentistry benefit for the remaining 2021 amount. The Plan denied your request. The Plan says these services are not covered benefits 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, 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 coronectomy (D7251), bone replacement graft for ridge preservation (D7953), deep sedation/general anesthesia (D9221 x2), and two adjunctive procedures (D9999 x2) provided on July 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on 
October 26, 2021 by a Medicare opt out provider. 
 
You asked the Plan to pay for the comprehensive oral evaluation. You say that when you enrolled with this 
plan nothing was explained to you about a provider opting in or out of Medicare, you were just told to submit 
the claim and it would be reimbursed. You also say that you do not understand how a provider opting in or out 
of Medicare affects the claim status for a claim that is not covered by Medicare. The Plan denied your request. 
The Plan says the treating provider is not part of the Medicare program. The Plan also says that the treating 
provider opted out of Medicare effective May 2, 2016, to May 2, 2022. 
 
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 
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 oral evaluation (D0150) provided on October 26, 2021 by a 
Medicare opt out provider.