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

 
We decided that the Plan does not have to pay an additional amount for an intraoral, periapical additional 
radiographic image (D0230), a resin-based composite, one surface, posterior (D2391), and a resin-based 
composite, four or more surfaces, posterior (D2394) provided on September 14, 2021, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay an additional amount for dental services. You say that there is something wrong with 
the denial on this claim and you would like the coverage reviewed. The Plan denied your request. The Plan 
says you have reached the maximum benefit allowed per calendar year for services rendered with an OON 
provider. 
 
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.  
 
We looked at the file and Medicare rules. The EOC confirms that if you receive services from an OON 
provider, you pay 50% - 75% of the allowed amount for listed dental services. The records show that you 
received your dental services from an OON provider. The records also show that you received the maximum 
allowed benefit for two resin-based fillings and a periapical x-ray. Specifically, you have received the total 
allowed amount paid for this claim. Based on this information, we decided that the Plan's rules for coverage of 
dental services have not been met. Therefore, we decided that the Plan does not have to pay an additional 
amount for an intraoral, periapical additional radiographic image (D0230), a resin-based composite, one 
surface, posterior (D2391), and a resin-based composite, four or more surfaces, posterior (D2394) provided on 
September 14, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve comprehensive orthodontic treatment of the adult 
dentition (D8090). 
 
You asked the Plan to pre-approve the dental service. You say that the requested service is medically 
necessary. The Plan denied your request. The Plan says comprehensive orthodontic treatment of the adult 
dentition 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested comprehensive 
orthodontic treatment of the adult dentition is not among those covered under this benefit.  Therefore, we decided that the Plan does not have to pre-approve comprehensive orthodontic treatment of the adult dentition (D8090).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prophylaxis (D1110) provided on September 29, 2021. 
 
You asked the Plan to pay for the prophylaxis. You say that when you signed for this plan, you were told that 
this plan covered up to $1,000 for dental and were not told about the limitations. You also say that you were 
told by your dentist that since you are a diabetic, you need a dental cleaning every 4 months. 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, prophylaxis (D1110) and is limited to 
two procedures per plan year. The record shows that you received prophylaxes (D1110) on April 29, 2021, and 
June 3, 2021 and your prophylaxis (D1110) benefit has been exhausted. Therefore, we decided that the Plan 
does not have to pay for the prophylaxis (D1110) provided on September 29, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve a pacemaker pulse generator (33225). 
 
You asked the Plan to pre-approve a pacemaker pulse generator. You say that this is medically reasonable and 
necessary for the enrollee's condition. The Plan denied your request. The Plan says that the criteria for coverage 
have not been met. 
 
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 pacemaker pulse generator. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case. 
Our physician reviewer found that at issue is the medical appropriateness and necessity of implantation of a 
dual chamber pacemaker. The mere presence of second-degree atrioventricular (AV) block and right bundle 
branch block would not mandate pacemaker implant. However, the physician has explained that because of 
significant ventricular arrhythmias requiring antiarrhythmic drug therapy, there is significant risk of inducing 
unheralded complete heart block. Hence, his plan is to implant the pacemaker and then initiate the 
antiarrhythmic drug. This is reasonable and clinically prudent.  In summary, the evidence would suggest that it 
is reasonable and appropriate to allow the physician authorization for pacemaker implantation in the clinical 
management of this patient. 
 
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 pacemaker pulse generator have been met. Therefore, we decided that the Plan 
has to pre-approve a pacemaker pulse generator (33225).  
 
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 pre-approve Manual wheelchair accessory, nonstandard seat frame 
depth, 22 to 25 inches (E2204) wheelchair accessory, adjustable height, detachable armrest, complete 
assembly, each (E0973) Adjustable angle footplate, each (E0040). 
You asked the Plan to pre-approve the wheelchair accessories. You say that you have attached the Medicaid fee 
schedule to show that these codes are separately payable and the Plan is supposed to follow Medicaid 
guidelines. The Plan denied your request. The Plan says these items are already included with the wheelchair 
and other approved accessories and are not separately billable. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at and Medicare rules. These items are already included with the approved wheelchair and other 
approved accessories. They are not separately billable. Based on this information, we decided that Medicare 
rules for coverage of the wheelchair accessories have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Manual wheelchair accessory, nonstandard seat frame depth, 22 to 25 inches (E2204) 
wheelchair accessory, adjustable height, detachable armrest, complete assembly, each (E0973) Adjustable 
angle footplate, each (E0040).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient hospital services for the enrollee. 
 
You asked the Plan to pre-approve inpatient hospital services. You say that these services are medically 
necessary. The Plan denied your request. The Plan says that there is no documentation provided to support the 
expectation the enrollee will require a greater than 2 midnight stay. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
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 inpatient hospital services. Our 
reviewer says that inpatient hospital services are not medically reasonable and necessary. The patient's recent 
documentation including preoperative clearance note does not describe the patient as high risk or unstable to 
justify inpatient status. There is no expectation that the patient would require hospital services that would likely 
cross 2 midnights. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria 
for inpatient hospital services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient hospital services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve inpatient hospital services for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Conformis custom knee implant. 
 
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 records show that you have 
advanced knee osteoarthritis and have been approved for a knee arthroplasty with inpatient admission. The 
records do not support that the custom implant is medically necessary for your 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a Conformis custom knee implant.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a fixed bridge (D6740, D6245) for teeth #8-#10. 
 
You asked the Plan to pre-approve a fixed bridge. You say that this dental work is necessary for you to eat. The 
Plan denied your request. The Plan says these services are 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 a 
fixed bridge (D6740, D6245) for teeth #8-#10.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the automatic grasp feature, addition to upper limb 
electric prosthetic terminal device (L6881) and microprocessor control feature, addition to upper limb 
prosthetic terminal device (L6882). 
 
You asked the Plan to pre-approve the additional features. You say that please review your records as you 
believe this was denied in error and should be approved. The Plan denied your request. The Plan says these 
features are both included in the already approved based electric hand code L6880. All grasp patterns are 
included in the L6880 code and separately billing for other codes is considered unbundling. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. All grasp patterns are included in the L6880 HCPCS code language. HCPCS code L6880 describes a complete terminal device that can only be used with HCPCS code L6026 when 
a partial hand residual limb contains no digits. HCPCS code L6880 has all the following characteristics: 
Includes all necessary components. This L code describes a product that is all-inclusive. Billing of any 
additional features or functions used to describe a manufacturer's terminal device is considered unbundling. 
The use of HCPCS code L6881 (automatic grasp feature, addition to upper limb electric prosthetic terminal 
device) would be considered unbundling. All switch/myoelectric controls are included in L6880 HCPCS code 
language. The use of code L6882 (Microprocessor control feature, addition to upper limb prosthetic terminal 
device) would be considered unbundling. Based on this information, we decided that Medicare rules for 
coverage of the additional features have not been met. Therefore, we decided that the Plan does not have to pre-
approve the automatic grasp feature, addition to upper limb electric prosthetic terminal device (L6881) and 
microprocessor control feature, addition to upper limb prosthetic terminal device (L6882).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the male vacuum erection system coded (L7900) and 
Unlisted special service, procedure or report (99199) purchased October 25, 2021. 
 
You asked the Plan to pay for the male vacuum erection system. You say that you would like to be reimbursed 
for the amount that the Plan should have covered. You looked up the vacuum system on the website and it 
showed it is covered at 50%. You did not see any mention of prior authorization. The Plan denied your request. 
The Plan says this item is not covered by Medicare under any normal circumstances. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the male vacuum erection system have not been met. Therefore, we decided that the Plan does not 
have to pay for the male vacuum erection system coded (L7900) and Unlisted special service, procedure or 
report (99199) purchased October 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120) and prophylaxis (D1110) 
provided on November 11, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a periodic oral evaluation and prophylaxis. You say that you attempted to make 
an appointment with your provider that is in-network. The provider's office scheduled an appointment for you 
in another office with a different provider. The Plan denied your request. The Plan says you have exceeded the 
maximum allowed benefit for the requested services. 
 
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 a periodic 
oral evaluation and prophylaxis once per calendar year.  
 
We looked at the file and Medicare rules. The EOC confirms that you receive one periodic oral exam and one 
prophylaxis once per calendar year. The records show you received a comprehensive oral exam and a 
prophylaxis on April 29, 2021; therefore, you have exhausted your maximum benefit for these services. Based 
on this information, we decided that the Plan's rules for coverage of a periodic oral evaluation and prophylaxis 
have not been met. Therefore, we decided that the Plan does not have to pay for a periodic oral evaluation 
(D0120) and prophylaxis (D1110) provided on November 11, 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 prophylaxis (D1110) provided on December 16, 2021. 
 
You asked the Plan to pay for the prophylaxis. You say that you are entitled to a cleaning every six months. 
The Plan denied your request. The Plan says this benefit is exhausted. 
 
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, routine cleanings are allowed twice per 
calendar year. The record shows that you received prophylaxes (D1110) on January 5, 2021, and June 15, 2021 
and your routine cleanings benefit has been exhausted.  
 
Therefore, we decided that the Plan does not have to pay for the prophylaxis (D1110) provided on December 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the post and core in addition to crown (D2952) provided on 
July 6, 2021. 
 
You asked the Plan to pay for the post and core in addition to crown. You say that your front tooth was rotted 
and cracked and needed a root canal. You also say that the first time it was done it was done horribly and needs 
to be redone somewhere else. The Plan denied your request. The Plan says this service 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, 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 post 
and core in addition to crown (D2952) provided on July 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 15 out of network acupuncture visits. 
 
You asked the Plan to pre-approve the acupuncture visits. You say that you are asking to spread 20 acupuncture 
visits throughout the year rather than putting them all in 90 days quadrants. You believe 12 is too much in 90 
days per the benefit. The Plan denied your request. The Plan says 5 acupuncture treatments has been approved 
from 1/06/2022 to 03/06/2022. The enrollee does not meet the criteria for the additional visits. 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plan's rules apply in this case. 
 
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 acupuncture visits. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found in this case the record indicates that the enrollee has low back pain. The record 
indicates that the enrollee has been approved for five visits between January 6, 2022 and March 6, 2022. The 
record indicates that the enrollee requests 15 additional visits at a frequency of 5/90 days. The elements of the 
coverage criteria are not satisfied and the requested service is not recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the acupuncture visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 15 out of network acupuncture visits.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance response with no transport. 
 You asked the Plan to pay for response with no transport. You say that this should be covered by the Plan. You 
say the doctor on the phone told the paramedics the enrollee did not need transport and you were forced to sign 
the forms. The Plan denied your request. The Plan says emergency or ambulance response with no transport is 
not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for emergency response or 
ambulance services when there is no transport. The ambulance company did not provide transport services on 
October 19, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither 
Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay 
for ambulance response with no transport.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on July 13, 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 were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of 
service (POS) code. 
 
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a 
laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have 
been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory 
services rendered on July 13, 2021.