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

 
We decided that the Plan does not have to pay for the adjunctive pre-diagnostic test (D0431), four periodontal 
scalings and root planings (D4342 x4), eight localized deliveries of antimicrobial agents (D4381 x8), four 
gingival irrigations (D4921 x4), two drugs or medicaments dispensed in the office for home use (D9630 x2), 
and mandibular partial denture (D5212) provided on December 6, 2021, and December 8, 2021. 
 
You asked the Plan to pay for the adjunctive pre-diagnostic test, scalings and planings, localized deliveries of 
antimicrobial agents, gingival irrigations, drugs or medicaments, and mandibular partial denture. You say that 
the provider assured you these services were covered which is why you had them done. You also say that the 
provider later told you that there was a mistake, but it was too late because the services were already done, 
leaving you with a $2,733.00 bill. The Plan denied your request. The Plan says these services are not covered 
expenses under your dental plan.  The Plan says that you did not contact the Plan prior to the December 6, 2021 date of service, but you did contact the Plan on December 7, 2021. The Plan also says that on this call you were advised there is no 
coverage for bridges or partial dentures under your 2021 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 
adjunctive pre-diagnostic test (D0431), four periodontal scalings and root planings (D4342 x4), eight localized 
deliveries of antimicrobial agents (D4381 x8), four gingival irrigations (D4921 x4), two drugs or medicaments 
dispensed in the office for home use (D9630 x2), and mandibular partial denture (D5212) provided on 
December 6, 2021, and December 8, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion of stabilization device (22869 and 22870). 
 
You asked the Plan to pre-approve the insertion of stabilization device (22869 and 22870). You say that the 
member suffers from severe leg and back pain and has failed conservative treatment. You say that the Vertiflex 
procedure is a good fit for this patient to resolve symptoms and avoid a massive expensive surgery. The Plan 
denied your request. The Plan says there are no current clinical indications for this device. 
 
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 insertion of stabilization device 
(22869 and 22870). Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found that interspinous stabilization devices 
remain experimental and 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 insertion of stabilization device (22869 and 22870) have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the insertion of stabilization device (22869 
and 22870).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an implant surgery (D6010 and D6011) for teeth #19, #3, and 
#5 to be provided by an out-of-network provider. 
 
You asked the Plan to pay for an implant surgery. You say that this dental work is medically necessary. 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 pay for an 
implant surgery (D6010 and D6011) for teeth #19, #3, and #5 to be provided by an out-of-network provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued admission to a skilled nursing facility (SNF) 
for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that the enrollee is absolutely in need of skilled 
nursing and skilled rehabilitation services on a daily basis. The Plan denied your request. The Plan says the stay 
is denied starting March 9, 2022.  
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found there are no 
identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee 
does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of 
illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continued admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composites (D2335) on tooth #'s 24, 25, 26, 
and 27 provided on May 5, 2021, and May 27, 2021. 
 
You asked the Plan to pay for the resin-based composites on tooth #'s 24, 25, 26, and 27. The Plan denied your 
request. The Plan says your benefits for this service have been satisfied and the frequency limitation 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 Plans coverage rules apply in this case.  
Though the Plan offers a dental benefit in excess of Medicare coverage, restorations (fillings) are limited to 
four procedure codes per calendar year. The record shows that you received resin-based composites (D2335) 
on tooth #'s 22 and 23 on May 5, 2021 and resin-based composites (D2335) on tooth #'s 28 and 29 on May 27, 
2021 which were covered by the Plan, and your restorations benefit has been exhausted. Therefore, we decided 
that the Plan does not have to pay for the resin-based composites (D2335) on tooth #'s 24, 25, 26, and 27 
provided on May 5, 2021, and May 27, 2021.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve a transcatheter ablation. 
 
You asked the Plan to pre-approve a transcatheter ablation. You say that the patient was started on Cardizem 
during a hospital admission and the additional information supports the request for this service. The Plan 
denied your request. The Plan says that a transcatheter ablation is only considered medically necessary when 
certain criteria are 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 transcatheter ablation. Our reviewer 
says that the requested service would be considered medically appropriate in this enrollees clinical 
management. Our physician reviewer found that recent randomized clinical studies have supported the role of 
catheter ablation for the treatment of symptomatic atrial fibrillation as an acceptable first-line alternative to 
medications in the treatment of patients with this arrhythmia. Clinical guidelines have been modified to reflect 
the findings of these new studies. 
 
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 transcatheter ablation have been met. Therefore, we decided that the Plan has 
to pre-approve a transcatheter ablation.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete mandibular denture (D5120), and a complete 
maxillary denture (D5110) provided by a participating provider on October 30, 2021. 
 
You asked the Plan to pre-approve a complete mandibular denture, and a complete maxillary denture. You say 
that you would like the Plan to pay for these dentures. The Plan denied your request. The Plan says D5120 and 
D5110 are not covered 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 pre-approve a 
complete mandibular denture (D5120), and a complete maxillary denture (D5110) provided by a participating 
provider on October 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bitewings (D0270), and intraoral radiographic imaging 
(D0220 and D0230) provided by a participating provider on April 29, 2021. 
 
You asked the Plan to pay for bitewings and intraoral radiographic imaging. You say that you do not feel like 
you should be held financially responsible for this. The Plan denied your request. The Plan says the benefit 
limit for provided dental services has already been 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.  
 
We looked at the file and Medicare rules. Evidence was provided to show that D0220, D0230, and D0274 were 
previously provided on March 22, 2021, and April 26, 2021. Based on this information, we decided that the 
Plan's rules for coverage of bitewings and intraoral radiographic imaging have already been met. Therefore, we decided that the Plan does not have to pay for bitewings (D0270), and intraoral radiographic imaging (D0220 
and D0230) provided by a participating provider on April 29, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ERCP and endoscopic catheterization provided by an 
out-of-network provider on November 5, 2021. 
 
You asked the Plan to pay for the ERCP and endoscopic catheterization. You say that the claim denied due to 
no authorization, and you are disputing for medical necessity. You say that the medical records should be 
reviewed, and the claim should be reprocessed. The Plan denied your request. The Plan says this provider is not 
a network provider, and the services were not approved in advance. 
  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 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 ERCP and endoscopic catheterization provided 
by an out-of-network provider on November 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an osseous surgery (D4260) to be provided by an out-
of-network provider. 
 
You asked the Plan to pre-approve an osseous surgery. You say that this dental work is medically necessary. 
The Plan denied your request. The Plan says the requested dental services are 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 pre-approve an 
osseous surgery (D4260) to be provided by an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Feraheme (ferumoxytol) injections. 
 
You asked the Plan to pre-approve the Feraheme treatments. You say that the requested treatment is necessary 
to increase the enrollee's iron levels. The Plan denied your request. The Plan says this cannot be covered 
without a failure of oral iron supplements. Also, there are preferred intravenous iron treatments that must be 
tried first, such as Venofer and Infed. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 the Feraheme treatments. Our reviewer 
says that the requested use of Feraheme is not considered medically reasonable and necessary at this time. Our 
physician reviewer found the enrollee has iron deficiency anemia. There has not been a failure of oral iron 
supplementation documented. The review has determined that, at this time, the requested IV iron treatment is 
not medically reasonable or necessary. 
 
 
 
 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Feraheme treatments have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Feraheme (ferumoxytol) injections.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service December 
20, 2021. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service December 20, 
2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70481 billed for date of service December 
29, 2021. 
 
You asked the Plan to pay for procedure code 70481. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70481 is bundled into payment for 
code 70470. 
 
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 70481 
is a column II code to column I code 70470. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70481 billed for date of service December 29, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral - complete series of radiographic images 
(D0210), prophylaxis - adult (D1110), periodic oral evaluation - established patient (D0120) provided 
November 30, 2021. 
 
You asked the Plan to pay for the complete series of x-rays, dental cleaning and periodic oral exam. You say 
that you don't understand why this claim is denied. The Plan denied your request. The Plan says you have 
exceeded the frequency limits for these 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 the complete 
series of x-rays once every five years and a dental cleaning and periodic oral exam once per calendar year. 
We looked at the file and Medicare rules. The Plan provided documentation showing that a periodic oral exam 
and dental cleaning were previously covered on May 12, 2021, and a complete series of x-rays was previously 
covered on and a panoramic x-ray on April 4, 2019. Based on this information, we decided that the Plan's 
frequency limits for coverage of the complete series of x-rays, dental cleaning and periodic oral exam have 
been exceeded. Therefore, we decided that the Plan does not have to pay for the intraoral - complete series of 
radiographic images (D0210), prophylaxis - adult (D1110), periodic oral evaluation - established patient 
(D0120) provided November 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services provided on December 9, 2020. 
 
You asked the Plan to pay for anesthesia services. The Plan denied your request. The Plan says the claim was 
filed beyond the timeframe. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for anesthesia services was not filed until December 13, 2021. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for anesthesia services provided on December 9, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services provided on June 24, 2020. 
 
You asked the Plan to pay for psychotherapy services. The Plan denied your request. The Plan says the claim 
was filed beyond the timeframe. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
 
 
 
 
 The record shows that a claim for psychotherapy services was not filed until August 3, 2021. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for psychotherapy services provided on June 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services billed with CPT codes 81162, 81292 
and 81351 provided on November 4, 2021. 
 
You asked the Plan to pay for the laboratory services billed with CPT codes 81162, 81292 and 81351. You say 
that the attached documents should be reviewed, and the claim reconsidered for payment. The Plan denied your 
request. The Plan says providers should use one unit of CPT code 81479 to report a comprehensive genomic 
panel.  The Plan follows Medicare rules. Medicare rules say that genetic testing is considered medically necessary to 
establish a molecular diagnosis of an inheritable disease when 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 pay for the laboratory services billed with CPT 
codes 81162, 81292 and 81351. Our reviewer says that although the enrollee displays clinical features of an 
associated disease, the available documentation does not support that the testing would directly impact the 
treatment being delivered. Our physician reviewer found that the documentation does not support that a 
definitive diagnosis remained uncertain after history, physical exam, pedigree analysis, genetic counseling, and 
completion of conventional diagnostic studies. 
 
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 laboratory services billed with CPT codes 81162, 81292 and 81351 have not 
been met. Therefore, we decided that the Plan does not have to pay for the laboratory services billed with CPT 
codes 81162, 81292 and 81351 provided on November 4, 2021.