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

 
We decided that the Plan does not have to pay for implant services on December 15, 2021. 
 
You asked the Plan to pay for implant services. You say that that you very surprised your claim was denied, 
and this will be your only claim ever on your lower teeth, as all are gone. The Plan denied your request. The 
Plan says the service is not covered under the member's contract. 
 
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 implant 
services on December 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance (D4910) provided by an out-of-
network provider on March 7, 2022. 
 
You asked the Plan to pay for periodontal maintenance. You say that you believe the Plan should pay for this. 
The Plan denied your request. The Plan says the rendered dental 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 
periodontal maintenance (D4910) provided by an out-of-network provider on March 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator (63650). 
 
You asked the Plan to pre-approve a spinal cord stimulator (63650). You say that the requested spinal cord 
stimulator (63650) is medically necessary. The Plan denied your request. The Plan says the enrollee does not 
meet criteria for a spinal cord stimulator (63650). 
 
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 a spinal cord stimulator (63650). Our 
reviewer says that the enrollee does not meet criteria for a spinal cord stimulator (63650). Our physician 
reviewer found the enrollee has chronic low back pain that is not responding to treatment. He has tried narcotic 
and non-narcotic pain medications, rest, ice, physical therapy, electric stimulators, chiropractic, massage, and 
exercise without relief. He has not had a surgical evaluation to determine if surgical intervention is possible to 
help with the pain. His Magnetic resonance imaging (MRI) shows degenerative disc disease and 
neuroforaminal stenosis at one level. He was cleared by a mental health professional for a trial of a spinal cord 
stimulator (SCS). Based on the documentation provided, the enrollee does not have an evidence-based 
indication for a SCS trial.  The request 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 a spinal cord stimulator (63650) have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a spinal cord stimulator (63650).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the progressive lenses (V2781) provided 
December 20, 2021. 
 
You asked the Plan to waive the copayment for the vision services. You say that you were advised that 
everything you had done on this date of service was covered under the Plan and you would not be responsible 
for any copays or coinsurance. The Plan denied your request. The Plan says the claim was reprocessed with the 
correct copayment applied 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $30 
copayment for progressive lenses in addition to glasses copayment.  
 
 You have been asked to pay $30 copayment for the vision services. The vision service falls within the Vision 
care benefit category. This means that you have been asked to pay the correct amount based on your contract 
with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for the progressive lenses (V2781) 
provided December 20, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for a crown (D2740) provided by an out-of-network provider on January 
13, 2022. 
 
You asked the Plan to pay for the crown. The Plan denied your request. The Plan says that you do not have out-
of-network benefits, so the service is not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.  
 
The Plan says the crown is not covered because you do not have out-of-network benefits. Based on the Plan 
contract, however, you may see an out-of-network provider under these benefits.  Therefore, we decided that 
the Plan has to pay for a crown (D2740) provided by an out-of-network provider on January 13, 2022.  
 
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 pay an additional amount for the oral exam (D0120) and prophylaxis 
(D1110) provided on March 9, 2022, by the out of network dentist. 
 
You asked the Plan to pay an additional amount for the dental services. You say that the provider's office 
advised they were in network. You also say that the provider's office advised they had not been notified they 
were no longer in network with your plan. The Plan denied your request. The Plan says out of network dentists 
may bill you for any amount greater than what the plan pays. 
 
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 and the services are listed as covered, 
no additional payment will be made. The record shows that the Plan paid 100% of the allowed amounts for the 
services you received. Out of network dentists may bill you for any amount greater than what the plan pays. 
Therefore, we decided that the Plan does not have to pay an additional amount for the oral exam (D0120) and 
prophylaxis (D1110) provided on March 9, 2022, by the out of network dentist.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on March 29, 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. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.  
 
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on March 29, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the 
enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an 
interdisciplinary approach to rehabilitation care. The enrollee was admitted for back pain after a fall. Medical problems are stable. There are no complex 
nursing or rehabilitation needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, in an intensive rehabilitation therapy program. While the enrollee has a need for physical and/or 
occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested LTACH admission is 
medically necessary. The Plan denied your request. The Plan says the requested LTACH admission is not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH admission is not medically necessary. Our physician reviewer found the enrollee 
was admitted with lower extremity cellulitis and ulcers in the setting of peripheral vascular disease and acute 
kidney injury. The record indicates that the enrollee is improving but still requires acute care services before 
transitioning to a lower level of care. The enrollee continues to receive acute care services, and these have not 
been denied. The medical record does not indicate that the enrollee requires services that he is not currently 
receiving but that would be available at the LTACH facility. The elements of the coverage rules are not 
satisfied. The requested service cannot be 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee's needs exceed the clinical 
capabilities of all lower levels of care in the geographical region. The Plan denied your request. The Plan says 
the enrollee can continue to receive care in the current inpatient setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee remains clinically unstable for transfer. There is no documentation 
provided indicating medical necessity for LTACH services. The enrollee is receiving appropriate care at the 
present acute care hospital. There are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. The requested LTACH services are not 
medically necessary, reasonable, and appropriate for the diagnosis and condition of 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the 
enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee has a past medical history of an above the knee 
amputation in 2019, coronary artery bypass grafting, diabetic neuropathy and is living at home with functional 
decline and weakness. Medical problems are stable. There are no complex nursing or rehabilitation needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, in an intensive rehabilitation therapy program. While the enrollee has a need for physical and/or 
occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an injectable bulking agent. 
 
You asked the Plan to pre-approve an injectable bulking agent. You say that the requested injectable bulking 
agent is medically necessary. The Plan denied your request. The Plan says the requested injectable bulking 
agent is 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 an injectable bulking agent. Our 
reviewer says that the requested injectable bulking agent is not medically necessary. Our physician reviewer 
found the record indicates that the enrollee has intrinsic sphincter deficiency. The provided record is 
insufficient to establish the medical necessity of the requested service. The record provided does not establish 
the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. The elements 
of the coverage criteria are not satisfied. 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 an injectable bulking agent have not been met. Therefore, we decided that the Plan does not have to pre-approve an injectable bulking agent.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for re-evaluation  post-operative office visit (D0171), 
unspecified preventive procedure (D1999), guided tissue regeneration (D4266), surgical removal of implant 
(D6100), unspecified oral surgery (D7999), and bone replacement graft for ridge preservation (D7953), 
provided by a participating provider on December 7, 2021. 
 
You asked the Plan to pay for re-evaluation  post-operative office visit, unspecified preventive procedure, 
guided tissue regeneration, surgical removal of implant, unspecified oral surgery, and bone replacement graft 
for ridge preservation. You say that you believe the Plan should pay for this. The Plan denied your request. The 
Plan says the rendered dental services 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 re-
evaluation  post-operative office visit (D0171), unspecified preventive procedure (D1999), guided tissue 
regeneration (D4266), surgical removal of implant (D6100), unspecified oral surgery (D7999), and bone 
replacement graft for ridge preservation (D7953), provided by a participating provider on December 7, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested LTACH admission is 
medically necessary. The Plan denied your request. The Plan says the requested LTACH admission is not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH admission is not medically necessary. Our physician reviewer found the enrollee 
was admitted with acute hypoxic respiratory failure secondary to decompensated heart failure. The record 
indicates that the enrollee is improving but still requires acute care services before transitioning to a lower level 
of care.    The enrollee continues to receive acute care services, and these have not been denied. The medical 
record does not indicate that the enrollee requires services that he is not currently receiving but that would be 
available at the LTACH facility. The elements of the coverage rules are not satisfied. The requested service 
cannot be 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bilateral genicular nerve ablation therapy. 
 
You asked the Plan to pre-approve bilateral genicular nerve ablation therapy. You say that the requested 
bilateral genicular nerve ablation therapy is medically necessary. The Plan denied your request. The Plan says 
the requested bilateral genicular nerve ablation therapy is 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 bilateral genicular nerve ablation 
therapy. Our reviewer says that the requested bilateral genicular nerve ablation therapy is not medically 
necessary. Our physician reviewer found the enrollee has bilateral osteoarthritis of both knees. He has had 
several intra-articular steroid injections which have produced months of relief at a time. He had a trial of 
viscosupplementation which did not produce sustained pain relief. He takes Tylenol #4 and is doing a home 
exercise program. He doesn't want to consider surgery at this time. The request is for radiofrequency ablation 
(RFA) of the genicular nerves. This is considered an experimental/investigational procedure that is the subject 
of ongoing clinical trials. Therefore, the request is considered 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 bilateral genicular nerve ablation therapy have not been met. Therefore, we 
decided that the Plan does not have to pre-approve bilateral genicular nerve ablation therapy.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the insertion of peripherally inserted central venous catheter 
(PICC), without subcutaneous port or pump, without imaging guidance (36569) provided on November 10, 2021.  
You asked the Plan to pay for the surgical service. You say that the service should be covered. The Plan denied 
your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible 
for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice 
is revoked. The Plan also says it is the provider's responsibility to verify the enrollee's coverage before 
rendering services and to know proper billing procedures for a member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the insertion of peripherally inserted central venous catheter 
(PICC), without subcutaneous port or pump, without imaging guidance (36569) provided on November 10, 2021.