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

 
We decided that the Plan does not have to pay for the localized deliveries of antimicrobial agents (D4381), 
periodontal scalings and root planings (D4341), gingival irrigations (D4921), and drugs or medicaments 
dispensed in the office for home use (D9630) provided on December 22, 2021. 
 
You asked the Plan to pay for the dental services. You say that the doctor mistakenly listed another insurance 
company. The Plan denied your request. The Plan says these procedures are not covered under your dental 
plan. The Plan also says you did not contact the Plan prior to this date of service to confirm which services are 
covered under your Plan's dental coverage. 
 
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 
localized deliveries of antimicrobial agents (D4381), periodontal scalings and root planings (D4341), gingival 
irrigations (D4921), and drugs or medicaments dispensed in the office for home use (D9630) provided on 
December 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluations (D0120), bitewing x-rays 
(D0274), and periodontal maintenance procedures (D4910) provided on January 27, 2022, and April 20, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the dental services. You say that you were told that you could go OON with the 
Plan you have. The Plan denied your request. The Plan says the dental services were received from an OON 
provider and are not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an OON provider. Therefore, we decided that the Plan does not have to pay for 
the periodic oral evaluations (D0120), bitewing x-rays (D0274), and periodontal maintenance procedures 
(D4910) provided on January 27, 2022, and April 20, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652, E0667) for the 
enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no mention in the medical record of edema extending to the chest, trunk and or 
abdomen nor is there clinical documentation of objective measurements to support lymphedema of the chest, 
trunk, or abdomen. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that based on the medical records provided, there is no documentation that the enrollee has lymphedema 
of the chest, trunk, or abdomen; the records only document lower extremity edema. It cannot be said that she 
has unique characteristics that would indicate the segmented pump over a standard pump. There is no 
documentation that the enrollee has tried and failed a four week trial of regular, daily, multiple-hour home 
usage of a basic compression pump after careful, in-person fitting, training and supervision by a technician as 
required by the LCD. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a pneumatic compression device (E0652, E0667) for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 74176 billed for date of service January 30, 
2022. 
 
You asked the Plan to pay for procedure code 74176. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 74176 is bundled into payment for 
code 74174. 
 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 74176 
is a column II code to column I code 74174. 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 74176 billed for date of service January 30, 
2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on March 14, 2022.

You asked the Plan to waive the copayment for lab services. You say that you never paid for lab services separately before. The Plan denied your request. The Plan says the copayment applied is correct.

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 $40 copayment for each lab drawn at an outpatient hospital visit. 

You have been asked to pay $40 copayment for lab services. Lab services fall within the Laboratory Services 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 laboratory services provided on March 14, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the injection, diagnostic or therapeutic agent 
paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or 
CT), lumbar or sacral; single level (64493) and injection, diagnostic or therapeutic agent, paravertebral facet 
(zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or 
sacral (64494). 
 You asked the Plan to pre-approve the facet block injections. You say that you would like to appeal the 
decision to deny. You have attached clinical information that is marked and states why. The Plan denied your 
request. The Plan says the records do not support that the enrollee meets the Medicare criteria 
 
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 facet block injections. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the prior facet blocks were labeled ineffective. Therefore, the request to repeat is 
deemed 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 Facet block injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the injection, diagnostic or therapeutic agent paravertebral facet (zygapophyseal) 
joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level 
(64493) and injection, diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves 
innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral (64494).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve diagnostic dental services (D9310) 
 
You asked the Plan to pre-approve the diagnostic dental services. You say that the services should be covered 
as you disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as 
they do not fall within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
diagnostic dental services (D9310)
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on January 14, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says these services are 
not payable. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the lab services provided on January 14, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for an inpatient admission provided by a participating provider on April 4, 
2022, to April 7, 2022. 
 
You asked the Plan to pay for an inpatient admission. You say that these services were medically necessary. 
The Plan denied your request. The Plan says that these services could have been provided at a lower level of 
care. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of an inpatient admission provided on April 4, 2022, to April 7, 2022, have been met. The Plan has failed to send in 
medical records to verify if these services could have been provided at a lower level of care. Therefore, we 
decided that the Plan has to pay for an inpatient admission provided by a participating provider on April 4, 
2022, to April 7, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the blood bank physician services rendered on February 28, 
2022. 
 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 are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 86077 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. 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 pay for the blood bank 
physician services rendered on February 28, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve canthoplasty for the enrollee. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says surgery to turn out the lower eyelid can be approved. 
 
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 procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the record indicates that the enrollee is undergoing entropion repair. The record provided is 
insufficient to establish the medical necessity of the addition of the requested procedure. 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.  
 
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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve canthoplasty for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the thermal destruction of intraosseous basivertebral 
nerve for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no evidence to establish the safety and efficacy of this procedure. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that documentation was/is lacking regarding reasonably detailed and/or evidenced findings supportive of 
the spinal vertebral bodies as being the overwhelming primary generators of the enrollees chronic persistent 
pain.  In this case, there were/are multiple plausible pathologic sources of significant pain generation. The non-
radiating midline back pain, the noted pain-aggravating and pain-relieving factors, along with the diminished 
and painful spinal motion (in all directions) and intact neurologic exam were/are all non-specific to any 
pathologic entities. Documentation does not support actual formal surgical ablation of pre-designated 
basivertebral nerves as being medically necessary and/or reasonable at this time. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an 
exception. Therefore, the request for Intracept intraosseous basivertebral nerve ablation at L4 and L5 vertebral 
bodies 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the thermal destruction of intraosseous basivertebral nerve for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76942 billed for date of service February 15, 
2022. 
 
You asked the Plan to pay for procedure code 76942. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76942 is bundled into payment for 
code 74160. 
 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 76942 
is a column II code to column I code 74160. 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 76942 billed for date of service February 15, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete upper denture (D5110) provided on May 3, 
2022. 
 
You asked the Plan to pay for the dental item. You say that your old denture never fit correctly. You say that 
you had 3 different adjustments that did not help. You also say that your new denture fits you beautifully. The 
Plan denied your request. The Plan says your benefit for the complete upper denture 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the complete upper denture was exhausted on date of service September 8, 2020. 
Therefore, we decided that the Plan does not have to pay for the complete upper denture (D5110) provided on 
May 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gingival irrigation (D4921) provided on April 19, 2022. 
 
You asked the Plan to pay for gingival irrigation. You say that the service was medically necessary as you were 
in pain and unable to eat. The Plan denied your request. The Plan says the service at issue 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 gingival 
irrigation (D4921) provided on April 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an extraction, of an erupted tooth or exposed root 
(D7140) to be rendered by an oral surgeon. 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says this service is not a covered benefit under your contractual 
policy. 
 
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 service is not among 
those covered under this benefit. Specifically, the request in this case is for a tooth extraction to be provided by 
an oral surgeon. However, the service is only covered when rendered by a participating general dentist. 
Therefore, we decided that the Plan does not have to pre-approve an extraction, of an erupted tooth or exposed 
root (D7140) to be rendered by an oral surgeon.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodontal procedure (D4999) provided on March 31, 
2022. 
 
You asked the Plan to pay for the periodontal procedure. You say that you were unaware that there would be a 
charge for this service. The Plan denied your request. The Plan says the denial for this service is correct, 
because periodontal procedures are not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a 
periodontal procedure (D4999) provided on March 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost share for periodontal scaling and root planing in all 
four quadrants (D4341) provided on October 28, 2021. 
 
You asked the Plan to reduce the cost share for periodontal scaling. You say that you were told you had a $60 
copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing 
amount. 
 
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 70% 
coinsurance for in-network periodontal scaling.  
 
You have been asked to pay a total of $495.60, which is 70% coinsurance of the allowed amount for 
periodontal scaling. Periodontal scaling falls within the Dental Services benefit category.  
 
Code Allowed Amount 70% Coinsurance 
D4341 $177 $123.90 
D4341 $177 $123.90 D4341 $177 $123.90 
D4341 $177 $123.90 
Total  $495.60 
 
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 reduce the cost share for periodontal scaling and root planing in all four quadrants 
(D4341) provided on October 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on November 22, 
2021. 
 
You asked the Plan to pay for the dental services. You say that you were told the services would be covered. 
The Plan denied your request. The Plan says your benefit for the requested item or service 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service November 15, 2021. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on 
November 22, 2021.