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

 
We decided that the Plan does not have to pay for a panoramic radiographic image (D0330) provided on May 
12, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial and were not made aware of the frequency limitation. 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 2/6/2020. Therefore, we 
decided that the Plan does not have to pay for a panoramic radiographic image (D0330) provided on May 12, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive drug test (G0483) provided July 26, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that your clinics complete presumptive urine 
drug testing for medical necessity of your patients who are prescribed opioids as part of your clinical 
regulations. The Plan denied your request. The Plan says the enrollee did not meet the Medicare rules for 
approval of definitive urine drug testing for 22 or more drug classes CPT code G0483. 
 
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 pay for the laboratory services. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee with chronic pain, is being treated with opioids, Lyrica, amitriptyline, 
and Voltaren Gel. Definitive drug testing was performed for multiple drug classes. However, the provided 
documentation did not include a prior and recent urine drug screening with abnormal or unexpected results to 
warrant follow-up definitive testing. Also, multiple drug classes not relevant to this enrollees clinical history 
were performed and were unnecessary. Therefore, this request for definitive drug testing will be considered not 
medically 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 laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pay for the definitive drug test (G0483) provided July 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve replacement of a knee and foot prosthetic (L5920, 
L5828, L5845, L5848, L5856, L5968, L5981). 
 
You asked the Plan to pre-approve replacement of a knee and foot prosthetic. You say that Medicare guidelines 
have all been met and it is medically necessary for you to receive this prosthesis with knee and foot. The Plan 
denied your request. The Plan says there is no indication why a new knee and foot are 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 replacement of prosthesis's. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found your current knee and foot are under warranty and a replacement of these 
items exceeds your functional need. The physician documentation does not support that there has been a 
significant change of functional and/or physiological need that would require a new knee or foot. There is no 
evidence of irreparable damage or wear/tear or significant change in prosthetic demand that require a new knee 
and foot. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of replacement of a knee and foot prosthetic have not been met. Therefore, we 
decided that the Plan does not have to pre-approve replacement of a knee and foot prosthetic (L5920, L5828, 
L5845, L5848, L5856, L5968, L5981).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a post removal (D2955) for tooth #4 provided by a 
participating provider. 
 
You asked the Plan to pre-approve a post removal. You say that these services are needed in order to get a root 
canal. The Plan denied your request. The Plan says the requested 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 pre-approve a 
post removal (D2955) for tooth #4 provided by a participating provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cardiac catheterization (93456, 93457, 93459). 
 
You asked the Plan to pre-approve cardiac catheterization. You say that the procedure is necessary. The Plan 
denied your request. The Plan says this is a request for multiple codes for heart catheterization for an enrollee 
with a history of prior PCI and recent positive MPI. The records do not indicate that the enrollee had a prior 
coronary bypass surgery with grafts. 
 
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 cardiac catheterization. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found while LHC (93458) is justified and has been approved. There is no evidence of 
previous coronary artery bypass grafting. As such, the requests for cardiac catheterization are not justified 
based on the documentation provided. As a result, it would not be considered medically appropriate and 
necessary in the enrollees clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of cardiac catheterization have not been met. Therefore, we decided that the Plan 
does not have to pre-approve cardiac catheterization (93456, 93457, 93459).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an astigmatism-correcting (A-C) intraocular lens (IOL) 
(V2787). 
 
You asked the Plan to pre-approve an A-C IOL. You say that the requested item/service is a medical necessity 
for the enrollee. The Plan denied your request. The Plan says the requested item/service is not a covered 
benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives an A-C IOL 
during cataract surgery, the enrollee will be responsible for the difference in cost between the A-C IOL and a 
conventional IOL.  
 
While an A-C IOL may be appropriate for the enrollee, neither the Plan nor Medicare covers the astigmatism-
correcting feature of an IOL. Therefore, we decided that the Plan does not have to pre-approve an astigmatism-
correcting (A-C) intraocular lens (IOL) (V2787).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CPAP device (E0601), motor replacement (E1399) and 
delivery, set up and/or dispensing service (A9901) provided on May 10, 2022, by an OON provider. 
 
  You asked the Plan to pay for CPAP machine, motor and delivery. You say that you sought treatment outside 
the network because they could not schedule the sleep testing and results delivery in less than 8 weeks. The 
Plan denied your request. The Plan says they will cover 2 months rental, which would have been sufficient time 
to be seen in network and obtain an in-network CPAP machine. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for CPAP device (E0601), motor replacement 
(E1399) and delivery, set up and/or dispensing service (A9901) on provided on May 10, 2022, by an OON 
provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre sensor glucose monitor. 
 
You asked the Plan to pre-approve a Freestyle Libre sensor glucose monitor. You say that you need this 
specific style of glucose blood monitor since it does not require you to pinch yourself. In order to qualify for 
the knee replacement surgery, you need to measure below 8 and this requires you to measure your blood sugar 
every 3 hours or less. The Plan denied your request. The Plan says you do not meet the established criteria for 
approval of the requested monitor. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections or require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of a Freestyle 
Libre sensor glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-
approve a Freestyle Libre sensor glucose monitor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services you received from an out-of-network provider on January 25, 2022.

You asked the Plan to pay for the dental services. You say that the treatment plan had begun with this provider in 2021, so it was not advisable to switch. The Plan denied your request. The Plan says the dental services were received from an out-of-network provider and are not covered by your supplemental benefits. In addition, the Plan contacted the provider in dispute in this case and they confirmed that you were advised by them that they were not in-network with your insurance. They advised that you insisted on receiving care from them despite this.

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 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 out-of-network provider. Therefore, we decided that the Plan does not have to pay for dental services you received from an out-of-network provider on January 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150) and surgical 
extraction (D7210) to be provided by an oral surgeon. 
 
You asked the Plan to pre-approve the comprehensive oral evaluation and surgical extraction. You say that you 
feel these services should be covered. The Plan denied your request. The Plan says the supplemental dental 
services benefit of your contract only provides coverage for dental services when they are performed by a 
participating general dentist. The Plan also says that dental services performed by an oral surgeon 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 pre-approve a 
comprehensive oral evaluation (D0150) and surgical extraction (D7210) to be provided by an oral surgeon.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gum medication for teeth 1,2,3,4,13,14,15 and 16 
(D4381) and Gingival irrigation per quadrant for Upper Right and Left Quadrant (D4921). 
 
You asked the Plan to pre-approve dental services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says this service is not covered under your 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 pre-approve gum 
medication for teeth 1,2,3,4,13,14,15 and 16 (D4381) and Gingival irrigation per quadrant for Upper Right and 
Left Quadrant (D4921).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable control system. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says you are 
able to control power options using their own switches. The Plan follows Medicare rules. Medicare rules say that wheelchair options and accessories are only covered 
under certain medical indications.  
 
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 requested services. Our physician 
reviewer found that you have cerebral palsy and weakness in lower extremities. You have the capacity to use 
your upper extremities. You do not require an integrated interface or expandable controller. Therefore, the 
request is not medically 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an expandable control system.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on January 18, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary and should be 
paid. The Plan denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on January 18, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve three (3) home health physical therapy visits (CPT code 
G0151 x3). 
 
You asked the Plan to pre-approve the home health physical therapy services. You say that the services are 
necessary. The Plan denied your request. The Plan says the services are not necessary.  
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health physical therapy 
services. Our physician reviewer found the documentation does not support that the enrollee requires additional 
skilled rehabilitation services to provide treatment that is medically 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 home health physical therapy services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve three (3) home health physical therapy visits (CPT code 
G0151 x3).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150) provided by 
an out-of-network provider. 
 
You asked the Plan to pre-approve the dental services. You say that the only in-network provider could not see 
you soon enough. The Plan denied your request. The Plan says dental services from an out-of-network provider 
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. 
 
You are requesting 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 out-of-network provider. Therefore, we decided that the Plan does not have to pre-approve a 
comprehensive oral evaluation (D0150) provided by an out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection(s), bone-substitute material (eg, calcium 
phosphate) into subchondral bone defect (ie, bone marrow lesion, bone bruise, stress injury, microtrabecular 
fracture), including imaging guidance and arthroscopic assistance for joint visualization (CPT code 0707T). 
 
You asked the Plan to pre-approve the services. You say that this treatment is necessary and best for the 
enrollee's short and long-term health of the enrollee's knee. The Plan denied your request. The Plan says the 
services are considered experimental and investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the records do not show three (3) months of conservative measures for knee pain. The Plan has already approved knee scope surgery. There is no clinical need for additional knee injection therapy for bone 
lesion during the surgery. More clinical info is needed to justify injection material during surgery. 
 
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 injection(s), bone-substitute material (eg, calcium phosphate) into subchondral bone defect 
(ie, bone marrow lesion, bone bruise, stress injury, microtrabecular fracture), including imaging guidance and 
arthroscopic assistance for joint visualization (CPT code 0707T).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone replacement graft for ridge preservation (D7953) 
and the localized delivery of antimicrobial agents (D4381). 
 
You asked the Plan to pre-approve a bone replacement graft for ridge preservation (D7953) and the localized 
delivery of antimicrobial agents (D4381). You say that the member has a very large bone loss, and it has 
caused an infection and mobility on the molar. You also say that it is urgent to extract it and put an implant 
because otherwise he will be kept without a molar on that side of the mouth. The Plan denied your request. The 
Plan says services a bone replacement graft for ridge preservation (D7953) and the localized delivery of 
antimicrobial agents (D4381) are non-covered codes per the EOC. 
 
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. The Plan only covers services listed in the EOC. Specifically, a bone 
replacement graft for ridge preservation (D7953) and the localized delivery of antimicrobial agents (D4381) are 
excluded from these benefits. Therefore, we decided that the Plan does not have to pre-approve a bone 
replacement graft for ridge preservation (D7953) and the localized delivery of antimicrobial agents (D4381).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the standby service, requiring prolonged attendance, each 30 
minutes (99360) provided on May 9, 2022. 
 
You asked the Plan to pay for the standby service. You say that the provider believed monitoring services were 
needed at the time of the procedure. The Plan denied your request. The Plan says this service is not covered by 
Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that standby services are not payable to physicians. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the standby service have not been met. Therefore, we decided that the Plan does not have to pay 
for the standby service, requiring prolonged attendance, each 30 minutes (99360) provided on May 9, 2022.