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

 
We decided that the Plan does not have to pre-approve the extractions of teeth #'s 11, 14, 15, and 32 and the 
periodontal services requested. 
 
You asked the Plan to pre-approve the additional extractions and periodontal services. You say that these 
services are required for the enrollee's condition. The Plan denied your request. The Plan says all covered 
services were approved. Remaining services 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 Plan's coverage rules apply in this case. Two extraction per year are 
covered which was approved through this request. Additional extractions are not covered, nor are periodontal 
services requested. 
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 the 
extractions of teeth #'s 11, 14, 15, and 32 and the periodontal services requested.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two white glass caps (D6740), and prosthodontics fixed 
(D6245) to be provided by a participating provider. 
 
You asked the Plan to pre-approve two white glass caps and prosthodontics fixed. You say that this dental work 
is medically necessary. The Plan denied your request. The Plan says these services are not medically necessary. 
 
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 covers two white 
glass caps and prosthodontics fixed when the services are medically necessary and reasonable.  
 
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 two white glass caps and prosthodontics 
fixed. Our reviewer says that the requested dental work is not medically necessary. Our physician reviewer 
found documentation provided was not complete (lacks radiographs of the area) to determine if the criteria for 
coverage for a fixed bridge replacing tooth #4 using #'s 3 and 5 as abutment retainers have been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of two white glass caps and prosthodontics fixed have not been met. Therefore, we 
decided that the Plan does not have to pre-approve two white glass caps (D6740), and prosthodontics fixed 
(D6245) to be provided by a participating provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services provided on January 5, 
2022. 
 
You asked the Plan to waive the copayment for the laboratory services. You say that the services should be 
covered as you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied 
correctly based on the services provided. 
 
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 a $35 
copayment for Outpatient diagnostic tests and therapeutic services and supplies.  
 
 
  You have been asked to pay a $35 copayment for the laboratory services. Laboratory services fall within the 
Outpatient diagnostic tests and therapeutic services and supplies 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 January 5, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the extractions (D41899 x 4) provided on July 30, 2021. 
 
You asked the Plan to pay for the dental services. You say that you need hip surgery. You say that you needed 
dental clearance. You also say that these extractions were medically necessary to prevent infection. The Plan 
denied your request. The Plan says that the services are routine dental in nature. The Plan also says that 
Medicare does not cover routine dental services. 
 
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 dental services. Our reviewer says that 
the extractions are considered medically reasonable and necessary in this case. Our physician reviewer found 
the provided medical records contain treatment notes of this surgical dental procedure. The reviewer found that 
removal of these teeth were medically reasonable and necessary to provide the best outcome of the hip 
replacement 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 dental services have been met. Therefore, we decided that the Plan has to 
pay for the extractions (D41899 x 4) provided on July 30, 2021.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve head and neck surgery to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the OON head and neck surgery. You say that your appointment with the 
network specialist you were referred to was cancelled. You say that you need this surgery as soon as possible. 
The Plan denied your request. The Plan says the care needed is available within their network of providers. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the surgery at issue in this appeal. The Plan has advised that they issued an 
authorization for the services with a different network provider from the one who you were originally referred 
to that was unavailable. We found no exception that would require the Plan to pre-approve services with an out of network provider. Therefore, we decided that the Plan does not have to pre-approve head and neck surgery 
to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the Cystourethroscopy services (52352 and 52332) provided on 
December 4, 2019, and December 17, 2019. 
 
You asked the Plan to pay for the Cystourethroscopy services. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says that payment has been denied. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. In this case, the Plan has not provided enough information to make a 
determination. The case file contains very little documentation. There is no denial reason or rationale with 
evidence based on Medicare criteria to support the denial of payment for these services. Therefore, we decided 
that the Plan has to pay for the Cystourethroscopy services (52352 and 52332) provided on December 4, 2019, 
and December 17, 2019.  
 
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the Euflexxa injection rendered on September 23, 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 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 J7323 is 2. The MAI value for this code is 2. You billed 4 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 Euflexxa injection rendered on September 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pharmacogenomics testing provided on November 2, 
2020. 
 
You asked the Plan to pay for the testing services. You say that medically necessary services were provided in 
good faith. The Plan denied your request. The Plan says coverage is limited to one test per specimen. 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We looked at the file and the rules. We find that the gene panel was billed with multiple codes. If a single 
procedure is performed, only one HCPCS/CPT code with one unit of service may be reported for the 
procedure. Based on this information, we decided that Medicare rules for coverage of the testing services have 
not been met. Therefore, we decided that the Plan does not have to pay for the pharmacogenomics testing 
provided on November 2, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a duplex scan of lower extremity arteries or arterial 
bypass grafts (93925), and bilateral upper or lower extremity arterial assessments to check blood flow in 
relation to a blockage (93923). 
 
You asked the Plan to pre-approve a duplex scan of lower extremity arteries or arterial bypass grafts (93925), 
and bilateral upper or lower extremity arterial assessments to check blood flow in relation to a blockage 
(93923). The Plan denied your request. The Plan says this service does not meet the LCD requirements. 
 
The Plan follows Medicare rules. 
 
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 duplex scan of lower extremity 
arteries or arterial bypass grafts (93925), and bilateral upper or lower extremity arterial assessments to check 
blood flow in relation to a blockage (93923). Our reviewer says that the requested services are not medically 
necessary. Our physician reviewer found that the physical exam did not document lower extremity peripheral 
pulse absence and there is no diabetic ulceration. ABI would be the first procedure of choice and if abnormal a 
duplex doppler arterial study would then be indicated. Absent such documentation the medical necessity of the 
requested test has not been established. 
 
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 duplex scan of lower extremity arteries or arterial bypass grafts (93925), and 
bilateral upper or lower extremity arterial assessments to check blood flow in relation to a blockage (93923) 
have not been met. Therefore, we decided that the Plan does not have to pre-approve a duplex scan of lower 
extremity arteries or arterial bypass grafts (93925), and bilateral upper or lower extremity arterial assessments 
to check blood flow in relation to a blockage (93923).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (80053) provided August 20, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed services. 
 
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 lab services (80053) provided August 20, 2021. have been met. No clinical records were provided. Therefore, we decided that the Plan does not have 
to pay for lab services (80053) provided August 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99214) provided on October 20, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says this provider is not a network provider with the Plan, and they have also 
determined that these services are not urgent or emergent, nor were they 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 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 an office visit (99214) provided on October 20, 
2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate services. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
clinical effectiveness of bone marrow aspirate during spinal fusion surgery has not been demonstrated in peer-
reviewed literature. 
 
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 requested services. Our physician 
reviewer found that bone marrow aspirate remains experimental for use as bone graft material in cases of spine 
fusion surgery. More research is needed to support its safety and efficacy. Therefore, the requested services are 
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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone marrow aspirate services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gemtesa. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says self-administered drugs are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Gemtesa.  
 
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the periodontal maintenance (D4910) provided on November 23, 2021. 
 
You asked the Plan to pay for the periodontal maintenance. You say that you would like this service to be 
covered at a 50% coinsurance. You also say that the periodontal maintenance takes place of regular cleanings. 
The Plan denied your request. The Plan says that you have received this service twice previously in a twelve-
month period. The Plan also says that they were advised the office wrote off a portion of your denied charges, 
leaving you responsible for $65. 
 
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 covers the 
periodontal maintenance when the services are medically necessary and reasonable. 
 
The record shows that you received a periodontal maintenance (D4910). The 2021 Evidence of coverage states 
that you have a maximum $2,500 allowance with a 50% coinsurance every year for supplemental 
comprehensive dental services. The Plan denied this service saying your maximum benefit had been exhausted. 
The 2021 EOC does not clearly provide any frequency limitations to the periodontal maintenance procedure. 
You reasonably believed this service would be covered at a 50% coinsurance. 
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of the periodontal maintenance have been met. Therefore, we decided that the Plan has to pay for the 
periodontal maintenance (D4910) provided on November 23, 2021.  
 
Please Note: The record shows that the Plan obtained a pay agreement stating you accept responsibility for any 
denied services. The Plan was also advised that the provider wrote off a portion of your denied charges, leaving 
you responsible for $65. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Stelara. 
 
You asked the Plan to pre-approve Stelara. You say that you would like the Plan to reconsider their denial. The 
Plan denied your request. The Plan says Stelara is not covered under the enrollee's Medicare Part B benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Stelara.  
 
Benefits for Stelara may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for angiography services (procedure codes 75710, 75774) 
provided to the enrollee on May 17, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the denied codes remain not supported. 
 
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, the CPT Code Manual definition of the denied codes is: 
 
CPT 75710: 
 
Angiography, extremity, unilateral, radiological supervision and interpretation 
 
CPT 75774: 
 
Angiography, selective, each additional vessel studied after basic examination, radiological supervision and interpretation (List separately in addition to code for primary procedure) 
 
We asked our coder 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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found after careful review of the operative 
report, there is insufficient documentation to confirm which procedures were performed on the left and right 
side, to confirm these procedures as inclusive to procedure CPT 37728. 
 
We looked at this coder'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 pay for angiography services (procedure codes 75710, 75774) provided to the enrollee on May 17, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an eye exam provided on October 5, 2021. 
 
You asked the Plan to waive the copayment for the eye exam. You say that the services should be covered as 
you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied correctly 
based on the services provided. 
 
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 a $40 
copayment for Vision care.  
 
 
  You have been asked to pay a $40 copayment for an eye exam. Eye exams fall 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 an eye exam provided on October 5, 2021.