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

 
We decided that the Plan does not have to pay for the periodic oral evaluation - established patient (D0120) and 
prophylaxis - adult (D1110) provided November 8, 2021. 
 You asked the Plan to pay for the periodic oral exam and dental cleaning. You say that you would like these 
services covered. The Plan denied your request. The Plan says these services are not covered because the 
provider has opted out of Medicare. 
 
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 periodic 
oral exam and dental cleaning when you see any licensed dental provider who accepts Medicare patients in the 
United States and has not opted out of Original Medicare. 
 
We looked at the file and Medicare rules. The services at issue in this appeal were provided in a non-urgent, 
non-emergent situation by the provider who has opted out of the Medicare program. Based on this information, 
we decided that the Plan's rules for coverage of the periodic oral exam and dental cleaning have not been met. 
Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation - established patient 
(D0120) and prophylaxis - adult (D1110) provided November 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an epidural injection provided on December 6, 2021. 
 
You asked the Plan to pay for an epidural injection. The Plan denied your request. The Plan says the Health 
Plan has not received the required clinical records to support the medical necessity of the service for the date of 
service requested. The records provided are undated and unsigned. There is insufficient documentation of 
response to prior injections. 
 
 
 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 epidural injection provided on 
December 6, 2021 have been met. The Plan has not received the required clinical records to support the 
medical necessity of the service for the date of service requested. Therefore, we decided that the Plan does not 
have to pay for an epidural injection provided on December 6, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting 
from November 26, 2021, to November 29, 2021. 
 You asked the Plan to pay for the self-administered drugs. You say that you were never told that you would be 
in the hospital as an observation patient. The Plan denied your request. The Plan says self-administered drugs 
are not covered under Medicare Part B. 
 
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 pay for the self-administered drugs 
provided in an outpatient setting from November 26, 2021, to November 29, 2021.  
 
Benefits for the self-administered drugs 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an epidural injection provided on November 29, 2021. 
 
You asked the Plan to pay for an epidural injection. The Plan denied your request. The Plan says the Health 
Plan has not received the required clinical records to support the medical necessity of the service for the date of 
service requested. The records provided are undated and unsigned. There is insufficient documentation of 
response to prior injections. 
 
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 epidural injection provided on 
November 29, 2021 have been met. The Health Plan has not received the required clinical records to support 
the medical necessity of the service for the date of service requested. Therefore, we decided that the Plan does 
not have to pay for an epidural injection provided on November 29, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional physical therapy visits. 
 
You asked the Plan to pre-approve the visits. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee was plateaued with physical therapy, and ongoing needs can be met with a 
home exercise program. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 visits. Our reviewer says that skilled 
services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. 
Our physician reviewer found the additional requested therapy generally is not accepted as specific and 
effective therapy for your condition beyond what was approved by the health plan. You have had prior therapy 
and the documentation does not reveal that the you require the unique skills of a professional therapist to safely 
and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, 
or by or under the supervision of a therapist. The requested services are not part of a maintenance program, and 
the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or 
deliver a program to maintain your current condition or to prevent or slow further deterioration. Ongoing 
skilled therapy is not medically necessary for your functional level. 
 
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 visits have not been met. Therefore, we decided that the Plan does not have 
to pre-approve additional physical therapy visits.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Velcade. 
 
You asked the Plan to pre-approve Velcade. You say that the services are necessary. The Plan denied your 
request. The Plan says that based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Velcade. Our reviewer says that the 
services are medically necessary. Our physician reviewer found Bortezomib yields high response rates in 
antibody-mediated autoimmune hematological diseases refractory to conventional immunosuppression. While 
the services do not meet compendia criteria, it does meet the literature. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Velcade have been met. Therefore, we decided that the Plan has to pre-approve 
Velcade.  
 
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 molecular pathology testing provided August 2, 2021 
 
You asked the Plan to pay for the molecular pathology testing. You say that the Tempus gene panel was 
ordered by the Plan's in-network provider. Attached please find a copy of the test requisition form, test results 
and CPT description. The Plan denied your request. The Plan says the records do not support the service billed. 
 The Plan must follow Medicare rules. Medicare rules say that 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 molecular pathology testing 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 the molecular pathology testing provided August 2, 2021
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional indwelling foley catheters (28 per month). 
 
You asked the Plan to pre-approve catheters. You say that you are appealing this denial. The Plan denied your 
request. The Plan says the denial of authorization for the additional supplies is correct, because Medicare only 
allows 2 indwelling catheters per month. 
 
Medicare only covers one catheter per month unless additional quantities are supported as medical necessity. 
 
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 catheters. Our reviewer says that the 
enrollee does not meet the Medicare criteria for the requested catheters. Our physician reviewer found these 
catheters are requested due to issues with urinary frequency which prevent sleeping. The documentation does 
not support a need for the additional quantity of indwelling catheters. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of catheters have not been met. Therefore, we decided that the Plan does not have 
to pre-approve additional indwelling foley catheters (28 per month).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve three core buildups, including any pins when required 
(D2950 x3) and a crown (D2740) for tooth #20. 
 
You asked the Plan to pre-approve the core buildups and crown. You say that you would like to appeal these 
services because you are only on social security. The Plan denied your request. The Plan says core buildup is 
not a covered expense under your dental plan. The Plan also says your crowns benefit has been satisfied and 
the frequency limitation has been exceeded. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, core buildup, including any pins when 
required (D2950) is not among those covered under this benefit. The contract says that crowns are limited to 2 
procedure codes per calendar year. The record shows that you have been approved to receive crowns (D2740) 
on tooth #'s 18 and 19, and your crowns benefit has been exhausted. Therefore, we decided that the Plan does 
not have to pre-approve three core buildups, including any pins when required (D2950 x3) and a crown 
(D2740) for tooth #20.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a full mouth debridement to enable a comprehensive 
oral evaluation and diagnosis on a subsequent visit (D4355). 
 
You asked the Plan to pre-approve the full mouth debridement. You say that you have not seen the dentist since 
2018. The Plan denied your request. The Plan says you had a regular cleaning or oral or periodontal evaluations 
within the past 12 months. The Plan also says that you cannot get this type of deep cleaning of your whole 
mouth within 12 months of these types of visits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, a full mouth debridement is covered to 
enable a comprehensive oral evaluation and diagnosis on a subsequent visit (D4355). The record shows that 
you received a comprehensive oral evaluation (D0150) on March 30, 2022, and you cannot receive this full 
mouth debridement because it has not been at least 12 months since this evaluation was provided. Therefore, 
we decided that the Plan does not have to pre-approve a full mouth debridement to enable a comprehensive oral 
evaluation and diagnosis on a subsequent visit (D4355).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cone beam computed tomography (CT) image capture 
(D0380). 
 
You asked the Plan to pre-approve a cone beam CT image capture. The Plan denied your request. The Plan 
says this service is not covered under the enrollee's benefit 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 a 
cone beam computed tomography (CT) image capture (D0380).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150) with a 
periodontist. 
 
You asked the Plan to pre-approve the dental service. You say that you need this for tooth # 6 and 7. You also 
say that you disagree with this denial. The Plan denied your request. The Plan says services must be performed 
by a participating general dentist. The Plan also says services performed by a periodontist 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, services performed by a periodontist 
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) with a periodontist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gingival irrigation (D4921 x 4), scaling in presence of 
generalized moderate or severe gingival inflammation (D4346), and take home drugs (D9630) provided on 
December 7, 2021. 
 
You asked the Plan to pay for the dental services. You say that you were advised you only needed to pay $91 
dollars for the services you received. You say that you received a bill for $109. You say that The Plan denied 
your request. The Plan says the gingival irrigation, scaling in the presence of gingival inflammation, and take 
home drug are not listed as covered services. 
 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 gingival irrigation, scaling in the 
presence of gingival inflammation, and take home drug are not among those covered under this benefit. 
Therefore, we decided that the Plan does not have to pay for the gingival irrigation (D4921 x 4), scaling in 
presence of generalized moderate or severe gingival inflammation (D4346), and take home drugs (D9630) 
provided on December 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gingival irrigation  per quadrant (D4921), drugs or 
medicaments dispensed in the office for home use (D9630), limited oral evaluation - problem focused (D0140) 
and intraoral - periapical first radiographic image (D0220) provided December 21, 2021, core buildup, including any pins when required (D2950) provided December 22, 2021, and interim partial denture (including 
retentive/clasping materials, rests, and teeth), maxillary (D5820) provided December 27, 2021. 
 
You asked the Plan to pay for the gingival irrigation, drugs, limited oral evaluation, intraoral x-rays, core 
buildup, and partial denture. You say that this provider is in the Plan's network. The Plan denied your request. 
The Plan says your claim has been reprocessed as in-network; however these services are not covered under 
your benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
gingival irrigation  per quadrant (D4921), drugs or medicaments dispensed in the office for home use 
(D9630), limited oral evaluation - problem focused (D0140) and intraoral - periapical first radiographic image 
(D0220) provided December 21, 2021, core buildup, including any pins when required (D2950) provided 
December 22, 2021, and interim partial denture (including retentive/clasping materials, rests, and teeth), 
maxillary (D5820) provided December 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the 2D oral/facial photographic images (D0350) and 
panoramic x-ray (D0330) provided on January 11, 2022. 
 
You asked the Plan to pay for the photographic images and panoramic x-ray. You say that your previous 
provider submitted claims for services you never received, so your frequency limitations should not have been 
exceeded in this case. The Plan denied your request. The Plan says they have agreed to reprocess this claim and 
pay for the comprehensive exam and the complete series of x-rays; however, 2D oral/facial photographic 
images are not covered by your benefit under any condition, and you are only covered for one complete series 
of x-rays or panoramic x-ray every five years. You had a complete series and a panoramic x-ray on the date in question, and because the complete series is covered in this case, the panoramic x-ray is denied as exceeding 
the frequency limitations of your 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. The Plan does not cover 
services which are not listed in the dental benefits chart section of the contract. The Plan can cover one 
complete series of x-rays or one panoramic x-ray every 5 calendar years. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the documentation supports that the 
requested items or services are not among those covered under this benefit or were provided in a frequency that 
exceeds what is covered by this benefit. Therefore, we decided that the Plan does not have to pay for the 2D 
oral/facial photographic images (D0350) and panoramic x-ray (D0330) provided on January 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on January 
19, 2022 by a Medicare opt out provider. 
 
You asked the Plan to pay for the periodontal maintenance. You say that the treating provider says that they 
accept Preferred Provider Organization (PPO) plans. You also say that at least a portion of this bill should be 
covered. The Plan denied your request. The Plan says this service was rendered by a provider who has opted 
out of Medicare. 
 
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 
covered when they are rendered by a provider who has opted out of Medicare. Therefore, we decided that the 
Plan does not have to pay for the periodontal maintenance (D4910) provided on January 19, 2022 by a 
Medicare opt out provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve eight surgical placements of implant bodies: endosteal 
implants (D6010 x8). 
 
You asked the Plan to pre-approve the endosteal implants. You say that you were advised that this could be the 
best treatment for you. The Plan denied your request. The Plan says this service is not covered under your 
benefit 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 eight 
surgical placements of implant bodies: endosteal implants (D6010 x8).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mandibular implant/abutment supported removable 
denture for edentulous arch (D6111). 
 
You asked the Plan to pre-approve a mandibular implant/abutment supported removable denture. You say that 
you need this procedure approved so you can have teeth. The Plan denied your request. The Plan says this 
service is not covered under your benefit package. 
 
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 
mandibular implant/abutment supported removable denture for edentulous arch (D6111).