Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve a permanent adjustable trans-prostatic implant (Urolift). 
 
You asked the Plan to pre-approve the services. You say that the guidelines do not necessitate a trial of medical 
therapy before consideration of this procedure. The Plan denied your request. The Plan says that the health plan 
has no contractual obligation to cover services that are not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically 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 the services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that the records show that the enrollee has significant benign prostatic hyperplasia (BPH( with bladder 
outlet obstruction. The UroLift System is currently indicated for the treatment of symptoms due to urinary 
outflow obstruction secondary to benign prostatic hyperplasia (BPH), including lateral and median lobe 
hyperplasia, in men 45 years of age or older. The current American Urological Association (AUA) 
guidelines do not necessitate a trial of medical therapy before consideration of this procedure and state that 
Urolift may be offered to patients that desire to avoid other therapies. 
 
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 been met. Therefore, we decided that the Plan has to pre-
approve a permanent adjustable trans-prostatic implant (Urolift).  
 
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 pay for an office visit provided on February 4, 2022. 
 
You asked the Plan to pay for the office visit. The Plan denied your request. The Plan says that the Plan 
requires utilization of network providers when possible and available and requires authorization for certain 
services. No medical necessity for an out-of-network provider such as an urgent or an emergent situation that 
has been documented.   
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for an office visit provided on February 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bitewings (D0274) provided on July 13, 2022. 
 
You asked the Plan to pay for the dental services. You say that it was necessary for your dentist to do the 
bitewings because they were beyond fixing. 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 the date of service of January 13, 2022. 
Therefore, we decided that the Plan does not have to pay for the bitewings (D0274) provided on July 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown and a prefabricated post and core (D2740, D2954) 
provided on May 25, 2022. 
 
You asked the Plan to pay for the crown and a prefabricated post and core. 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 pay for a crown 
and a prefabricated post and core (D2740, D2954) provided on May 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the dental extraction (D7210) provided on January 15, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay more for the dental services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says you are responsible for any charged amount above the Plans cost-
sharing amount when your services are received from an out-of-network provider. 
 
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 have been asked to pay 50% of the allowed amount plus the difference between the out-of-network 
providers charges and the Plans payment. 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 pay more for the dental 
extraction (D7210) provided on January 15, 2022, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Fundus Photography provided on June 29, 2022. 
 
You asked the Plan to pay for Fundus Photography. The Plan denied your request. The Plan says Fundus 
Photography is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that Fundus Photography is not covered for routine 
screening. 
 
We looked at the file and Medicare rules. Medicare says that Fundus Photography is not covered for routine 
screening. Therefore, we decided that the Plan does not have to pay for Fundus Photography provided on  
June 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positioning pillow. 
 
You asked the Plan to pre-approve a positioning pillow. You say that the item should be covered. The Plan 
denied your request. The Plan says this item does not primarily serve a medical purpose. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a positioning pillow.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve an office visit. You say that you would like to request reconsideration of the 
denied authorization. The Plan denied your request. The Plan says the provider is out-of-network, and it was 
determined these services can be received in-network. 
 
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 items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the aspirin and nitroglycerin provided in an outpatient setting 
on June 23, 2022. 
 
You asked the Plan to pay for the self-administered drugs. You say that you do not understand why this is 
being denied. The Plan denied your request. The Plan says the drugs you received in an outpatient setting are 
considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D 
prescription drug plan. The Plan also says the drugs you received 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 aspirin and nitroglycerin 
provided in an outpatient setting on June 23, 2022.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an advanced foot with addition. 
 
You asked the Plan to pre-approve an advanced foot with addition. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says you do not meet criteria for the requested items. 
 
The Plan follows Medicare rules. Medicare rules say that an advanced foot with addition is covered for 
enrollees who are at a K3 functional level. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an advanced foot with addition. Our 
reviewer says that the documentation does not support that the requested items are medically reasonable or 
necessary. Our physician reviewer found you have a medical history including diabetes mellitus and a previous 
traumatic right-sided below the knee amputation. A level 3 ambulator has the ability or potential for ambulation 
with variable cadence. Typical of the community ambulator who has the ability to traverse most environmental 
barriers and may have vocational, therapeutic or exercise activity that demands prosthetic utilization beyond 
simple locomotion. The documentation does not support that you are at a K3 functional level. Therefore, you 
do not meet criteria for the requested advanced foot with addition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an advanced foot with addition have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an advanced foot with addition.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gingival irrigation  per quadrant (D4921x4), and topical 
application of fluoride varnish (D1206) provided on April 19, 2022. 
 
You asked the Plan to pay for gingival irrigation  per quadrant (D4921x4), and topical application of fluoride 
varnish (D1206). You say that the provider is contracted and therefore the visit should be covered. The Plan 
denied your request. The Plan says these services are not covered under the 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 pay for gingival 
irrigation  per quadrant (D4921x4), and topical application of fluoride varnish (D1206) provided on April 19, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on July 7, 2022, to July 12, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental 
services on July 7, 2022, to July 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wheelchair accessory, power seat elevation system 
(E2300). 
 
You asked the Plan to pre-approve a wheelchair accessory. You say that the requested equipment is needed. 
The Plan denied your request. The Plan says your request is not a covered benefit because Medicare does not 
consider this feature to be primarily medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
 
 The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a wheelchair accessory, power seat elevation system 
(E2300).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an abutment (D6057) and a crown (D6058) for tooth #7 
provided on July 20, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were in pain and needed this procedure to 
be done. 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 the date of service of August 30, 2021. 
Therefore, we decided that the Plan does not have to pay for an abutment (D6057) and a crown (D6058) for 
tooth #7 provided on July 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a porcelain/ceramic crown (D2740) for tooth number 12 
provided on May 6, 2022. 
 
You asked the Plan to pay for a porcelain/ceramic crown (D2740) for tooth number 12. You say that you called 
the dental office on three separate occasions to be sure that this was approved, and the dental office kept telling 
you it was. The Plan denied your request. The Plan says proper authorization was not obtained. 
 
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 a 
porcelain/ceramic crown (D2740) when the services are pre-authorized. 
 
 
  We looked at the file, and the Plan rules. The Plan rules say that this service must be pre-authorized. The record 
shows that there was no preauthorization for this service. Based on this information, we decided that the Plan's 
rules for coverage of a porcelain/ceramic crown (D2740) for tooth number 12 have not been met. Therefore, we 
decided that the Plan does not have to pay for a porcelain/ceramic crown (D2740) for tooth number 12 
provided on May 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a periodic oral evaluation (D0120) and an adult 
prophylaxis (D1110) provided on March 10, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you had your semi-annual routine 
cleaning and checkup at an in-network provider, and the Plan paid the claim as if the provider was not an in-
network provider. The Plan denied your request. The Plan says you are responsible for any charged amount 
above the Plans cost-sharing amount when your services are received from an out-of-network provider. 
 
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 have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for a periodic oral evaluation (D0120) and an 
adult prophylaxis (D1110) provided on March 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction of erupted tooth or exposed root (D7140 x 2) 
on tooth #25 and #26 provided on June 7, 2022. 
 
You asked the Plan to pay for the dental services. You say that no one explained to you how to correctly use 
your dental benefits 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 the same date of service June 7, 2022, 
for tooth #23 and #24. Therefore, we decided that the Plan does not have to pay for the extraction of erupted 
tooth or exposed root (D7140 x 2) on tooth #25 and #26 provided on June 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair. 
 
You asked the Plan to pre-approve the requested wheelchair. You say that you are unable to be independent. 
The Plan denied your request. The Plan says the request does not meet the criteria. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
We looked at the file and the rules. A smaller power wheelchair was requested for use outside of the home. 
Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. 
Therefore, we decided that the Plan does not have to pre-approve a power wheelchair.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a percutaneous nerve stimulator (L8697). 
 
You asked the Plan to pay for the percutaneous nerve stimulator. You say that this service was medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that Neurostim system/NSS, P-Stim, ANSiStim, E-
Pulse, and NSS-2 Bridge, other current or future devices when used for the procedure auricular peripheral 
nerve stimulation or electro-acupuncture, would be considered a non-covered service. 
 
We looked at the file and Medicare rules. This device is considered electro-acupuncture and is non-covered 
under Medicare rules. Based on this information, we decided that Medicare rules for coverage of the 
percutaneous nerve stimulator have not been met. Therefore, we decided that the Plan does not have to pay for 
a percutaneous nerve stimulator (L8697).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implant (D6010) for tooth # 3. 
 
You asked the Plan to pre-approve the dental service. You say that you need this service. The Plan denied your 
request. The Plan says an implant is not listed as a covered dental service. 
 
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 implant is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an implant 
(D6010) for tooth # 3.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76882 billed for date of service May 23, 
2022. 
 
You asked the Plan to pay for procedure code 76882. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 76882 is bundled into payment for code 93971. 
 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 76882 
is a column II code to column I code 93971. 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 76882 billed for date of service May 23, 2022.