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

 
We decided that the Plan does not have to pay for the intravenous moderate (conscious) sedation/analgesia 
(D9239 and D9243) or pay more for the two surgical extractions (D7210 x2) provided on February 9, 2022. 
 
You asked the Plan to pay for the intravenous moderate (conscious) sedation/analgesia and to pay more for the 
surgical extractions. You say that your teeth had to be extracted otherwise the surrounding teeth would get 
damaged. You also say that the sedation was required given the nature of the surgery. The Plan denied your 
request. The Plan says there is no coverage for intravenous moderate (conscious) sedation/analgesia. The Plan 
also says that you are responsible for 50% of the charges for an extraction from an in-network provider. 
 
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, intravenous moderate (conscious) sedation/analgesia (D9239 and D9243) is not among those covered under this benefit. The contract also clearly states that you are responsible for a 50% coinsurance for extractions that are rendered by an in-network provider. Therefore, we decided that the Plan does not have to pay for the intravenous moderate (conscious) sedation/analgesia (D9239 and D9243) or pay more for the two surgical extractions (D7210 x2) provided on 
February 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an alveoloplasty not in conjunction with extractions, 
one to three teeth or tooth spaces, per quadrant (D7321). 
 
You asked the Plan to pre-approve an alveoloplasty not in conjunction with extractions. You say that you 
cannot wear your dentures due to the bones in your gums sticking out. You need this surgery approved. The 
Plan denied your request. The Plan says the procedure code is not listed and therefore not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an 
alveoloplasty not in conjunction with extractions, one to three teeth or tooth spaces, per quadrant (D7321).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic parental drugs rendered on February 3, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
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 
therapeutic parental drugs rendered on February 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for partial denture repair (code D5650) and surgical extraction 
(code 7210) provided on December 6, 2021. 
 
You asked the Plan to pay for the denture repair and extraction. You say that you thought the provider was in-
network. The Plan denied your request. The Plan says that you have exceeded your $2,000 maximum 
allowance for 2021. 
 
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 contract says you 
have a maximum allowance amount of $2,000 per year for supplemental comprehensive dental services. 
 
We looked at the file, the Plans rules, and Medicares rules. The record shows you exceeded your maximum 
allowance for supplemental comprehensive dental services in February 2021. Therefore, we decided that the 
Plan does not have to pay for partial denture repair (code D5650) and surgical extraction (code 7210) provided 
on December 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay the remaining amount for the prophylaxis (D1110) and periodic 
oral evaluation (D0120) provided on January 4, 2022, and the resin-based composite (D2331) provided on 
January 6, 2022, by an out of network provider. 
 
You asked the Plan to pay the remaining amount for the prophylaxis, oral evaluation, and composite. You say 
that you did not know your provider was no longer in the Plan's network. The Plan denied your request. The 
Plan says you have been charged the correct cost sharing amount. 
 
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 offers a dental benefit in excess of Medicare coverage. The requested items or services were received 
from an out of network provider, and you have been charged the correct cost sharing amounts. Therefore, we 
decided that the Plan does not have to pay the remaining amount for the prophylaxis (D1110) and periodic oral 
evaluation (D0120) provided on January 4, 2022, and the resin-based composite (D2331) provided on January 
6, 2022, by an out of network provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Etoposide and Cisplatin. 
 
You asked the Plan to pre-approve Etoposide and Cisplatin. You say that this drug is medically reasonable and 
necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Etoposide and Cisplatin. Our reviewer 
says that the requested drugs are not medically reasonable and necessary. Our physician reviewer found the 
enrollee is a 77-year-old diagnosed with non-small cell lung cancer, large cell neuroendocrine carcinoma of the 
lung diagnosed in 2021. In this case, the requested use of Etoposide and Cisplatin is not FDA-approved for the 
enrollees diagnosis as the patient has progressed on prior treatment with platinum and single agent therapy is 
now recommended. In addition, the use of Etoposide and Cisplatin is not supported by one of the major drug 
compendia or by clinical research that appears in a Medicare-approved medical journal. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Etoposide and Cisplatin have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Etoposide and Cisplatin.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81206 and 81292) provided on 
August 31, 2021. 
 
You asked the Plan to pay for codes 81206 and 81292. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 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 find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT code 81479. Therefore, we decided that the Plan does not have 
to pay for the laboratory services (81206 and 81292) provided on August 31, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction (D7140) provided on February 10, 2022. 
 
You asked the Plan to pay for the extraction. You say that you would like to appeal this service. The Plan 
denied your request. The Plan says this service is not a covered expense under your dental plan. The Plan also 
says that you did contact the Plan prior to this date of service and were advised that extractions 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 pay for the 
extraction (D7140) provided on February 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the placement of intra-socket biological dressing (D7922) 
and consultation (D9310) provided on February 17, 2022. 
 
You asked the Plan to pay for the placement of intra-socket biological dressing and consultation. You say that 
you would like to appeal these services. The Plan denied your request. The Plan says these services are not 
covered benefits under your dental 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. 
 
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 
placement of intra-socket biological dressing (D7922) and consultation (D9310) provided on February 17, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acute inpatient hospital care. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the enrollee was approved for a 
revision of total knee arthroplasty and will need inpatient admission after surgery. The Plan denied your 
request. The Plan says there is no documentation provided to support the expectation the enrollee will require a 
greater than 2 midnight stay. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.   
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient admission are met in this case. Our 
physician reviewer found the enrollee is approved for a revision of total knee arthroplasty. The record does not 
document that the treating physician has a reasonable expectation of a length of stay spanning 2 or more 
midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for acute inpatient hospital care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mass spectrometry services coded 83789 provided on 
December 29, 2021. 
 
You asked the Plan to pay for the mass spectrometry services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services billed are not separately 
payable. 
 
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 83789 
is a column II code to column I code 80307. 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 the mass spectrometry services coded 83789 provided on 
December 29, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Orthovisc (J7324). 
 
You asked the Plan to pre-approve Orthovisc. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says the requested drug has not been prescribed for a 
medically accepted indication. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Orthovisc. Our reviewer says that the 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the 
enrollee has a diagnosis of osteoarthritis of the hip. The FDA has not stated that the requested drug is indicated 
for the enrollee's condition. The Medicare-approved drug compendia do not contain a supportive citation for 
the use of the requested drug in the enrollee's clinical situation. 
 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Orthovisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve treatment with Orthovisc (J7324).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the neuromonitoring services provided on December 9, 2021. 
 
You asked the Plan to pay for the services provided. You say that the modifier is correct because the facility 
did not provide the service at issue. The Plan denied your request. The Plan says the claim denied correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that CPT code 95940 was billed with CPT code 95955. CPT code 95940 is eligible for payment when 
billed with this code pair. However, the code was not billed with a modifier suitable for payment. Based on this 
information, we decided that Medicare rules for coverage of the services provided have not been met.  
 
The file shows that codes 95938, 95955, and 95870 were billed with a TC modifier. The codes at issue were 
not billed with the appropriate modifier. Therefore, we decided that the Plan does not have to pay for the 
neuromonitoring services provided on December 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit with a specialist (99215) to be provided 
by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an office visit. You say that the requested visit is needed for therapeutic 
drug level monitoring. The Plan denied your request. The Plan says the medical records do not show a need for 
a higher level of care. The Plan also says the requested visit can be done safely with an in-network provider. 
 
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 with a specialist (99215) to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantation of hypoglossal nerve neurostimulator 
array. 
 
You asked the Plan to pre-approve an implantation of hypoglossal nerve neurostimulator. You say that the 
requested service is a medical necessity for the enrollee. The Plan denied your request. The Plan says medical 
necessity rules for the requested service have not been met. 
 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 an implantation of hypoglossal nerve 
neurostimulator. Our reviewer says that the requested service is not considered medically reasonable and 
necessary in this case. Our physician reviewer found that coverage criteria for hypoglossal nerve stimulator 
implantation require that the enrollee have an AHI of 15 to 65 events per hour. The available medical records 
indicate that the enrollee had mild obstructive sleep apnea (OSA)... with an AHI of 11 (based on 4% 
scoring). 
 
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 implantation of hypoglossal nerve neurostimulator have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an implantation of hypoglossal nerve 
neurostimulator array.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a genetic panel (81227, 81230, 81225, 81226) provided on 
August 25, 2021. 
 
You asked the Plan to pay for a genetic panel. You say that this is supported by the diagnosis. The Plan denied 
your request. The Plan says this was not billed correctly. 
 
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 find that CPT codes 81227, 81230, 81225, 81226 are not supported in the medical record. Specifically, 
these codes were used to report a panel, which should be bill Based on this information, we decided that Medicare rules for coverage of a genetic panel have not been met. Therefore, we decided that the Plan does not 
have to pay for a genetic panel (81227, 81230, 81225, 81226) provided on August 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on October 11, 2020. 
 
You asked the Plan to pay for the medical services. You say that the enrollee provided different insurance 
information and you were unaware of this coverage. The Plan denied your request. The Plan says you did not 
timely file this claim. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the medical services was not filed until November 2, 2021. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for medical services provided on October 11, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you need transportation 
to get to your medical appointments. The Plan denied your request. The Plan says you have utilized the 
maximum number of transportation trips allowed per year. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 12 trips per year.  
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the SNF admission. You say that the requested admission to a SNF is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a SNF is not 
medically necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF admission. Our reviewer says 
that you do not meet the Medicare criteria for SNF care. Our physician reviewer found you do not have any 
parental medication; complex wound care or nutrition given via a feeding tube. You are medically stable 
without any acute exacerbations of chronic medical problems. Although further rehabilitation services would 
be appropriate to improve function, as a practical matter, the intermittent skilled services can be provided at a 
lower level of care than a skilled nursing facility. 
 
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 SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97014 billed for date of service September 
10, 2021. 
 
You asked the Plan to pay for procedure code 97014. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says this is an invalid procedure code. 
 
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 find that CPT code 97014 has a Status Indicator of I on the Physician Fee Schedule. This means that CPT 
code 97014 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for 
coverage of procedure code 97014 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 97014 billed for date of service September 10, 2021.