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

 
We decided that the Plan does not have to pre-approve crown - porcelain fused to high noble metal (D2750) for 
tooth #30, Maxillary partial denture - cast metal framework with resin denture bases (D5213) and Deep 
cleaning Periodontal scaling and root planing lower right quadrant and upper left quadrant (D4341). 
 
You asked the Plan to pre-approve crown - porcelain fused to high noble metal (D2750) for tooth #30, 
Maxillary partial denture - cast metal framework with resin denture bases (D5213) and Deep cleaning 
Periodontal scaling and root planing lower right quadrant and upper left quadrant (D4341). You say that the 
dental services are medically necessary. The Plan denied your request. The Plan says crown - porcelain fused to 
high noble metal (D2750) for tooth #30 and Deep cleaning Periodontal scaling and root planing lower right 
quadrant and upper left quadrant (D4341) are not medically necessary. The Plan also says that Maxillary partial 
denture - cast metal framework with resin denture bases (D5213) is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
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 crown - porcelain fused to high noble 
metal (D2750) for tooth #30 and Deep cleaning Periodontal scaling and root planing lower right quadrant and 
upper left quadrant (D4341) have been met. Specifically, due to the lack of adequate documentation, a 
determination of need for these services could not be made. Additionally, the file shows that Maxillary partial 
denture - cast metal framework with resin denture bases (D5213) is not a covered dental benefit. Therefore, we 
decided that the Plan does not have to pre-approve crown - porcelain fused to high noble metal (D2750) for 
tooth #30, Maxillary partial denture - cast metal framework with resin denture bases (D5213) and Deep 
cleaning Periodontal scaling and root planing lower right quadrant and upper left quadrant (D4341).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator (E1392). 
 
You asked the Plan to pre-approve the portable oxygen concentrator. You say that this equipment is medically 
necessary. The Plan denied your request. The Plan says the enrollee has equipment already that meets their 
needs. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have portable oxygen tanks. The portable oxygen tanks serve the same purpose as the 
requested portable concentrator. Therefore, we decided that the Plan does not have to pre-approve a portable 
oxygen concentrator (E1392).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional trips for routine transportation beyond the 
Plan's 24-trip limit. 
 
You asked the Plan to pre-approve additional routine transportation. You say that the enrollee needs 
transportation to medical appointments. The Plan denied your request. The Plan says the enrollee's 
transportation benefit has been exhausted. 
 
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 24 trips per year.  
 We looked at your request, the records in the case file, and the rules. The Plan provided documentation 
showing that the Plan has covered 24 routine transports. Based on this information, we decided that the enrollee 
has exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the 
Plan does not have to pre-approve additional trips for routine transportation beyond the Plan's 24-trip limit.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a posterior lumbar arthrodesis procedure using the 
Minuteman G3-R MIS fusion plate. 
 
You asked the Plan to pre-approve a posterior lumbar arthrodesis procedure using the Minuteman G3-R MIS 
fusion plate. You say that the service is medically necessary. The Plan denied your request. The Plan says the 
service is experimental. 
 
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 a posterior lumbar arthrodesis 
procedure using the Minuteman G3-R MIS fusion plate. Our reviewer says that the requested service is not 
considered medically reasonable and necessary in this case. Our physician reviewer found this procedure is 
experimental and more research is needed to show safety and efficacy for back pain. 
 
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 posterior lumbar arthrodesis procedure using the Minuteman G3-R MIS fusion plate have not been met. Therefore, we decided that the Plan does not have to pre-approve a posterior 
lumbar arthrodesis procedure using the Minuteman G3-R MIS fusion plate.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.

You asked the Plan to pre-approve SNF care. You say that your needs would be better met at a SNF. You say that you cannot do anything by yourself and need access to daily therapy. The Plan denied your request. The Plan says a SNF is not medically necessary, and your needs can be met at a lower level of care.

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 SNF care. Our reviewer says that the requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that you have no identifiable skilled nursing or identifiable skilled therapy service needs. You do not require skilled nursing or therapy services on a daily basis as an inpatient in a SNF setting.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a comprehensive oral evaluation (D0150), an adult 
prophylaxis (D1110), bitewings (D0274) and an intraoral - periapical first radiographic image (D0220) 
provided on July 25, 2022. 
 
You asked the Plan to pay more for the dental services. You say that if you are out of state and have issues, the 
Plan should cover your expenses. 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 comprehensive oral evaluation (D0150), an 
adult prophylaxis (D1110), bitewings (D0274) and an intraoral - periapical first radiographic image (D0220) 
provided on July 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown - porcelain fused to high noble metal (D2750) 
for tooth # 9. 
 
You asked the Plan to pre-approve a crown - porcelain fused to high noble metal (D2750) for tooth # 9. You 
say that the services are medically necessary The Plan denied your request. The Plan says a crown - porcelain 
fused to high noble metal (D2750) for tooth # 9 is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a crown - porcelain fused to high noble 
metal (D2750) for tooth # 9. Our reviewer says that the requested Crown - porcelain fused to high noble metal 
(D2750) for tooth # 9 is not considered medically reasonable and necessary in this case. Our physician 
reviewer found due to the lack of adequate documentation a determination of the need for a crown restoration 
(D2750) for tooth #9 could not be made. 
 
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 crown - porcelain fused to high noble metal (D2750) for tooth # 9 have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a crown - porcelain fused to high 
noble metal (D2750) for tooth # 9.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the full series x-rays (D0210) provided on July 7, 2022. 
 
You asked the Plan to pay for the dental service. You say that you needed the x-rays done so the dentist could 
see clearly how to treat you. The Plan denied your request. The Plan says he denial of payment for this service 
is correct, because the full series x-rays 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 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 full 
series x-rays (D0210) provided on July 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup (D2950) for tooth #12 provided on August 
4, 2022. 
 
You asked the Plan to pay for the dental service. You say that you would like to appeal the denied dental 
service because it was necessary. The Plan denied your request. The Plan says the denial of payment for this 
service is correct, because core buildup is 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 pay for the core 
buildup (D2950) for tooth #12 provided on August 4, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transport chair and seat cushion. 
 
You asked the Plan to pre-approve a transport chair and seat cushion. You say that the enrollee needs these 
items. The Plan denied your request. The Plan says the enrollee's home must be located within the service area. 
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and 
pre-approved care.   
 
We looked at the file and Medicare rules. Review of the file shows that the enrollees new residence is located  
outside of the Plans covered service area. Based on this information, we decided that Medicare rules for 
coverage of a transport chair and seat cushion have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a transport chair and seat cushion.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for definitive drug testing (G0482) provided on March 30, 2022.

You asked the Plan to pay for definitive drug testing. You say that this service was necessary and was reported correctly. The Plan denied your request. The Plan says that the record does not support this service as billed, as only 14 drug classes are supported as tested in this case.

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 code G0482 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers, 15-21 drug class(es), including metabolite(s), if performed.

We find that CPT code G0482 is supported in the medical record. Specifically, the record supports that at least 15 drug classes were tested in this case, including alcohol biomarkers, amphetamines, antidepressants (not otherwise specified), benzodiazepines, buprenorphine, cocaine, fentanyls, heroin metabolite, methadone, methylenedioxyamphetamines, methylphenidate, opiates, opioids and opiate analogs, oxycodone and skeletal muscle relaxants. Based on this information, we decided that Medicare rules for coverage of definitive drug testing have been met. Therefore, we decided that the Plan has to pay for definitive drug testing (G0482) provided on March 30, 2022. 

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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an oral evaluation (D0150), intraoral radiographic images 
(D0210), and oral photo images (D0250) provided on June 22, 2022. 
 
You asked the Plan to pay for the dental services. You say that it was medically necessary for you to get these 
procedures done. The Plan denied your request. The Plan says your benefit for the oral evaluation and intraoral 
radiographic images has already been exhausted and the denial of payment for the oral photo images is correct, 
because they 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 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 oral evaluation and intraoral radiographic images was exhausted on the date of 
service of January 17, 2022, also the oral photo images are not among those covered under this benefit. 
Therefore, we decided that the Plan does not have to pay for an oral evaluation (D0150), intraoral radiographic 
images (D0210), and oral photo images (D0250) provided on June 22, 2022.  
 
Your complaint about experience with the provider is not a valid appeal for medical coverage. This part of your 
complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision 
about these types of complaints.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lower extremity study to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve lower extremity study. You say that you know the provider is not in-
network, but you still want to see this provider. The Plan denied your request. The Plan says the service can be 
provided by 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 
lower extremity study to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a resin-based composite and core build up (D2393, D2950) 
provided on July 11, 2022. 
 
You asked the Plan to pay for the resin-based composite and core build up. 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 resin-
based composite and core build up (D2393, D2950) provided on July 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transcutaneous electrical nerve stimulator (TENS) 
unit. 
 
You asked the Plan to pre-approve the requested device. The Plan denied your request. The Plan says the 
coverage criteria are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. The records show that the requested device is being requested for 
chronic low back pain. Based on this information, we decided that Medicare rules for coverage of the requested 
device have not been met. Therefore, we decided that the Plan does not have to pre-approve a transcutaneous 
electrical nerve stimulator (TENS) unit.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on April 18, 2022. 
 
You asked the Plan to pay for physician's services. The Plan denied your request. The Plan says non-emergent, 
non-urgent services with out-of-network providers require prior authorization. 
 
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 physician's services provided on April 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown restoration (D2751) for tooth #22. 
 
You asked the Plan to pre-approve the dental service. You say that you need the dental service done because 
your tooth is chipped and broken in half, and it cuts your tongue. The Plan denied your request. The Plan says 
the x-rays of the enrollee's teeth did not show the tooth has to have a lot of missing from a cavity or has a lot of 
damage from being broken; therefore, the denial of authorization for this service is correct. 
 
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 dental 
service 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 the dental service. Our reviewer says 
that the requested dental service is not medically reasonable and necessary. Our physician reviewer found that 
the documentation provided does not meet the criteria for coverage for a crown restoration (D2751) for tooth 
#22 
 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 the dental service have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a crown restoration (D2751) for tooth #22.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on  
July 27, 2022. 
 
You asked the Plan to pay for the dental services. You say that you did not think that the most recent 
exam was the same and thought this was only routine. The Plan denied your request. The Plan says your benefit 
for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service July 30, 2020. Therefore, 
we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on 
July 27, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code J2001 billed for date of service October 20, 
2021. 
 
You asked the Plan to pay for procedure code J2001. You say that this should be paid for. The Plan denied your 
request. The Plan says payment for code J2001 is bundled into payment for code 20611. 
 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 J2001 
is a column II code to column I code 20611. 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 J2001 billed for date of service October 20, 
2021.