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

 
We decided that the Plan does not have to pay for the additional intraoral periapical x-ray (D0230) provided on 
December 22, 2021. 
 
You asked the Plan to pay for the additional intraoral periapical x-ray. You say that you were told by your 
dentist that the x-ray was necessary for the filling procedure scheduled in January 2022. The Plan denied your 
request. The Plan says this service is not a covered benefit 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 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 
additional intraoral periapical x-ray (D0230) provided on December 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services you received from July 19, 2021, to 
September 9, 2021. 
 
You asked the Plan to pay for the dental services. You say that you were not aware that this dentist has opted 
out of Medicare. The Plan denied your request. The Plan says the dentist you used has opted out of Medicare, 
so their services are not covered. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care.  
 
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. Therefore, we decided that the Plan does not have to pay for dental 
services you received from July 19, 2021, to September 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lumbar-sacral orthosis (CPT code L9650) provided on 
October 26, 2021. 
 
You asked the Plan to pay for the lumbar-sacral orthosis. You say that the claim should be paid. The Plan 
denied your request. The Plan says the services are not supported by the records. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the lumbar-sacral orthosis have not been met. Review of the file 
shows that no Proof of Delivery (POD) was provided. Therefore, we decided that the Plan does not have to pay 
for the lumbar-sacral orthosis (CPT code L9650) provided on October 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a back-up oxygen tank. 
 
You asked the Plan to pre-approve a back-up oxygen tank. You say that this is medically necessary for you to 
receive a second portable oxygen device. The Plan denied your request. The Plan says only one oxygen 
delivery system is covered at a time. 
 
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 a portable oxygen concentrator. This device serves the same purpose as a back-up 
oxygen tank. Therefore, we decided that the Plan does not have to pre-approve a back-up oxygen tank.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an out-of-network provider on 
January 20, 2022. 
 
You asked the Plan to pay for dental services. You say that you do not feel like you should be responsible for 
these charges. The Plan denied your request. The Plan says services provided out-of-network 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. The Plan covers covered 
dental services when the services are provided by a participating provider.  
 
We looked at the file and Medicare rules. Services were provided by an out-of-network provider. Based on this 
information, we decided that the Plan's rules for coverage of dental services have not been met. Therefore, we 
decided that the Plan does not have to pay for dental services provided by an out-of-network provider on 
January 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an incisional biopsy of oral tissue soft (D7286) provided by a 
participating provider on August 2, 2021. 
 
You asked the Plan to pay for an incisional biopsy of oral tissue soft. You say that you would like the Plan to 
pay for this. The Plan denied your request. The Plan says the rendered dental benefit 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 an 
incisional biopsy of oral tissue soft (D7286) provided by a participating provider on August 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ultrasonic bone growth stimulator (E0760). 
 
You asked the Plan to pre-approve an ultrasonic bone growth stimulator. You say that this device is medically 
necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage 
have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that an ultrasonic bone growth stimulator is subject to the 
coverage criteria listed in the Medicare rules section. 
 
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 ultrasonic bone growth stimulator. 
Our reviewer says that the requested ultrasonic bone growth stimulator is not medically reasonable and 
necessary. Our physician reviewer found the enrollee has a diagnosis of a non-healing fracture of the lateral 
residual patella. There is partial healing of this noted at the deeper aspect near the patellar button. The fracture however is still visible and is not completely healed. In this case, the criteria for coverage have not been met as 
the documentation does not support that there has been no clinically significant evidence of fracture healing 
between the two sets of radiographs. 
 
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 ultrasonic bone growth stimulator have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an ultrasonic bone growth stimulator (E0760).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete denture - maxillary (D5110) and complete 
denture - mandibular (D5120) provided January 13, 2022. 
 
You asked the Plan to pay for the complete upper and lower dentures. You say that your provider told you that 
insurance would cover 50% of the cost of the dentures. The Plan denied your request. The Plan says the 
dentures 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 
complete denture - maxillary (D5110) and complete denture - mandibular (D5120) provided January 13, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mastectomy (19300). 
 
You asked the Plan to pre-approve the mastectomy. You say that the procedure is medically necessary. The 
Plan denied your request. The Plan says this procedure 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 the mastectomy. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the record indicates that the enrollee has gynecomastia. The record provided does not indicate 
that an evaluation for reversible or malignant causes of gynecomastia has been performed. The record provided 
is insufficient to determine the medical necessity of the requested service. 
 
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 mastectomy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a mastectomy (19300).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Oncotype DX genomic prostate score test provided on 
March 19, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this 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 pay for the testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee is a 68-year-old male with PSA 6.5 and biopsy from 2020 negative. Magnetic resonance imaging (MRI) showed suspicious lesions of the prostate and MRI guided biopsy showed 2 cores out of 14 
with prostate cancer: Gleason 6, low-grade. Oncotype DX genomic prostate score test was provided. This type 
of testing has no conclusive and high quality evidence to support its use in this clinical situation to show testing 
would lead to a significant change in treatment and improved overall outcome. Therefore, this request for 
Oncotype DX genomic prostate score test will be considered not medically necessary at this time. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for the Oncotype DX genomic prostate score test provided on March 19, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing (81405). 
 
You asked the Plan to pre-approve genetic testing. You say that this service is medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that genetic testing is covered when the test results 
provide the clinician with information that will improve patient outcomes and/or change physician care and 
treatment of the patient. 
 
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 genetic testing. Our reviewer says that 
this test is not medically necessary. Our physician reviewer found this test would not alter the treatment plan. 
The requested genetic testing is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not 
have to pre-approve genetic testing (81405).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) provided on October 
28, 2021. 
 
You asked the Plan to pay for the periodic oral evaluation. You say that you have been eligible for dental 
coverage in the past. The Plan denied your request. The Plan says you were not eligible for dental coverage on 
this date of service. The Plan also says they confirmed with the dental department that your dental benefit 
termed as of January 1, 2021, and you did not have any dental benefits during the 2021 plan year. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation 
(D0120) provided on October 28, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance transportation services provided on October 1, 2021. 
 
You asked the Plan to pay for the services provided. You say that no other transportation was available. The 
Plan denied your request. The Plan says the services are not allowed separately. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 The file shows that the extra ambulance attendant, oxygen supplies, and unlisted services were provided. We 
find that these services are not separately payable and are included in the base rate. Based on this information, 
we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not 
have to further pay for the ambulance transportation services provided on October 1, 2021.  
 
If the provider is billing you for charges beyond any applicable cost-sharing amounts, please contact the Plan directly.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for gauze and self-adherent bandages (A6222, 
A6266, A6454) provided on March 15, 2022. 
 
You asked the Plan to waive the coinsurance for the gauze and self-adherent bandages. You say that the 
services should be covered as you disagree with the charges. The Plan denied your request. The Plan says the 
coinsurance applied correctly based on the services provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for Durable medical equipment (DME) and related supplies.  
 
 
  You have been asked to pay a 20% coinsurance for gauze and self-adherent bandages (total allowed is $694.53 
x 20% = $138.91). Gauze and self-adherent bandages fall within the Durable medical equipment (DME) and 
related supplies benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for gauze and self-adherent 
bandages (A6222, A6266, A6454) provided on March 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the four two dimensional (2D) oral/facial photographic 
images (D0350 x4) provided on January 27, 2022. 
 
You asked the Plan to pay for the 2D oral/facial photographic images. You say that you went in for a routine 
tooth cleaning and without asking, they took a number of routine facial photographic images that you assumed 
were a required routine step before the tooth scaling procedures. You also say that before making the 
appointment, you confirmed with the Plan that the office was in-network, and you feel that the Plan does cover 
100% dental benefits. The Plan denied your request. The Plan says this service is not a covered benefit 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 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 four 
two dimensional (2D) oral/facial photographic images (D0350 x4) provided on January 27, 2022.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to hold you harmless for the two retainer crowns (D6740 x2). We decided that the 
Plan does not have to pay for the pontic (D6245).  
 
You asked the Plan to pay for the pontic (D6245) and two retainer crowns (D6740 x2). You say that you 
applied for additional dental coverage, effective December 1, 2021, knowing you would be getting a bridge. 
You also say that it was your understanding this coverage would provide about $2,000 of what was to be a total 
of $3,725 for the services. The Plan says that these services are not covered expenses under your dental plan. 
 
We decided that the Plan has to hold you harmless for the two retainer crowns (D6740 x2).  
 
The Plan follows Medicare rules. Medicare rules say that the health plan must provide you with a clear and 
accurate description of the Original Medicare and/or mandatory/optional supplemental benefits offered under 
your plan contract including applicable conditions and limitations and any other conditions associated with the 
use or receipt of the benefits. Medicare rules also say that for a service or item that is normally not covered, but 
could be covered under some conditions, the Evidence of Coverage (EOC) alone is not adequate notice of non-
coverage. If no notice of non-coverage is given, the enrollee is held harmless. 
 
The record shows that you received two retainer crowns which were denied by the Plan as not a covered 
expense. The 2022 EOC lists crowns as a covered benefit, and limited to 2 procedures per calendar year. The 
EOC does not state specifically what types of crowns are covered, nor does the EOC refer you to another 
document which lists exactly what dental procedure codes are covered. These services were also rendered by 
an in-network provider. You reasonably believed these services would be covered because crowns are listed as 
a covered benefit in the 2022 EOC. Therefore, we decided that the Plan has to hold you harmless for the two 
retainer crowns (D6740 x2).  
 
We also decided that the Plan does not have to pay for the pontic (D6245). 
 
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 pontic 
(D6245). 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer (J1439). 
 
You asked the Plan to pre-approve Injectafer. The Plan denied your request. The Plan says this request does not 
meet the Plan's Part B step therapy criteria for the requested drug. 
 
  Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Injectafer. Our reviewer says that 
Injectafer is not medically reasonable and necessary. Our physician reviewer found the provided records do not 
indicate that the enrollee has tried and failed the Plan's preferred step one alternative. Our reviewer found that 
the record does not indicate that the enrollee has a contraindication to, or would have an adverse effect from the 
Plan's preferred step one alternative. Our physician reviewer also found that the elements of the coverage 
criteria are not satisfied, and the requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer (J1439).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that you would like the plan to reconsider their denial. The 
Plan denied your request. The Plan says the requested drug does not meet criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Prolia.  
 
Benefits for Prolia may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.