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

 
We decided that the Plan does not have to pay for the surgical placement of implant body: endosteal implant 
(D6010), prefabricated abutment (D6056), deep sedation/general anesthesia (D9222 and D9223), and 
intravenous moderate (conscious) sedation/analgesia (D9239) provided on August 11, 2020 by a Medicare opt 
out provider. 
 
You asked the Plan to pay for the endosteal implant, prefabricated abutment, deep sedation/general anesthesia, 
and intravenous moderate (conscious) sedation/analgesia. You say that you thought you had coverage when 
you needed some extensive services. You also say that you need some help because you live on social security 
and still owe half of the total bill. The Plan denied your request. The Plan says you received these services from 
a provider who chose not to receive Medicare funds. The Plan also says that the treating provider opted out of 
Medicare effective March 24, 2016, to March 24, 2024. 
 
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 
surgical placement of implant body: endosteal implant (D6010), prefabricated abutment (D6056), deep 
sedation/general anesthesia (D9222 and D9223), and intravenous moderate (conscious) sedation/analgesia 
(D9239) provided on August 11, 2020 by a Medicare opt out provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shingles vaccine provided on June 16, 2021, and August 
18, 2021. 
 
You asked the Plan to pay for the shingles vaccine. You say that your doctor told you that you should get the 
new shingles vaccine and that it was preventive. You say that you believed this was part of the preventive exam 
and were told you would not be billed. The Plan denied your request. The Plan says this vaccine is only 
covered under Part D. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the shingles vaccine. 
The Plan follows the same rules.  
 
 
 
 
 
 
 Records do not show that you have been injured or directly exposed to any illness related to the shingles 
vaccine. Therefore, we decided that the Plan does not have to pay for the shingles vaccine provided on June 16, 
2021, and August 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2750) for tooth # 4. 
 
You asked the Plan to pre-approve the dental service. You say that your dentist advised you do not have 8 
points of biting contact due to previous extractions. You also say that the records submitted may have been 
before the extraction. The Plan denied your request. The Plan says the crown for tooth # 4 is not medically 
necessary. 
 
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 a crown for tooth # 4 is not medically necessary. Our physician reviewer found the provided 
documentation indicates that tooth # 4 has an existing three surface amalgam restoration that does not show any 
signs of breakdown or decay. The reviewer found that there are posterior contacts on teeth #5 and 28, 12 and 
21, 13 and 20, and 15 and 18, making for eight contacts. The reviewer found that there is no clear structural reason to place a crown on tooth # 4 as the restoration appears intact and there is no apparent caries. Therefore, 
the reviewer found that there would be no necessity for a crown on tooth # 4. 
 
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 (D2750) for tooth # 4.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve crowns (D2750) for teeth # 10, 11, 18 and 19. 
 
You asked the Plan to pre-approve the crowns. You say that the services are medically necessary. The Plan 
denied your request. The Plan says that the crowns cannot be approved due to inadequate filling. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the provided documentation does not clearly show that the criteria 
for coverage have not been met. We have requested this information, but nothing was received. Therefore, we 
decided that the Plan has to pre-approve crowns (D2750) for teeth # 10, 11, 18 and 19.  
 
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 a crown (D2740), and a core build-up (D2950) provided by a 
participating provider on July 22, 2021. 
 
You asked the Plan to pay for a crown and a core build-up. You say that you would like the Plan to pay for this. 
The Plan denied your request. The Plan says the rendered services are 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 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 a crown 
(D2740), and a core build-up (D2950) provided by a participating provider on July 22, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve pontics (D6245) for tooth #'s 3, 9, and 14 and retainer crowns 
(D6740) for tooth #'s 8 and 15. 
 
You asked the Plan to pre-approve the pontics and retainer crowns. You say that you do not want dentures. You 
also say that the bridge is for one front tooth, and you eventually would like to get implants for the other teeth 
which is why you do not want dentures. The Plan denied your request. The Plan says that the information 
provided does not say why a denture cannot be used to replace your missing teeth. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not provide digital quality x-rays for this case. We asked for this 
document, but it was not provided to us. Without this information we cannot determine that the Plan's coverage 
rules support the denial of payment in this case. Consequently, the Plan has not substantiated their denial of 
payment in this case. Therefore, we decided that the Plan has to pre-approve pontics (D6245) for tooth #'s 3, 9, 
and 14 and retainer crowns (D6740) for tooth #'s 8 and 15.  
 
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 the anesthesia services (99100) provided on June 8, 2021. 
 
You asked the Plan to pay for code 99100. 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 looked at the file and Medicare rules. Code 99100 has a status code of "B" under the Medicare Physicians 
Fee Schedule Database (MPFSDB) and no separate payment is made for this code under the fee schedule as 
payment is bundled into the payment for the services to which this code is incident to. Therefore, we decided 
that the Plan does not have to pay for the anesthesia services (99100) provided on June 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crowns (D2740) for tooth #'s 22, 26, and 27, core 
buildups, including any pins when required (D2950) for tooth #'s 22, 26, and 27, and local anesthesia in 
conjunction with operative or surgical procedures (D9215) for tooth #'s 22, 26, and 27. 
 
You asked the Plan to pre-approve the crowns, core buildups, and local anesthesia. You say that crowns are 
recommended. The Plan denied your request. The Plan says tooth #'s 22, 26, and 27 exhibit attrition from 
occlusal wear. 
 
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. The Plan covers the crowns, 
core buildups, and local anesthesia 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 crowns, core buildups, and local 
anesthesia. Our reviewer says that the documentation provided does not meet the criteria for coverage for the 
crowns, core buildups, and local anesthesia. Our physician reviewer found tooth #'s 22, 26, and 27 do not 
exhibit significant coronal breakdown to warrant these services. 
 
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 crowns, core buildups, and local anesthesia have not been met. Therefore, 
we decided that the Plan does not have to pre-approve crowns (D2740) for tooth #'s 22, 26, and 27, core 
buildups, including any pins when required (D2950) for tooth #'s 22, 26, and 27, and local anesthesia in 
conjunction with operative or surgical procedures (D9215) for tooth #'s 22, 26, and 27.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on January 
24, 2021. 
 
You asked the Plan to pay for the dental service. You say that you would like the fee for a standard cleaning be 
paid towards the periodontal maintenance. The Plan denied your request. The Plan says periodontal 
maintenance is not listed as a covered 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 periodontal maintenance is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
periodontal maintenance (D4910) provided on January 24, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Pembrolizumab and Zirabev. 
 
You asked the Plan to pre-approve Pembrolizumab and Zirabev. You say that you would like reconsideration 
because the requested drugs are medically necessary. The Plan denied your request. The Plan says 
Pembrolizumab and Zirabev are not medically necessary. 
 
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 Pembrolizumab and Zirabev. Our 
reviewer says that the requested use of Pembrolizumab and Zirabev is not FDA-approved for the enrollees 
diagnosis. Our physician reviewer found the use is not supported by one of the major drug compendia or by 
clinical research that appears in a CMS-approved medical journal. This combination is not standard. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Pembrolizumab and Zirabev have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Pembrolizumab and Zirabev.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient mental health services provided on November 
5, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there was no 
documentation of contact in the patient record. 
 The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the services have not been met. Specifically, the record does not include documentation of a 
consultation or an attempt to consult the enrollee's primary/attending physician as required by Medicare rules. 
Therefore, we decided that the Plan does not have to pay for the outpatient mental health services provided on 
November 5, 2021.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the transit securement package. 
 
You asked the Plan to pre-approve the transit securement package. You say that you would like reconsideration 
based on the records submitted. The Plan denied your request. The Plan says this item is meant for use outside 
the home. 
 
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.  
 
The item at issue in this appeal is 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 the transit securement package.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nplate for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requested drug Nplate is not medically reasonable and necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found the documentation does 
not support that the enrollee has had an inadequate response to corticosteroids. The review has determined that 
the documentation does not support that the Nplate is medically reasonable and necessary for the patient. The 
documentation does not support that the Nplate is safe and effective for the patient. 
 
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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Nplate for the enrollee.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the presumptive drug testing provided on August 23, 2021. 
 
You asked the Plan to pay for the testing services. You say that drug testing is needed to monitor possible 
opioid abuse. The Plan denied your request. The Plan says that genetic testing was not approved by the 
ordering provider. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
In this case, the CPT Code Manual Definition of code 80307 is Drug test(s), presumptive, any number of drug 
classes, any number of devices or procedures; by instrument chemistry analyzers (e.g., utilizing immunoassay 
[e.g., EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (e.g., GC, HPLC), and mass spectrometry 
either with or without chromatography, (e.g., DART, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, 
LDTD, MALDI, TOF) includes sample validation when performed, per date of service. 
 
We looked at the file and the rules. The records provided show that the enrollee received presumptive and 
definitive drug testing. There are no records indicating genetic testing was billed or provided. The Plan has not 
made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny 
your request.  Therefore, we decided that the Plan has to pay for the presumptive drug testing provided on 
August 23, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (86077-59) provided on November 6, 2021. 
 
You asked the Plan to pay for code 86077-59. 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 claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 86077-59 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of code 
86077-59 have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory 
services (86077-59) provided on November 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and prophylaxis 
(D1110) provided on December 1, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that the financial 
coordinator from the dentist office said that they never cancelled and are still currently in the Plan's network. 
The Plan denied your request. The Plan says services performed by an OON provider are not covered because 
your healthcare plan does not have OON benefits. The Plan also says that you did not contact the Plan prior to 
this date of service to verify if the treating provider was still in-network. 
 
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, you are responsible for 100% of the 
cost for dental services rendered by an OON provider. Therefore, we decided that the Plan does not have to pay 
for the periodic oral evaluation (D0120) and prophylaxis (D1110) provided on December 1, 2021 by an out-of-
network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation feature and attendant control for 
a power mobility device. 
 
You asked the Plan to pre-approve power seat elevation feature and attendant control. You say that it is 
recommended that the enrollee have these wheelchair components. The Plan denied your request. The Plan 
says the denial of authorization for these components is correct, because a power seat elevation is excluded 
from Medicare coverage and an attendant control is non-covered when provided in addition to a beneficiary-
operated drive control system. 
 
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature is non-covered, 
and an attendant control is non-covered when provided in addition to a beneficiary-operated drive control.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of power seat elevation feature and attendant control have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a power seat elevation feature and attendant control for a power mobility 
device.