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

 
We decided that the Plan does not have to pay for panoramic imaging (D0330) provided by participating 
provider on July 21, 2022. 
 
You asked the Plan to pay for panoramic imaging. You say that these are the only kind of x-rays you can get 
done. The Plan denied your request. The Plan says the rendered dental x-ray is not a covered dental 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 
panoramic imaging (D0330) provided by a participating provider on July 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lightweight wheelchair (K0003) and related 
accessories. 
 
You asked the Plan to pre-approve a lightweight wheelchair and accessories. You say that the requested items 
are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for 
durable medical equipment have not been met. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that a lightweight wheelchair and accessories is being requested for use in a SNF or hospital. 
Therefore, we decided that the Plan does not have to pre-approve a lightweight wheelchair (K0003) and related 
accessories.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral x-rays and a comprehensive oral evaluation  
(D0274, D0150, D0230, D0220) on June 6, 2022 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. 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 June 6, 2022. Therefore, 
we decided that the Plan does not have to pay for intraoral x-rays and a comprehensive oral evaluation  
(D0274, D0150, D0230, D0220) on June 6, 2022
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve Keytruda. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug is 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 Keytruda. Our reviewer says that the 
documentation does not support that the requested drug is medically reasonable or necessary. Our physician 
reviewer found the enrollee has a diagnosis/medical history of bilateral squamous cell lung cancer. The 
enrollee has been receiving treatment with Keytruda since June 2020 and has shown signs of disease 
progression on lung imaging studies. Continued use of Keytruda is not Food and Drug Administration-
approved for treatment of squamous cell lung cancer that has shown signs of disease progression on Keytruda.  
 
 Continued use of Keytruda for treatment of squamous cell lung cancer that has shown signs of disease 
progression on Keytruda is not supported by one of the major drug compendia or by clinical research that 
appears in a CMS-approved medical journal. Therefore, the enrollee does not meet criteria for the requested 
drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a retainer crown (D6752) and a pontic (D6242) provided by 
an out-of-network provider on June 13, 2022. 
 
You asked the Plan to pay for a retainer crown and a pontic. You say that you are on a fixed income, and you 
cannot afford this bill. The Plan denied your request. The Plan says the rendered dental services are not covered 
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 retainer 
crown (D6752) and a pontic (D6242) provided by an out-of-network provider on June 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing provided on April 26, 2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the testing was billed 
incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that the test panel is a single test with multiple 
components and is characterized by a single unit of service.  
 
We looked at the file and Medicare rules. In this case, the requested testing was billed with multiple codes and 
units, instead of a single unit of service as required by 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 testing provided on April 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing (0089U) provided on January 15, 2021. 
 
You asked the Plan to pay for laboratory testing. You say that these services were necessary and should be 
paid. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim and was 
correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on October 6, 2021. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for laboratory testing have not been met. 
Therefore, we decided that the Plan does not have to pay for laboratory testing (0089U) provided on January 
15, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on June 2, 
2022, to June 16, 2022. 
 
You asked the Plan to waive the copayment for hospital care. You say that you thought everything was 
paid/covered in full by your Plan. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
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 $390 
copayment for inpatient hospital care per day for days 1-5 and $0 after day 5. This inpatient hospital stay lasted 
14 days, resulting in a copayment of $1,950 ($390 per day for 5 days = $1950). 
 
You have been asked to pay $390 copayment per day for hospital care. This item/service falls within the per 
day for days 1-5 and $0 after day 5 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 copayment for 
inpatient hospital care provided on June 2, 2022, to June 16, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve medial branch blocks (MBBs) with anesthesia. 
 
You asked the Plan to pre-approve MBB anesthesia. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says the records do not show why the enrollee needs anesthesia for this 
procedure. 
 
The Plan follows Medicare rules. Medicare rules state that individual consideration may be given in rare, 
unique circumstances if the medical necessity of sedation for facet joint interventions is unequivocal and clearly documented in the medical record. 
 
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 MBB anesthesia. Our reviewer says 
that the enrollee does not meet the Medicare criteria for the requested facet joint interventions with anesthesia. 
Our physician reviewer found while cervical medial branch blocks are medically necessary, anesthesia 
services/sedation are not reasonable or necessary during a cervical MBB. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MBB anesthesia have not been met. Therefore, we decided that the Plan does 
not have to pre-approve medial branch blocks (MBBs) with anesthesia.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for moderate sedation services (99152) billed for date of service 
April 1, 2022. 
 
You asked the Plan to pay for moderate sedation services. You say that you have provided medical records to 
support the code at issue. The Plan denied your request. The Plan says the available records do not support the 
service 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. 
 
In this case, the CPT Code Manual definition of code 99152 is "Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older." 
 
We find that CPT code 99152 is not supported in the medical record. Specifically, the available records do not 
indicate the presence of an independent trained observer. Based on this information, we decided that Medicare 
rules for coverage of moderate sedation services have not been met. Therefore, we decided that the Plan does 
not have to pay for moderate sedation services (99152) billed for date of service April 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periapical x-rays (D0220, D0230) and an adjunctive pre-
diagnostic test (D0431) provided on June 22, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says periapical x-rays (D0220, D0230) and an adjunctive pre-
diagnostic test (D0431) are not covered by your routine 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 periapical 
x-rays (D0220, D0230) and an adjunctive pre-diagnostic test (D0431) provided on June 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 36140 and 36200 billed for date of service 
February 16, 2022. 
 
You asked the Plan to pay for procedure codes 36140 and 36200. The Plan denied your request. The Plan says 
payment for codes 36140 and 36200 are bundled into payment for code 36246. 
 
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 36140 and 36200 are column II codes to column I code 36246. The 
codes at issue have 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 codes 36140 and 36200 billed for date of service February 16, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a computed tomography, abdomen and pelvis provided on 
May 16, 2022. 
 
You asked the Plan to pay for the computed tomography, abdomen and pelvis. The Plan denied your request. 
The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or 
unrelated to the members terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, 
covers all hospice care from the effective date of election to the date of discharge or revocation. During the 
election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal 
illness until the first day of the month following the month in which hospice was revoked or discharged. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on May 12, 2022. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for a computed tomography, 
abdomen and pelvis provided on May 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on September 2, 
2021. 
 
You asked the Plan to pay for the limited oral evaluation. 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 limited 
oral evaluation (D0140) provided on September 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the scaling and root planning (D4341). 
 
You asked the Plan to pre-approve the dental services. You say that the enrollee's medical needs indicate 
periodontal disease. The Plan denied your request. The Plan says there was no evidence of radiographic 
calculus and pocket depths of 5mm or more; therefore, medical necessity was not established for the dental 
procedures requested. 
 
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 
services 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 services. Our reviewer says 
that based on the documentation submitted, the requested dental services are not medically reasonable and 
necessary. Our physician reviewer found that in this instance there is only noted bone loss in the area of the 
mesial of tooth #5 where there is blunting of the interproximal bone, along with #30 and #19. The pocket 
readings are 4mm or less in those areas with the exception of the distal of #19 which has a 5mm pocket. The 
upper left does not show any appreciable area of bone loss. Given the provided information, there are not four 
or more involved teeth in any one quadrant as evidenced in the bone levels seen on the provided x-rays. 
 
In order to qualify there must be a loss of clinical attachment on four or more teeth in any one quadrant and/or 
root surface calculus. This is not seen in the present case, with only one area of bone loss seen in any one 
quadrant. 
 
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 services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the scaling and root planning (D4341).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve six physical therapy visits. 
 
You asked the Plan to pre-approve therapy visits. You say that additional physical therapy is medically 
necessary. The Plan denied your request. The Plan says that the remaining six physical therapy visits are not 
medically necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy visits. Our reviewer says that 
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that the additional physical therapy visits are not medically necessary 
or reasonable based on the review of documentation provided. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of therapy visits have not been met. Therefore, we decided that the Plan does not 
have to pre-approve six physical therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic assy egg switch, a light module led, a dual 
marker light fender assy R and a dual marker light fender assy L (K0108x4). 
 
You asked the Plan to pre-approve wheelchair accessories. You say that you have wounds on your bottom, and 
you need the cushion to alleviate pain. You cannot walk and you solely use your wheelchair as your mode of 
transportation. The Plan denied your request. The Plan says the requested egg switch is included with the 
expandable controller. This cannot be requested separately. The Plan also says the LED light module and 
fender light assembly does not serve a medical purpose and cannot be covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve an electronic assy egg switch, a light module led, a dual 
marker light fender assy R and a dual marker light fender assy L (K0108x4).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110). 
 
You asked the Plan to pre-approve a complete maxillary denture. You say that when you enrolled in this plan 
you were told that the denture would be covered. The Plan denied your request. The Plan says this service is 
not covered under your 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 a 
complete maxillary denture (D5110).  
 
Your complaint about being misled by the Plan representative 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve enteral nutritional formula, complete with intact 
nutrients (Boost or Ensure) (B4150). 
 
You asked the Plan to pre-approve enteral nutritional formula. You say that the enrollee current weight is in the 
80-90 pounds range and continues to decrease. The doctor has ordered the recommended Boost Very High 
Calorie twice a day, to prevent further weight loss. The Plan denied your request. The Plan says Medicare does 
not cover oral nutritional supplements. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. 
 
The items you asked the Plan to pre-approve are considered nutritional supplements. Although these may be 
appropriate, neither Medicare nor the Plan provides coverage for them. Therefore, we decided that the Plan 
does not have to pre-approve enteral nutritional formula, complete with intact nutrients (Boost or Ensure) 
(B4150).