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

 
We decided that the Plan does not have to pay for the root canal (D3330) provided on January 3, 2022. 
 
You asked the Plan to pay for the dental service. You say that you feel you were not notified in a timely 
manner in order to add the optional supplemental dental coverage to your plan. The Plan denied your request. 
The Plan says root canal 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the root canal is not among those 
covered under this benefit. Additionally, the record shows that you were not enrolled in the optional 
supplemental on the date of service in this case. Therefore, we decided that the Plan does not have 
to pay for the root canal (D3330) provided on January 3, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lower spine 
(72148). 
 
You asked the Plan to pre-approve an MRI of the lower spine. You say that you are upset with the Plan for 
denying the MRI you need. The Plan denied your request. The Plan says you do not meet the Medicare criteria 
for approval. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
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 an MRI of the lower spine. Our 
reviewer says that due to the absent demonstration of the immediate medical necessity of the MRI, the exam 
should be denied. Our physician reviewer found the duration of the back pain is not in the records, but the last 
encounter was April 2, 2022. No neurological abnormality was noted, and no detailed analysis of reflexes etc. 
was in the records. Our reviewer found that the lumbar spine x-rays of March 30, 2022 were negative. Our 
physician reviewer also found that no red flag has been demonstrated to provide a mandate of an immediate 
MRI without first attempting a 6-week conservative trial of therapy including physical therapy. 
 
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 MRI of the lower spine have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lower spine (72148).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional physical therapy visits to be provided by a 
network provider. 
 
You asked the Plan to pre-approve the 10 additional physical therapy visits. You say that the enrollee is still in 
need of physical therapy. The enrollee has used 20 visits but needs at least 10 more because her progress has 
been delayed due to the coronavirus pandemic. The Plan denied your request. The Plan says the physical 
therapy visits are not medically necessary, and the enrollee did not meet the Medicare criteria for coverage. 
 
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 the 10 additional physical 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 requested therapy 
generally is not accepted as specific and effective therapy for the enrollees hip condition beyond what was 
approved by the health plan. The requested services are not part of a maintenance program, and the specialized 
skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a 
program to maintain the patient's current condition or to prevent or slow further deterioration. The enrollee has 
been instructed in a home exercise program. 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 10 additional physical therapy 
visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 10 additional 
physical therapy visits to be provided by a network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mandibular denture repair (D5511) and semi-precision 
attachment (D6192) provided on March 2, 2022, and reline mandibular denture (D5751) provided on March 7, 2022. 
 
You asked the Plan to pay for denture repair, attachment, and to reline dentures. You say that you were not 
advised that you could have enrolled for additional dental coverage. The Plan denied your request. The Plan 
says mandibular denture repair (D5511), semi-precision attachment (D6192), and reline mandibular denture 
(D5751) are not covered by your supplemental dental benefits. 
 
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 mandibular denture repair (D5511) and semi-precision attachment (D6192) provided on March 2, 2022, and 
reline mandibular denture (D5751) provided on March 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the interim partial denture (D5820) provided on March 11, 2022.
You asked the Plan to pay for the dental service. You say that the provider advised that you could get a brand new partial. You say they advised it would be mostly taken care of. You also say that you went in wanting your current partial denture repaired but changed your mind when you were told a new one would be covered. The Plan denied your request. The Plan says interim partial denture 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 Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the interim partial denture is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the interim partial denture (D5820) provided on March 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for the filling (D2391) for tooth # 21 
provided on September 10, 2021. 
 
You asked the Plan to pay an additional amount for the dental service. You say that you went to the dentist for 
2 fillings. You say that you advised the dentist that you were experiencing extreme sensitivity from previous 
work. You also say that you are not satisfied with the work from this dentist. The Plan denied your request. The 
Plan says the annual maximum benefit of $1,000 has 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, the annual maximum benefit has been 
exhausted. The record shows that the Plan paid $737 for services received on July 8, 2021, $82 for services 
received on August 3, 2021, and $181 for services received on September 10, 2021. $737 + $82 + $181 = 
$1,000. Therefore, we decided that the Plan does not have to pay an additional amount for the filling (D2391) 
for tooth # 21 provided on September 10, 2021.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for the Arthroscopy (29823) provided on November 30, 2021. 
 
You asked the Plan to pay for code 29823. You say that the medical records support the billing of code 29823 
provided on November 30, 2021. The Plan denied your request. The Plan says that the medical records do not 
support the billing of code 29823 provided on November 30, 2021. 
 
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 29823 is Arthroscopy, shoulder, surgical; debridement, extensive, 3 or more discrete structures (eg, 
humeral bone, humeral articular cartilage, glenoid bone, glenoid articular cartilage, biceps tendon, biceps 
anchor complex, labrum, articular capsule, articular side of the rotator cuff, bursal side of the rotator cuff, 
subacromial bursa, foreign body[ies]). 
 
We asked our coder 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 code 29823. Our reviewer says that the medical records 
support the billing of code 29823 provided on November 30, 2021. Our reviewer found the enrollee was being 
treated for strain of muscle(s) and tendon(s) of the rotator cuff of the left shoulder and superior glenoid labrum 
lesion of left shoulder. She underwent a for left shoulder examination under anesthesia, left shoulder 
arthroscopy, medium full-thickness bursal-sided supraspinatus rotator cuff repair using a single-row technique, 
extensive debridement of degenerative labral tear, subacromial decompression, and distal clavicular coplaning 
on November 30, 2021.  
 
Procedure note supports the use of code 29823 based on the following documentation- "An arthroscopic shave 
was used to perform an extensive debridement of all damaged labrum bringing it back down to a stable rim 
flush with the articular surface of the glenoid..... An arthroscopic bur was used to perform a full subacromial 
decompression without difficulty...There was evidence for downward osteophytosis of the distal clavicle with 
impingement upon the bursal and rotator cuff tendon. Distal coplaining was conducted without difficulty." 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 29823 have been met. Therefore, we decided that the Plan has to pay for 
the Arthroscopy (29823) provided on November 30, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gingival irrigation  per quadrant (D4921) provided 
February 17, 2022. 
 
You asked the Plan to pay for the gingival irrigation. You say that your dental maintenance has been approved 
in the past after submitting dental history. The Plan denied your request. The Plan says this service is 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 
gingival irrigation  per quadrant (D4921) provided February 17, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gemtesa tablet. 
 
You asked the Plan to pre-approve Gemtesa. You say that you would like this claim reprocessed and approved 
for payment. The Plan denied your request. The Plan says this drug is not covered under the enrollee's medical 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Gemtesa tablet.  
 
Benefits for Gemtesa may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac fusion surgery. 
 
You asked the Plan to pre-approve the requested services. You say that there is significant degeneration in the 
sacroiliac joints. The Plan denied your request. The Plan says alternative or contributing diagnoses causing the 
enrollee's pain have not been ruled out. 
 
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 requested services. Our physician 
reviewer found that the enrollee is  being treated for pain in the bilateral hips. She presents with bilateral 
sacroiliac (SI) joint pain. She did have an SI joint injection with about 90% symptom relief for 3 weeks before 
the pain started to come pain. She has increasing pain in the left greater than right SI joint, at this time. The 
exam reveals tenderness to palpation noted over the left SI area as well as the left low back region. However, 
detailed documentation is not evident regarding imaging or radiographic evidence supporting sacroiliac 
pathology. Additionally, the examinations do not demonstrate at least 3 positive SI joint provocative tests. 
Multiple other plausible pain generators including at the lumbosacral spine are evident. There are limited large-
scale, long-term references showing the safety and efficacy of the requested surgery in this clinical setting. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity 
of this request as an exception to guidelines. Therefore, the requested sacroiliac fusion surgery, in this case, is 
not medically reasonable or 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve sacroiliac fusion surgery.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cone beam CT image (D0383) provided by an out-of-
network provider on March 16, 2022. 
 
You asked the Plan to pay for a cone beam CT image. You say that you needed these services because of an 
accidental fall. The Plan denied your request. The Plan says D0383 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 a cone 
beam CT image (D0383) provided by a participating provider on March 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost share for repair of broken retentive materials on tooth 
#22 (D5630) provided on April 20, 2022. 
 
You asked the Plan to reduce the cost share for the repair. You say that you disagree with the amount paid by 
the insurance company. The Plan denied your request. The Plan says you have been charged the correct cost 
sharing amount. 
 
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 $50 
dental deductible and 50% coinsurance after the deductible is met for prosthetic repair. 
 
The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay a 
total of $162.50 for the repair on April 20, 2022. The dental deductible was not met at the time of service; 
therefore, $50 was applied to satisfy the deductible. The Plan has followed Medicare rules by clearly disclosing 
in the contract that there is $50 deductible which applies to dental services. This cost sharing is a contractual 
obligation that had not been met at the time the repair was received on April 20, 2022.  
 
The allowed amount remaining after you paid your deductible is $115 ($165 original allowed amount - $50 
deductible paid = $115 remaining allowed amount). You have been asked to pay $57.50, which is 50% of the 
remaining allowed amount for the repair ($115 remaining allowed amount x 50% coinsurance = $57.50). You 
have also been asked to pay $55, which is the difference between the total amount billed and the original 
allowed amount ($220 total billed amount - $165 original allowed amount = $55).  Prosthetic repair falls within 
the Dental Services 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 reduce the cost share for repair of broken 
retentive materials on tooth #22 (D5630) provided on April 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the routine foot care provided on December 6, 2021. 
 
You asked the Plan to pay for the routine foot care. 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. 
 
The Plan must follow Medicare rules. The rules say that routine foot care is not covered. The only exception is 
for those who have a condition that results in severe loss of circulation or areas of poor sensation in the legs or 
feet or have fungal nails.  
 
Records do not show that any of these conditions are present. The services you are asking the Plan to pay for 
are routine foot care services. Based on this information, we decided that Medicare rules for coverage of the 
routine foot care have not been met. Therefore, we decided that the Plan does not have to pay for the routine 
foot care provided on December 6, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on September 1, 2021. 
 
You asked the Plan to pay for the lab services. You say that you would like this claim reprocessed based no the 
medical records. The Plan denied your request. The Plan says you billed with an incorrect place of service on 
the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on September 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided by a 
participating provider on January 24, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for this. 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 November 9, 2020. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) 
provided by a participating provider on January 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve retainers - cast metal for resin bonded fixed prosthesis 
(D6545). 
 
You asked the Plan to pre-approve retainers. You say that this service is necessary. The Plan denied your 
request. The Plan says this service is 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 pre-approve 
retainers - cast metal for resin bonded fixed prosthesis (D6545).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a fabricated abutment on tooth #11 (D6057) and an implant 
crown on tooth #11 (D6058) provided on March 15, 2022. 
 
You asked the Plan to pay for an abutment and an implant crown. You say that this service was for an 
implantable crown, and it should be covered. The Plan denied your request. The Plan says fabricated abutment 
(D6057) and an implant crown (D6058) are not covered by 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 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 
fabricated abutment on tooth #11 (D6057) and an implant crown on tooth #11 (D6058) provided on March 15, 2022.