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

 
We decided that the Plan does not have to pre-approve an endosteal implant (D6010), custom fabricated 
abutment (D6057), and supplies and materials provided by a physician (99070). 
 
You asked the Plan to pre-approve the dental services. You say that you have been waiting and trying to get 
seen since March 2022. The Plan denied your request. The Plan says an endosteal implant (D6010), custom 
fabricated abutment (D6057), and supplies and materials provided by a physician (99070) 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 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 an 
endosteal implant (D6010), custom fabricated abutment (D6057), and supplies and materials provided by a 
physician (99070).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sling operation for stress incontinence (57288). 
 
You asked the Plan to pre-approve a sling operation for stress incontinence. You say that the requested service 
is a medical necessity for the enrollee. The Plan denied your request. The Plan says medical-necessity rules for 
the requested service have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a sling operation for stress 
incontinence. Our reviewer says that the requested service is not considered medically reasonable and 
necessary in this case. Our physician reviewer found that the enrollee experiences urgency and stress urinary 
incontinence, with no leakage observed with cough or Valsalva during urodynamic testing. According to the 
most recent American Urological Association (AUA) guidelines there must be: "Objective demonstration of 
stress urinary incontinence with a comfortably full bladder (any method)". The records provided have not 
documented this requirement. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a sling operation for stress incontinence have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a sling operation for stress incontinence (57288).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hearing aids (V5298) provided March 14, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the hearing aids. You say that you did not know that these services would not be 
covered and cannot afford the cost. The Plan denied your request. The Plan says hearing aids are not covered 
when provided OON. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when purchased through the Plans hearing aid vendor.  
 
We looked at the file and the Plan's rules. In this case the hearing aids were purchased OON. Based on this 
information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we 
decided that the Plan does not have to pay for hearing aids (V5298) provided March 14, 2022, by an out-of-
network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for emergency room (ER) visits provided 
from April 18, 2022, to May 28, 2022. 
 
You asked the Plan to waive the copayments for the ER visits. You say that your insurance plan changed and 
you cannot afford the copayments. 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 $90 
copayment for each emergency care service.  
 
 
 
 
 
 You have been asked to pay a $90 copayment for each of the ER visits, for a total of $180. The ER visits fall 
within the Emergency Care 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 copayments for emergency 
room (ER) visits provided from April 18, 2022, to May 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and complete 
mandibular denture (D5120). 
 
You asked the Plan to pre-approve the complete dentures. You say that your dentures were made in 1996, and 
there is not enough material left to do any more relines. You also say that your dentures need to be replaced. 
The Plan denied your request. The Plan says these services are not covered expenses 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 pre-approve a 
complete maxillary denture (D5110) and complete mandibular denture (D5120).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on September 7, 2021. 
 
You asked the Plan to pay for the testing services. You say that this test is consistent with the standard of care. 
The Plan denied your request. The Plan says the services require modifier 26. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
 
 We looked at the file and the rules. The claim information does not show that the services were billed with a 
modifier as required for payment. Based on this information, we decided that Medicare rules for coverage of 
the testing services have not been met. Therefore, we decided that the Plan does not have to pay for the lab 
services provided on September 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 standard power wheelchair with single power 
option (K0856) and related accessories. 
 
You asked the Plan to pre-approve a Group 3 standard power wheelchair. You say that the requested power 
wheelchair is a medical necessity for you. The Plan denied your request. The Plan says medical-necessity rules 
for the requested power wheelchair have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a Group 3 standard power wheelchair. 
Our reviewer says that the requested power wheelchair is not medically reasonable and necessary in this case. 
Our physician reviewer found that you have a neurologic disorder with functional deficits. Criteria for a power 
wheelchair are met. However, the documentation does not indicate that you have any pressure injuries or 
require intermittent catheterization of the bladder that would necessitate power tilt or recline. The 
documentation doesn't indicate you meet criteria for a Group 3 power wheelchair. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Group 3 standard power wheelchair have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a Group 3 standard power wheelchair with single power option 
(K0856) and related accessories.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from September 22, 2022, 
forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from September 22, 2022, forward. You say that 
the services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue 
are not medically necessary. 
 The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric care from 
September 22, 2022, forward. Our reviewer says that the enrollee does not meet the criteria for acute inpatient 
mental health treatment beyond the date in question of September 22, 2022, forward. Our physician reviewer 
found the enrollee did not require inpatient mental health treatment beyond September 22, 2022, as she was not 
a danger to herself or others and did not have any delusions, auditory or visual hallucinations. It did not appear 
that active treatment was taking place beyond the date in question. It did not appear that the services for the 
dates in question were reasonably expected or medically necessary to improve the enrollees condition or for 
the purpose of diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care from September 22, 2022, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from September 22, 
2022, forward.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation services provided on September 16, 
2021. 
 
You asked the Plan to pay for the billed services. You say that the service was coded correctly. The Plan denied 
your request. The Plan says the billed service cannot be verified. 
 
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 records do not show that 
the sedation services required the presence of an independent trained observer. Based on this information, we 
decided that Medicare rules for coverage of the billed services have not been met. Therefore, we decided that 
the Plan does not have to pay for the moderate sedation services provided on September 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service April 23, 
2022, to May 20, 2022. 
 
You asked the Plan to pay for procedure code S9328. You say that this is a service only code. The Plan denied 
your request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. 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 pay for procedure 
code S9328 billed for date of service April 23, 2022, to May 20, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve PrimaGen Allograft. 
 
You asked the Plan to pre-approve PrimaGen Allograft. You say that the medical records support the need for 
this. The Plan denied your request. The Plan says The use of PrimaGen Allograft is not proven in the setting of 
posterior lumbar spine fusion surgery. The surgery itself has been approved, this is just a denial of the 
PrimaGen Allograft. 
 
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 PrimaGen Allograft. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found you are being treated for spinal stenosis lumbar region with neurogenic claudication. 
You presented with continued back and leg pain with bilateral lower extremity neurogenic claudication. The 
health plan approved the T12-S1 posterior lumbar fusion with inpatient admission. However, there is limited 
published, large-scale, long-term peer-reviewed literature that shows PrimaGen Allograft to be an effective 
and/or safe treatment for the noted pathology. Peer-reviewed literature notes that further studies are needed to 
evaluate the efficacy of bone graft substitutes. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested 
PrimaGen Allograft in the setting of posterior lumbar spine 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 PrimaGen Allograft have not been met. Therefore, we decided that the Plan 
does not have to pre-approve PrimaGen Allograft.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an attendant control and attendant control mounting 
hardware (K0108). 
 
You asked the Plan to pre-approve an attendant control and attendant control mounting hardware. You say that 
this should not be denied as a repair when it is a modification. The Plan denied your request. The Plan says this 
request exceeds your needs and cannot be covered. 
 
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 an attendant control and attendant 
control mounting hardware. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found there is no documentation that the 
attendant control and attendant control mounting hardware at issue in this case meet Medicare criteria. 
Provided medical records from your treating physician do not document that the requested attendant control 
and attendant control mounting hardware are 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 an attendant control and attendant control mounting hardware have not been 
met. Therefore, we decided that the Plan does not have to pre-approve an attendant control and attendant 
control mounting hardware (K0108).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crutch substitute (E0118). 
 
You asked the Plan to pre-approve a crutch substitute. You say that the enrollee requires the equipment for use 
within the home. The Plan denied your request. The Plan says that there is insufficient published clinical 
literature demonstrating safety and effectiveness in the Medicare population to establish the medical necessity 
for these products. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a crutch substitute have not been met. Therefore, we decided that the Plan does not have to pre-
approve a crutch substitute (E0118).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for outpatient surgery performed on March 9, 
2022. 
 
You asked the Plan to waive the deductible for outpatient surgery. You say that you should not be responsible 
for this amount. The Plan denied your request. The Plan says the deductible has been applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $550 deductible which applies to outpatient surgery.  
 
The item or service you asked the Plan outpatient surgery falls within the benefit category outpatient surgery. 
The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $550 deductible which 
applies to outpatient surgery. This cost sharing is a contractual obligation that had not been met at the time 
outpatient surgery was received on March 9, 2022. Therefore, we decided that the Plan does not have to waive 
the deductible for outpatient surgery performed on March 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the commode chair (CPT code E0163). 
 
You asked the Plan to pre-approve the commode chair. You say that the commode chair is necessary. The Plan 
denied your request. The Plan says your request is not medically necessary because your records do not show 
that you are confined to a single room, that there is no toilet on the level of your home, or that you do not have 
toilet facilities in your home. 
 
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 commode chair. Our physician 
reviewer found the documentation does not support that you are confined to a room or a level of the home 
without a toilet. Furthermore, there is no indication that you cannot utilize the regular toilet facilities. 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 commode chair have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the commode chair (CPT code E0163).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal scaling and root planing - four or more teeth per 
quadrant (D4341). 
 
You asked the Plan to pay for periodontal scaling and root planing. You say that you need a deep cleaning. The 
Plan denied your request. The Plan says this service is not covered when performed by a periodontist. 
 
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 periodontal 
scaling and root planing when performed by a participating general dentist. 
 
 
 
 
 
 
 
 We looked at the file and Medicare rules. In this case the periodontal scaling and root planing is requested to be 
performed by a periodontist. Based on this information, we decided that the Plan's rules for coverage of 
periodontal scaling and root planing have not been met. Therefore, we decided that the Plan does not have to 
pay for periodontal scaling and root planing - four or more teeth per quadrant (D4341).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Celebrex. 
 
You asked the Plan to pre-approve Celebrex. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
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 Celebrex.  
 
Benefits for Celebrex 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve biologic materials to aid in soft and osseous tissue 
regeneration, per site (D4265). 
 
You asked the Plan to pre-approve biologic materials to aid in soft and osseous tissue regeneration. You say 
that you need this service. 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 
biologic materials to aid in soft and osseous tissue regeneration, per site (D4265).