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

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), and intraoral - 
complete series of radiographic images (D0210) provided on October 15, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were charged $200 at your dental check-up 
and the office manager informed you the Plan would reimburse you. You also say that nowhere on your card or 
information that you have to wait 3 years before you can receive another x-ray and comprehensive evaluation. 
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 comprehensive oral evaluation and intraoral - complete series of radiographic 
images was exhausted on date of service November 9, 2021. Therefore, we decided that the Plan does not have 
to pay for a comprehensive oral evaluation (D0150), and intraoral - complete series of radiographic images 
(D0210) provided on October 15, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service November 
13, 2022. 
 You asked the Plan to pay for procedure code 70450. You say that the member had multiple exams done on 
this date of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into 
payment for code 70496. 
 
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 70450 
is a column II code to column I code 70496. This claim has 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 code 70450 billed for date of service November 13, 
2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on June 15, 2022, to July 6, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for home health services. You say that these services were medically necessary. The 
Plan denied your request. The Plan says these services could have been provided in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for home health services provided on June 15, 2022, 
to July 6, 2022, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Horizant tablet. 
 
You asked the Plan to pre-approve Horizant. You say that the enrollee needs this drug. You also say that the 
enrollee has tried and failed gabapentin, pregabalin, duloxetine, and Gralise. The Plan denied your request. The 
Plan says the requested drug is not covered. 
 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 Horizant tablet.  
 
Benefits for Horizant 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 pay for crown - porcelain fused to high noble metal (D2750) and 
prefabricated post and core in addition to crown (D2954) provided on December 5, 2022. 
 
You asked the Plan to pay for dental services. You say that crowns are included in your dental coverage, but 
your services are being denied. The Plan denied your request. The Plan says these services are 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. Crown - porcelain fused to 
high noble metal (D2750) and prefabricated post and core in addition to crown (D2954) are not covered under 
the Plans dental benefits. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D2750 and D2954 are 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for crown 
- porcelain fused to high noble metal (D2750) and prefabricated post and core in addition to crown (D2954) 
provided on December 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for rest home visit provided on November 09, 2022. 
 
You asked the Plan to pay for rest home visit. You say that the facility should have been responsible for 
obtaining authorization. The Plan denied your request. The Plan says that unauthorized, out-of-network care is 
not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for rest home visit provided 
on November 09, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Rhopressa. 
 
You asked the Plan to pre-approve Rhopressa. You say that the patient has tried and failed other glaucoma 
medications but their condition has been under control with Rhopressa. The Plan denied your request. The Plan 
says self-administered drugs are not covered under the patient's medical benefits. 
 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 Rhopressa.  
 
Benefits for Rhopressa 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88305 billed for date of service October 
28, 2022. 
 You asked the Plan to pay for procedure code(s) 88305. You say that this service was medically necessary. The 
Plan denied your request. The Plan says this code is included in the facility payment and is not separately 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88305. This means 
there is both a professional and technical component for the CPT code(s). In this case, an appropriate modifier 
to indicate the professional component has not been billed with CPT code(s) 88305. Based on this information, 
we decided that Medicare rules for coverage of procedure code 88305 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code(s) 88305 billed for date of service October 28, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on December 9, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
December 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periapical first radiographic image (D0220) and intraoral- 
periapical each additional radiographic image(D0230) provided on November 29, 2022. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. 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 April 18, 2022. 
Therefore, we decided that the Plan does not have to pay for periapical first radiographic image (D0220) and 
intraoral- periapical each additional radiographic image(D0230) provided on November 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the supply allowance for a continuous glucose monitor 
(CGM). 
 
You asked the Plan to pre-approve the supply allowance for the CGM. You say that you are requesting 
approval for the monitor because the enrollee is at risk for low blood sugars. The Plan denied your request. The 
Plan says the Medicare criteria was not met. 
  The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
the supply allowance for the CGM have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the supply allowance for a continuous glucose monitor (CGM).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Feraheme. 
 You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found that the enrollee has unspecified iron 
deficiency anemia. She had a trial of Infed in 2021 and Retacrit was started in September of 2021. She has not 
tried and failed the Plan's required drug, Venofer. The records do not show that Venofer would be 
contraindicated or less effective; therefore, Feraheme is not reasonable or medically necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Feraheme.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a custom fabricated abutment (D6057) and an abutment 
supported crown (D6058) for tooth #7 provided on December 15, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are appealing the denied claim because 
crowns are a covered benefit. The Plan denied your request. The Plan says the denial of payment for these 
services is correct, because implant and all related services are not covered by the Plan. 
 Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a custom 
fabricated abutment (D6057) and an abutment supported crown (D6058) for tooth #7 provided on December 
15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pontic - porcelain/ceramic tooth #21 (D6245), 
abutment supported porcelain/ceramic crown tooth #18 and 21 (D6058), and  custom fabricated abutment  
includes placement tooth #22 (D6057). 
 
You asked the Plan to pre-approve the dental services. You say that your dental provider states the Plan denied 
your decision since they had finished the completed work on your mouth. You also say that you hope the Plan 
can rectify their decision. 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 February 17, 2023. 
Therefore, we decided that the Plan does not have to pre-approve a pontic - porcelain/ceramic tooth #21 
(D6245), abutment supported porcelain/ceramic crown tooth #18 and 21 (D6058), and  custom fabricated 
abutment  includes placement tooth #22 (D6057).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for limited oral evaluation - problem focused (D0140), intraoral 
- periapical first radiographic image (D0220) and cone beam CT capture and interpretation with limited field of 
view  less than one whole jaw (D0364) provided on December 22, 2022. 
 
You asked the Plan to pay for dental services. You say that you are entitled to two visits per year for cleaning, 
examination, consultation and sometimes x rays including analysis; therefore, these services should be paid for. 
The Plan denied your request. The Plan says these services are 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. Limited oral evaluation - 
problem focused (D0140), intraoral - periapical first radiographic image (D0220) and cone beam CT capture 
and interpretation with limited field of view  less than one whole jaw (D0364) are not covered under the 
Plans dental benefits. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D0140, D0220 and 
D0364 are not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pay for limited oral evaluation - problem focused (D0140), intraoral - periapical first radiographic image 
(D0220) and cone beam CT capture and interpretation with limited field of view  less than one whole jaw 
(D0364) provided on December 22, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health skilled nursing services provided on June 21, 
2022, to July 14, 2022. 
 
You asked the Plan to pay for the home health skilled nursing services. The Plan denied your request. The Plan 
says prior authorization rules may apply for network services. Prior to receiving home health services, a doctor 
must certify that you need home health services and will order home health services to be provided by a home 
health agency. You must be homebound, which means leaving your home is a major effort.  Your network provider is responsible for requesting prior authorization. Our plan recommends pre-
authorization of the service when provided by an out-of-network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the services at issue in this appeal. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for home health skilled nursing services provided on June 21, 2022, 
to July 14, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiological services provided on December 8, 2022, billed 
with code 73030. 
 
You asked the Plan to pay for radiology services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says the procedure is inconsistent with the modifier 
used. 
 
The Plan must follow Medicare rules. Medicare rules say that the procedure code must be billed with the 
correct modifier to represent the diagnosis code when appropriate. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of radiology services provided have not been met. In this case, procedure code 73030 was billed with 
diagnosis code M25.511, described as pain in right shoulder. As such, the procedure code was not billed with 
the correct anatomic modifier. Therefore, we decided that the Plan does not have to pay for radiological 
services provided on December 8, 2022, billed with code 73030.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tymlos injection. 
 
You asked the Plan to pre-approve Tymlos. You say that the enrollee has tried and failed Prolia and Forteo. 
You also say that the enrollee needs to start this drug as soon as possible. The Plan denied your request. The 
Plan says the requested drug is not covered. 
 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 Tymlos injection.  
 
Benefits for Tymlos 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the compression stockings identified with code A6534 that 
were issued on September 21, 2022, to September 29, 2022. 
 
You asked the Plan to pay for the compression stockings. You say that you feel like these services should be 
covered. The Plan denied your request. The Plan says these compression stockings are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6534 
are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that 
compression bandages and gradient compression wraps are covered only when they are used as dressings over 
a qualifying wound. 
 
The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you 
do not have a medical condition for which compression stockings can be covered or paid for by Medicare. 
Therefore, we decided that the Plan does not have to pay for the compression stockings identified with code 
A6534 that were issued on September 21, 2022, to September 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the supply allowance for a continuous glucose monitor 
(CGM). 
 
You asked the Plan to pre-approve the supply allowance for the CGM. You say that the requested device help 
you avoid high sugar levels and helps you control your diabetes. The Plan denied your request. The Plan says 
the Medicare criteria was not met. 
  The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of the supply 
allowance for the CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve 
the supply allowance for a continuous glucose monitor (CGM).