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

 
We decided that the Plan does not have to pay for the implant maintenance procedures when prostheses are 
removed and reinserted, including cleansing of prostheses and abutments (D6080) and the precision 
attachment, by report (D5862) provided on January 31, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not a covered benefit under 
your contractual policy. 
 
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 services provided are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the implant 
maintenance procedures when prostheses are removed and reinserted, including cleansing of prostheses and 
abutments (D6080) and the precision attachment, by report (D5862) provided on January 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for extractions (D7210), therapeutic parental drugs (D9610), and 
anesthesia (D9222 and D9223), provided by a participating provider on April 5, 2022. 
 
You asked the Plan to pay for extractions, therapeutic parental drugs, and anesthesia. You say that you would 
like the Plan to pay for this. The Plan denied your request. The Plan says these services have been processed 
correctly. 
 
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. 
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of extractions and anesthesia have not been met due to the maximum dental allowance amount being 
met and exhausted. Therapeutic parental drugs is not a covered benefit. Therefore, we decided that the Plan 
does not have to pay for extractions (D7210), therapeutic parental drugs (D9610), and anesthesia (D9222 and 
D9223), provided by a participating provider on April 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve heavy-duty frame. 
 
You asked the Plan to pre-approve heavy-duty frame. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that Suppliers must not bill HCPCS code K0108 in 
addition to the base wheelchair for construction materials or for a heavy duty package reflecting the type of 
material used to construct the manual wheelchair base. 
 
We looked at the file and Medicare rules. Review of the file shows that the heavy-duty frame is being 
requested under code K0108. This item is specifically not covered. Based on this information, we decided that 
Medicare rules for coverage of heavy-duty frame have not been met. Therefore, we decided that the Plan does 
not have to pre-approve heavy-duty frame.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81206, 81235, 81292, 81301, and 
81321) provided on September 28, 2021. 
 
You asked the Plan to pay for codes 81206, 81235, 81292, 81301, and 81321. You say that you would like the 
Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not 
covered as billed.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT code 81479. Therefore, we decided that the Plan does not have 
to pay for the laboratory services (81206, 81235, 81292, 81301, and 81321) provided on September 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hot or cold pack therapy (97010) provided on March 9, 2022. 
 
You asked the Plan to pay for code 97010. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 97010 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 97010 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of code 97010 have not been met. Therefore, we decided that the Plan does not have to pay for the hot or cold 
pack therapy (97010) provided on March 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown (D2740) for tooth # 14 provided on March 28, 2022. 
 
You asked the Plan to pay for the dental service. You say that your dentist found a slow growing cavity 
between tooth # 14 and an adjacent tooth. You say that in order for your dentist to remove the cavity, the crown 
on tooth # 14 needed to be removed and replaced. The Plan denied your request. The Plan says your benefit for 
a crown for tooth # 14 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 Plan's 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 crown for tooth # 14 was exhausted on date of service May 16, 2018. Therefore, we 
decided that the Plan does not have to pay for the crown (D2740) for tooth # 14 provided on March 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oral hygiene instructions (D1330), gingival irrigation 
(D4921), and an unspecified periodontal procedure (D4999), provided by a participating provider on December 
17, 2021. 
 
You asked the Plan to pay for oral hygiene instructions, gingival irrigation, and an unspecified periodontal 
procedure. You say that you were in a lot of pain, and needed these services done. The Plan denied your 
request. The Plan says the rendered dental services are not covered. 
 
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 oral 
hygiene instructions (D1330), gingival irrigation (D4921), and an unspecified periodontal procedure (D4999), 
provided by a participating provider on December 17, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee's health and functional mobility status 
will be seriously harmed by any delays in transfer to an acute inpatient rehabilitation unit. The Plan denied your 
request. The Plan says the IRF services you are requesting do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
  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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found at the current level of function, the enrollee does not need intensive therapies 
consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach in an 
IRF. Our reviewer found that an IRF admission is not medically necessary based on a lack of medical 
complexity and acute rehabilitation nursing needs and high functional level. Our physician reviewer also found 
that while the enrollee may benefit from continued physical therapy and occupational therapy, the enrollee's 
rehabilitation needs can be safely provided in a lower intensity and alternate setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that you were approved for a 
Charcot's joint repair and will need inpatient admission after surgery. The Plan denied your request. The Plan 
says the requested services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case. Our physician reviewer found that you are approved for Charcot's joint repair. The record does not 
document that the treating physician has a reasonable expectation of a length of stay spanning 2 or more 
midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided on April 1, 2022. 
 You asked the Plan to pay for the self-administered drugs. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says the self-administered drugs provided are 
not covered under the enrollee's Medicare Part B 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 pay for the self-administered drugs 
provided on April 1, 2022.  
 
Benefits for the self-administered drugs 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 the periapical x-rays (D0220, D0230 x 2) provided on 
January 6, 2022. 
 
You asked the Plan to pay for the dental services. You say that you received a bill for $68. You say that it was 
your understanding that your plan covered routine dental check-up for free. You also say that you did not know 
the x-rays would not be covered. The Plan denied your request. The Plan says periapical x-rays are not listed as 
covered services. 
 
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 periapical x-rays are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the periapical x-
rays (D0220, D0230 x 2) provided on January 6, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infrared therapy (97026) provided from September 4, 2021, 
to October 1, 2021. 
 
You asked the Plan to pay for infrared therapy. You say that these services were medically necessary and were 
billed appropriately. The Plan denied your request. The Plan says infrared therapy is not covered by Medicare 
or the Plan. The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. Medicare rules say that infrared therapy is not shown to be effective treatment, and 
therefore is not medically necessary. 
 
We looked at the file and Medicare rules. Infrared therapy is not covered by Medicare. Therefore, we decided 
that the Plan does not have to pay for infrared therapy (97026) provided from September 4, 2021, to October 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve back pocket/pouch for wheelchair. 
 
You asked the Plan to pre-approve back pocket/pouch for wheelchair. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the requested item is not a covered benefit. 
 
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 back pocket/pouch for wheelchair.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hot or cold packs therapy (97010) provided on September 29, 2021. 
 
You asked the Plan to pay for hot or cold packs therapy. You say that this service was medically necessary and 
was billed appropriately. The Plan denied your request. The Plan says payment for this service is always 
included in the payment for another service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. We find that CPT code 97010 has a status 
indicator of B on the Physician Fee Schedule. This means that CPT code 97010 is not separately payable. 
Based on this information, we decided that Medicare rules for coverage of hot or cold packs therapy have 
not been met. Therefore, we decided that the Plan does not have to pay for hot or cold packs therapy 
(97010) provided on September 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transit kit (K0108) for a power wheelchair. 
 
You asked the Plan to pre-approve a transit kit. You say that the requested item is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the 
requested item does not serve a primarily medical purpose. 
 
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. Therefore, we 
decided that the Plan does not have to pre-approve a transit kit (K0108) for a power wheelchair.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional home health physical therapy (PT) visits. 
 
You asked the Plan to pre-approve additional PT visits. The Plan denied your request. The Plan says the 
additional visits are not reasonable and necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 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 additional PT visits. Our reviewer says 
that additional PT visits are not medically reasonable and necessary. Our physician reviewer found there is no 
documentation that further skilled therapy services are required to effectively provide treatment, care, and/or 
services in order to improve the enrollee's level of function, or to establish/perform a maintenance program to 
maintain the patient's level of function and/or prevent deterioration. Our reviewer also found that the records do 
not support that the complexity of the patient's conditions are such that the skills of a professional therapist are 
required to achieve further improvement in the patient's symptoms or functional status. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional PT visits have not been met. Therefore, we decided that the Plan does 
not have to pre-approve 10 additional home health physical therapy (PT) visits.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for medication assisted treatment provided from April 9, 2021, to 
September 10, 2021. 
 
You asked the Plan to pay for medication assisted treatment. You say that these claims should not have been 
denied. The Plan denied your request. The Plan says that enrollee's must receive their medical services from an 
in-network provider with the exception being urgent or emergent services. The Plan also says that non-
emergent services with non-contracted providers require prior authorization before services are rendered. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan failed to provide the requested 2021 Evidence of Coverage (EOC) for 
this appeal. Without the correct 2021 EOC, we cannot determine whether the non-participating provider is able 
to be paid for the submitted claims. Therefore, we decided that the Plan has to pay for medication assisted 
treatment provided from April 9, 2021, to September 10, 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 cone beam computed tomography (CT) capture and 
interpretation for temporomandibular joint (TMJ) series including two or more exposures (D0368) provided on 
October 8, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit under 
your contractual policy. 
 
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 service provided is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the cone beam 
computed tomography (CT) capture and interpretation for temporomandibular joint (TMJ) series including two 
or more exposures (D0368) provided on October 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unspecified removable prosthodontic procedure (D5899) 
provided on February 10, 2022. 
 
You asked the Plan to pay for the removable prosthodontic procedure. You say that you were not clearly told 
that this denture was not covered by your insurance. The Plan denied your request. The Plan says the 
unspecified removable prosthodontic procedure (D5899) is not a covered service under 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 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 
unspecified removable prosthodontic procedure (D5899) provided on February 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prosthetic attachments. 
 
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 services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes L5645, L5785, L5668, and L5629 describe 
below-knee additions. 
 
We looked at the file and Medicare rules. The file shows that the enrollee does not have a below-knee 
amputation. The requested prosthetic additions described by codes L5645, L5785, L5668, and L5629 exceed 
the enrollees needs. 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 prosthetic attachments.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and a complete 
series of radiographic images (D0210), provided by a participating provider on March 23, 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 June 10, 2021. Therefore, 
we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and a complete 
series of radiographic images (D0210), provided by a participating provider on March 23, 2022.