Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block. 
 
You asked the Plan to pre-approve a genicular nerve block. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
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 genicular nerve block. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the review has determined that the genicular nerve blocks are considered 
experimental/investigational in nature. The requested block is not reasonable or 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 a genicular nerve block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a genicular nerve block.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on June 14, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the services requested are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental 
services on June 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve orthopedic shoes. 
 
You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says these items are not a covered benefit under your 
contractual policy or by Medicare.  
Medicare rules state that therapeutic shoes, inserts and/or modifications to therapeutic shoes are covered if all 
of the criteria are met. The Plan follows these same rules.   
 
We reviewed the case file and Medicare rules. Based on this information, we have decided that you do not meet 
criteria for coverage of the requested items. Specifically, the record states that you have diabetes; however, the 
record does not show that you have one or more of the required additional conditions indicated. Additionally, 
documentation of a diabetic foot exam has not been provided. Therefore, we decided that the Plan does not 
have to pre-approve orthopedic shoes.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infectious agent detection by nucleic acid (DNA or RNA) 
(87506) provided June 3, 2022. 
 You asked the Plan to pay for the laboratory service. You say that please review the medical documentation 
and reprocess the claim for payment. The Plan denied your request. The Plan says the services are not covered. 
In the absence of clinical information, medical necessity and coverage cannot be determined 
 
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 87506 is Infectious agent detection by nucleic acid (DNA 
or RNA); gastrointestinal pathogen (e.g., Clostridium difficile, E. coli, Salmonella, Shigella, norovirus, 
Giardia), includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, 
multiple types or subtypes, 6-11 targets. 
 
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 the laboratory service. Our reviewer says that the requested 
items/services are not considered medically reasonable and necessary in this case. Our reviewer found the 
enrollee presented to the emergency deparatment with loose stools and weight loss. The enrollee was started on 
antibiotics and sent home, but diarrhea worsened on antibiotics. The enrollee was diagnosed with noninfective 
gastroenteritis and colitis. Testing was performed however, there was insufficient evidence of an infectious 
process at the time of using DNA/RNA infectious agent detection to justify this testing. Also, there was no 
clear clinical situation that would suggest this testing would be more appropriate or more effective leading to 
improved outcome compared to standard stool culture or other standard testing methods. Therefore, the testing 
(87506) was not supported by the records and will be considered not medically necessary. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pay for the infectious agent detection by nucleic acid (DNA or RNA) (87506) provided June 
3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a porcelain/ceramic retainer crown for tooth# 18 
(D6740), a porcelain/ceramic pontic for tooth# 19 (D6245), and a porcelain/ceramic retainer crown for  
tooth# 20 (D6740). 
 
You asked the Plan to pre-approve these dental items. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says these dental items are not covered under the 
enrollees 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 requested items are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
porcelain/ceramic retainer crown for tooth# 18 (D6740), a porcelain/ceramic pontic for tooth# 19 (D6245), and 
a porcelain/ceramic retainer crown for tooth# 20 (D6740).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a mandibular partial denture - cast metal framework with 
resin denture bases (D5214) provided on June 30, 2022. 
 
You asked the Plan to pay for a mandibular partial denture - cast metal framework with resin denture bases 
(D5214). You say that your existing lower partial did not give you the ability to chew food as it was so poorly 
fitted. You say that you are requesting financial help on the new lower partial. The Plan denied your request. 
The Plan says this service is not covered under the benefit package. 
 
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 
mandibular partial denture - cast metal framework with resin denture bases (D5214) provided on June 30, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve power wheelchair electric connection between 
controller and two or more power options, power wheelchair access harness, expandable controller upgrade, 
and a residual limb support mount. 
 
You asked the Plan to pre-approve power wheelchair electric connection between controller and two or more 
power options, power wheelchair access harness, expandable controller upgrade, and a residual limb support 
mount. You say that you disagree with the Plan's denial. The Plan denied your request. The Plan says the 
requested accessories are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that wheelchair accessories are only covered for 
certain indications. 
 
We looked at the file and Medicare rules. Review of the file shows that there is no medical need to control the 
requested power options through the joystick. The documentation shows that the enrollee has four out of five 
strength in the upper limbs. The physical therapist notes document that the enrollee is independent with feeding 
and grooming. This means the enrollees upper limb strength and function are adequate for the enrollee to be 
able to control the power options using their own switches which are included in the allowance of these power 
options. Code E1028 (residual limb support mount) is a column II code to column I code E1020 (residual limb 
support system for wheelchair). A Column II code is included in the allowance for the corresponding Column I 
code when provided at the same time. This means the requested residual limb support mount is bundled into 
payment for another item already approved. Based on this information, we decided that Medicare rules for 
coverage of power wheelchair electric connection between controller and two or more power options, power 
wheelchair access harness, expandable controller upgrade, and a residual limb support mount have not been 
met. Therefore, we decided that the Plan does not have to pre-approve power wheelchair electric connection 
between controller and two or more power options, power wheelchair access harness, expandable controller 
upgrade, and a residual limb support mount.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for general anesthesia (D9222 and D9223) and an endosteal 
implant (D6010) provided by a participating provider on February 18, 2022. 
 
You asked the Plan to pay for general anesthesia and an endosteal implant. You say that these services are 
covered benefits; therefore, you needed these services. The Plan denied your request. The Plan says the 
rendered dental services are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Because theres no coverage for D6010, the deep sedation/general 
anesthesia (D9222 and D9223) denied. Therefore, we decided that the Plan does not have to pay for general 
anesthesia (D9222 and D9223) and an endosteal implant (D6010) provided by a participating provider on 
February 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an endosteal implant (D6010) and a sinus augmentation 
with bone or bone substitutes (D7951) provided by a participating provider. 
 
You asked the Plan to pre-approve an endosteal implant and a sinus augmentation with bone or bone 
substitutes. You say that these services are medically necessary. The Plan denied your request. The Plan says 
the requested dental services are not 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 pre-approve an 
endosteal implant (D6010) and a sinus augmentation with bone or bone substitutes (D7951) provided by a 
participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the placement of intra-socket biological dressing 
(D7922) 
 
You asked the Plan to pre-approve the placement of intra-socket biological dressing. You say that the services 
should be covered as you disagree with the denial. The Plan denied your request. The Plan says the services 
denied correctly as they do not fall within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
placement of intra-socket biological dressing (D7922)
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral - complete series of radiographic images (D0210) 
provided on May 11, 2022. 
 
You asked the Plan to pay for intraoral - complete series of radiographic images (D0210). You say that you 
were told that all services would be covered. The Plan denied your request. The Plan says these services are not 
covered under the benefit package. 
 
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 intraoral - 
complete series of radiographic images (D0210) provided on May 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an adjustment of a maxillofacial prosthetic (D6010) 
 
You asked the Plan to pre-approve the adjustment of a maxillofacial prosthetic. You say that the services 
should be covered as you disagree with the denial. The Plan denied your request. The Plan says the services 
denied correctly as they do not fall within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an 
adjustment of a maxillofacial prosthetic (D6010)
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic screening laboratory testing (81479). 
 
You asked the Plan to pre-approve a genetic screening. You say that you want to know if you are at risk for 
cancer or disease because much of your family is deceased and you do not know why. The Plan denied your 
request. The Plan says the requested testing would be considered a screening as you do not have symptoms or 
signs of a particular disease or any cancer, and therefore is not covered by Medicare or the Plan. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 The test at issue in this appeal, genetic laboratory testing, is being requested solely for screening purposes. 
Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not 
have to pre-approve genetic screening laboratory testing (81479).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core build-up including pins (D2950) and the pontic 
(D6242) provided on May 24, 2022. 
 
You asked the Plan to pay for the core build-up (D2950) and the pontic (D6242). You say that you were not 
aware that the material used to replace the bridge was not covered. You say if you had known, you would not 
have gotten the bridge replaced. The Plan denied your request. The Plan says the services are not covered 
benefits. 
 Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the core build-ups (D2950) and pontics 
(D6242) are not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pay for the core build-up including pins (D2950) and the pontic (D6242) provided on May 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on May 4, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the service 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 the dental 
services on May 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the missing or invalid procedure codes (D0001) provided on 
June 17, 2022. 
 
You asked the Plan to pay for the missing or invalid procedure codes. You say that you paid for these services 
with your charge card and would like to be reimbursed. The Plan denied your request. The Plan says there is no 
coverage for procedure code D0001 as this is not a dental procedure. 
 
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 
missing or invalid procedure codes (D0001) provided on June 17, 2022.  
 
Please Note: The Plan contacted the providers office on August 24, 2022, and was advised that the charges 
were paid and applied to an in-house dental plan through the dental office. Please contact the Plan or providers 
office for any questions in regard to this.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee medical management and rehab needs 
require an IRF stay and close physician supervision. The Plan denied your request. The Plan says IRF is not 
medically necessary. The enrollee does not need an intensive care team for their care. The enrollees needs can 
be provided safely in other settings such as SNF, home health, or outpatient therapy. 
 
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 while the medical record supports a need for physical and/or occupational therapy, 
there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
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 IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on December 15, 2021 billed 
with codes 81206, 81162, 81292, and 81306. 
 
You asked the Plan to pay for the genetic testing billed. The Plan denied your request. The Plan says the 
services were billed incorrectly. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
December 15, 2021 billed with codes 81206, 81162, 81292, and 81306.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Escitalopram tab 10mg. 
 
You asked the Plan to pre-approve a prescription drug. You say that the enrollee has anxiety and has been 
stable on this dose for several years. The Plan denied your request. The Plan says this medication does not fall 
under Part B coverage. The enrollee does not have pharmacy (drug) benefits administered by the Plan. The 
enrollee does have a drug plan which provides its own pharmacy 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 Escitalopram tab 10mg.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on March 16, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the services are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental 
services on March 16, 2022.