Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a recliner chair. 
 
You asked the Plan to pre-approve a recliner chair. You say that this chair is necessary for your condition. The 
Plan denied your request. The Plan says although the seat lift mechanism will be covered, the chair itself does 
not fit the Medicare definition of a durable medical equipment and will be denied coverage. 
 
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 a recliner chair.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 83789 billed for date of service February 24, 
2022. 
 
You asked the Plan to pay for procedure code 83789. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 83789 is bundled into payment for codes G0481 and 
80307. 
 
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 83789 
is a column II code to column I codes G0481 and 80307. 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 83789 billed for date of service 
February 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve epidural steroid injections. 
 
You asked the Plan to pre-approve epidural steroid injections. You say that epidural steroid injections are 
medically necessary. The Plan denied your request. The Plan says epidural steroid injections do not meet the 
Medicare LCD coverage criteria. 
 
The Plan follows Medicare rules. 
 
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 epidural steroid injections. Our 
reviewer says that epidural steroid injections are not medically necessary. Our physician reviewer found in this 
case the request is for bilateral interlaminar epidural steroid injections at L4-L5.  It is not considered medically 
reasonable and necessary to perform CESIs or ILESIs at more than one (1) level during the same session. 
Therefore, it is not medically reasonable and necessary to perform CESIs or ILESIs bilaterally. The review has 
determined that the requested ILESIs do not meet the Medicare LCD coverage criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of epidural steroid injections have not been met. Therefore, we decided that the 
Plan does not have to pre-approve epidural steroid injections.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for core build up on tooth #25 (D2950) and a 
crown on tooth #25 (D2740) provided on February 25, 2022. 
 
You asked the Plan to waive the cost share for the dental services. You say that you disagree with the denial of 
dental services. The Plan denied your request. The Plan says your dental allowance amount has been exhausted. 
 
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 have a $1,500 dental allowance for supplemental preventive and comprehensive dental services every year. The contract says 
you are responsible for any amount over and above the allowance amount.  
 
The record shows your annual dental allowance was exhausted during the processing of this claim. You have 
been asked to pay $256 for core build up and a crown. Core build up and a crown fall within the Dental 
Services benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the cost share for core build up on tooth #25 
(D2950) and a crown on tooth #25 (D2740) provided on February 25, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate services. 
 
You asked the Plan to pre-approve bone marrow aspirate services. You say that you went to physical therapy 
which made your condition worse. You say that you were in excruciating pain and were sent to a specialist who 
stated you need the requested surgery. The Plan denied your request. The Plan says the guidelines for coverage 
have not been met. The Plan says that medical studies haven't proven that this procedure is helpful for 
treatment of the enrollee's health problem. 
 
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 bone marrow aspirate services. Our 
reviewer says that bone marrow aspirate services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found bone marrow aspirate remains experimental. More research is needed when bone marrow aspirate is used as bone graft material. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bone marrow aspirate services have not been met. Therefore, we decided that 
the Plan does not have to pre-approve bone marrow aspirate services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a surgical extraction. 
 
You asked the Plan to pre-approve the requested extraction. You say that there is no way to get a regular 
extraction. The Plan denied your request. The Plan says surgical dental extractions 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 Plans coverage rules apply in this case. 
 
Although the Plan offers a dental benefit in excess of Medicare coverage, the requested service is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a surgical 
extraction.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on 
April 7, 2022. 
 
You asked the Plan to pay for the comprehensive oral evaluation. You say that you would like this service to be 
covered because you were following up with your dental care as needed. 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 14, 2021. Therefore, 
we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on April 
7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cardiac risk assessment genetic screening testing rendered to 
the enrollee on October 25, 2021. 
 
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. 
The Plan says the documentation submitted on appeal indicates that this testing was initiated by the laboratory 
and not the treating physician. 
 
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 pay for the testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the reviewed documentation indicates that the enrollee has diagnoses of hypertension, shortness of 
breath and edema. There was no specific clinical rationale for the requested laboratory studies. The review has determined that the services at issue in this case were not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have 
to pay for cardiac risk assessment genetic screening testing rendered to the enrollee on October 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bone replacement graft for ridge preservation - per site 
(D7953) provided on April 14, 2022. 
 
You asked the Plan to pay for the bone replacement graft. You say that you don't understand why this is not 
covered as it is part of trying to save the tooth, and not just pulling it or filling up the space. The Plan denied 
your request. The Plan says the service provided is not a covered benefit 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 pay for a bone 
replacement graft for ridge preservation - per site (D7953) provided on April 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the simple extraction (D7140) provided on July 22, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the simple extraction. You say that the Plan needs to pay the treating provider 
because they did their job. The Plan denied your request. The Plan says the dental services were received from 
an out-of-network provider and are not covered by your supplemental 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. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for the simple extraction (D7140) provided on July 22, 2021, by an out-of-network (OON) provider.  
 Your complaint about the first provider you went to not helping you is not a valid appeal for medical coverage. 
This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to 
make a decision about these types of complaints.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Kineret for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not covered under Part B. 
 
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 Kineret for the enrollee.  
 
Benefits for this drug 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Humira. 
 
You asked the Plan to pre-approve Humira. You say that the enrollee's eye pressure has gone down since using 
Humira. You say that the requested drug is medically necessary. The Plan denied your request. The Plan says 
the enrollee does not have pharmacy benefits administered under this contract. The Plan says that the enrollee 
has Corning Incorporated, which provides its own pharmacy benefits. The Plan says that the enrollee's 
prescription coverage is provided through SilverScript. 
 
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 Humira.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are requesting reconsideration, 
please see clinical summary attached. The Plan denied your request. The Plan says based on Medicare 
guidelines the LTACH services you are requesting do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is receiving appropriate care at the present setting. The enrollee does not 
require services at the LTACH that are not available at the health care setting where they are currently 
receiving care. The Plan has approved ongoing care in the current acute care setting. The requested LTACH 
services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 
and able to be furnished safely and effectively only on an inpatient basis. 
 
 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bone replacement grafts (D4263) provided by a participating 
provider May 11, 2022. 
 
You asked the Plan to pay for bone replacement grafts. You say that you think the Plan should pay for this. The 
Plan denied your request. The Plan says the rendered dental work 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 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 bone 
replacement grafts (D4263) provided by a participating provider on May 11, 2022.
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 these services are medically necessary. The Plan 
denied your request. The Plan says that the member does not show the physician, skilled nursing or therapy 
needs characteristically given in an IRF. 
 
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. The 
complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for back pain after a fall 
and had kyphoplasty. The enrollees medical problems are stable. There are no complex nursing or 
rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. 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. There is not a 
reasonable expectation that this patient will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition 
does not meet Medicare criteria for IRF 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implant supported crowns (D6066). 
 
You asked the Plan to pre-approve the implant supported crowns. You say that you need the crowns because 
you are having trouble eating and speaking. The Plan denied your request. The Plan says this service is not 
covered. 
 
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 
implant supported crowns (D6066).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial nursing facility care provided on February 2, 2022. 
 
You asked the Plan to pay for initial nursing facility care. The Plan denied your request. The Plan says services 
from non-participating providers are not covered under open access unless preauthorized. 
 
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 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 initial nursing facility care provided on February 2, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 75716 billed for date of service November 8, 
2021. 
 You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says an 
appropriate modifier was not 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.  
 
In this case, we have confirmed that code 75716 is a column II code to column I code 75630. 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 75716 
billed for date of service November 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the localized delivery of antimicrobial agents via a controlled 
release vehicle into diseased crevicular tissue, per tooth (D4381 x 5), gingival irrigation-per quadrant  
(D4921 x 2), drugs and/or medicaments dispensed in the office for home use (D9630), and the periodontal 
scaling and root planing services-four or more teeth per quadrant (D4341 x 2) provided on March 19, 2022. 
 
You asked the Plan to pay for these items/services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request.  
 
 The Plan says the localized delivery of antimicrobial agents via a controlled release vehicle into diseased 
crevicular tissue per tooth, gingival irrigation-per quadrant, and the drugs and/or medicaments dispensed in the 
office for home use are not covered under your contractual policy. Additionally, the Plan says you have 
exhausted the allowable benefit for the periodontal scaling and root planing services provided in this case. 
 
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 localized delivery of antimicrobial 
agents via a controlled release vehicle into diseased crevicular tissue per tooth, gingival irrigation-per quadrant, 
and the drugs and/or medicaments dispensed in the office for home use, are not among those items/services 
covered under this benefit. Additionally, you have exhausted the allowable benefit for the periodontal scaling 
and root planing services provided in this case. Specifically, the Plan contract covers one procedure per 
quadrant of periodontal scaling and root planing services every three calendar years. You previously received 
these services on May 20, 2021, which was paid for by the Plan. Therefore, you have exhausted the allowable 
benefit. Therefore, we decided that the Plan does not have to pay for the localized delivery of antimicrobial 
agents via a controlled release vehicle into diseased crevicular tissue, per tooth (D4381 x 5), gingival irrigation-
per quadrant (D4921 x 2), drugs and/or medicaments dispensed in the office for home use (D9630), and the 
periodontal scaling and root planing services-four or more teeth per quadrant (D4341 x 2) provided on  
March 19, 2022.