Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee exceeds the established 
criteria for LTACH and the LTACH is medically necessary. The Plan denied your request. The Plan says 
authorization because LTACH is not medically necessary and the enrollee's needs can continue to be met at the 
current facility until the enrollee's condition is stable for transfer to an alternate level of care, such as a skilled 
nursing facility (SNF). 
 
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 record indicates that the enrollee is improving but still requires acute care 
services.   
 
The enrollee continues to receive acute care services, and these have not been denied. The medical record does 
not indicate that the enrollee requires services that he is not currently receiving but that would be available at 
the LTACH facility. 
 
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 long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial maxillary denture (D5213), and a partial 
mandibular denture (D5214) to be provided by a participating provider. 
 
You asked the Plan to pre-approve a partial maxillary denture and a partial mandibular denture. You say that 
you would like approval for these services. The Plan denied your request. The Plan says the benefit limit 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 Plans coverage rules apply in this case. The Plan covers a partial 
maxillary denture and a partial mandibular denture once every five years.  
 
We looked at the file and Medicare rules. Evidence was provided to show that dentures were provided on July 
5, 2017. D5213 and D5214 are not eligible until July 5, 2022. Based on this information, we decided that the Plan's rules for coverage of a partial maxillary denture and a partial mandibular denture have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a partial maxillary denture (D5213), and a 
partial mandibular denture (D5214) to be provided by a participating provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system (E2300). 
 
You asked the Plan to pre-approve a power seat elevation system (E2300). You say that you would like the 
Plan to reconsider their denial. The Plan denied your request. The Plan says a power seat elevation system 
(E2300) is statutorily non-covered by Medicare and the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Medicare specifically excludes coverage of power seat elevation 
systems coded as E2300. Therefore, we decided that the Plan does not have to pre-approve a power seat 
elevation system (E2300).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950) 
provided January 25, 2022. 
 
You asked the Plan to pay for the core buildup. You say that you were only told that the Plan covers up to 
$2,000. The Plan denied your request. The Plan says this service is not covered under your benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the core 
buildup, including any pins when required (D2950) provided January 25, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the scanning computerized ophthalmic 
diagnostic imaging (SCODI) rendered on January 26, 2022. 
 
You asked the Plan to waive the copayment for these services. You say that you should not be paying for the 
services. The Plan denied your request. The Plan says the copayment was applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $75 
copayment for each covered diagnostic procedure or test at a network doctor's office.  
 
Review of the file shows that you received eye imaging on January 26, 2022. Per the contract with the Plan, 
there is a $75 copayment for each covered diagnostic procedure or test at a network doctor's office. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. However, the Medicare 
allowed amount for these services was $41.01. Given that the allowed amount was less than the $75 
copayment, you have been asked to pay $41.01 for these services. Therefore, we decided that the Plan does not 
have to waive the copayment for the scanning computerized ophthalmic diagnostic imaging (SCODI) rendered 
on January 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pontic (D6245). 
 
You asked the Plan to pre-approve the pontic. You say that this service is medically necessary. The Plan denied 
your request. The Plan says this service is not covered under your benefit plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
pontic (D6245).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the optometry services provided on November 5, 2021. 
 
You asked the Plan to pay for the services provided. You say that you were told a referral was not needed. The 
Plan denied your request. The Plan says the services are not paid separately. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 In this case, the CPT Code Manual definition of code 99072 is additional supplies, materials, and clinical staff 
time over and above those usually included in an office visit or other non-facility service(s), when performed 
during a Public Health Emergency, as defined by law, due to respiratory-transmitted infectious disease. We 
find that CPT code 99072 has a status indicator of B on the Physician Fee Schedule. This means that CPT code 
99072 is not separately payable. 
 
The CPT Code Manual definition of code 3072F is low risk for retinopathy (no evidence of retinopathy in the 
prior year) (DM). We find that this code is used for reporting purposes only. Based on this information, we 
decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided 
that the Plan does not have to pay for the optometry services provided on November 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for advance care planning services provided to the enrollee on 
October 13, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the appropriate modifier was not billed with this edit. 
 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 99497 
is a column II code to column I code 99223. 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 advance care planning services provided to the enrollee on 
October 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve retainer crowns (D6740 x 2) and pontics (D6245 x 2). 
 
You asked the Plan to pre-approve a fixed bridge. You say that your dentist submitted for a bridge replacement 
as it was broken. You say that they thought you might be able to use it. You say that the dentist accidentally 
threw it away. You say that you now have an exposed nerve and is not eating right. You also say that you can 
only swallow on one side of your mouth. The Plan denied your request. The Plan says fixed bridge is not a 
covered dental service. 
 
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 fixed bridge is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
retainer crowns (D6740 x 2) and pontics (D6245 x 2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) provided 
on November 23, 2021. 
 
You asked the Plan to pay for the comprehensive periodontal evaluation. You say that you did not exhaust your 
dental maximum last year. You also say that you would like to request a reversal of the $100.00 you paid. The 
Plan denied your request. The Plan says the limitation for oral exams has been met and paid for the 2021 
benefit year. 
 
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, you are limited to 2 preventive exams 
every calendar year. The record shows that you received a periodic oral evaluation (D0120) on April 26, 2021, 
and a comprehensive oral evaluation (D0150) on June 22, 2021 and your preventive exams benefit has been 
exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive periodontal 
evaluation (D0180) provided on November 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete series of intraoral x-rays (D0210) and four two 
dimensional (2D) oral/facial photographic images (D0350 x4) provided on December 20, 2021. 
 
You asked the Plan to pay for the complete series of intraoral x-rays and 2D oral/facial photographic images. 
You say that you checked with the receptionist several times and were told they accepted your insurance. You 
also say that you are on a fixed income and cannot afford this bill. The Plan denied your request. The Plan says 
the complete series of intraoral x-rays and 2D oral/facial photographic images are not covered expenses under 
your dental plan. The Plan also says that you did not contact the Plan prior to this date of service to verify 
benefits and provider eligibility.  
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 complete series of intraoral x-rays 
(D0210) and 2D oral/facial photographic image (D0350) are not among those covered under this benefit. 
Therefore, we decided that the Plan does not have to pay for the complete series of intraoral x-rays (D0210) 
and four two dimensional (2D) oral/facial photographic images (D0350 x4) provided on December 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and bitewing x-rays 
(D0274) provided on October 13, 2021. 
 
You asked the Plan to pay for the periodic oral evaluation and bitewing x-rays. You say that you agreed to the 
x-rays because you were told they did not have any on file. You also say that you did not receive and exam, 
and the dentist only kept their distance. The Plan denied your request. The Plan says your benefit plan has 
limits for how often these procedures are 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, exams are limited to two procedures 
per calendar year. The record shows that you received comprehensive oral evaluations (D0150) on February 
10, 2021, and June 7, 2021 and your exams benefit has been exhausted. The Plan contract also says that 
bitewing x-rays are limited to one procedure per calendar year. The record shows that you received bitewing x-
rays (D0274) on February 10, 2021 and your bitewing x-rays benefit has been exhausted. Therefore, we 
decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and bitewing x-rays 
(D0274) provided on October 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) 
provided on September 8, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the problem focused limited oral evaluation. You say that you feel the Plan 
provided you and your provider a lack of accurate representation of benefits for an allowed amount and 
possible reductions on the basis of provider status of being in-network versus OON. The Plan denied your 
request. The Plan says the cost share was applied correctly per your plan benefits. The Plan also says that cost-
sharing is a contractual obligation of the Plan and cannot be waived. 
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, you are responsible for the difference 
between the billed amount and allowed amount for covered dental services that are received OON. Therefore, 
we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) 
provided on September 8, 2021 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implantation of the Aurora Spine ZIP Interspinous 
Fixation device to L5-S1. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that the clinical value and effectiveness of the Aurora Spine ZIP 
Interspinous Fixation device in the setting of degenerative disc disease and spondylolisthesis have not been 
demonstrated in the peer-reviewed literature. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. The interspinous 
device is experimental. More research is needed. Our physician reviewer found that your condition does not 
meet criteria for coverage of these services. 
 
 
 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 implantation of the Aurora Spine ZIP Interspinous Fixation device to L5-S1.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hand x-ray rendered on November 15, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that modifier -26 is required for separate payment of 
the PC services when furnished in a different payment locality than the TC. 
 
We looked at the file and Medicare rules. The file shows that the services were not billed with the required -26 
modifier to allow for separate PC payment. Therefore, we decided that the Plan does not have to pay for the 
hand x-ray rendered on November 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mounting system for a speech generating device (E2512) 
provided on September 20, 2021. 
 
You asked the Plan to pay for the mounting system for a speech generating device. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says the records do not 
include a valid Proof of Delivery. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  The record does not contain a valid proof of delivery for the supplies provided in this case. Specifically, the 
record does not include a proof of delivery for the billed date of service. The documentation submitted 
indicates that this supply was shipped on September 2, 2021 and delivered on September 4, 2021. The record 
shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, 
we decided that the Plan does not have to pay for the mounting system for a speech generating device (E2512) 
provided on September 20, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from May 9, 2022, forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care. You say that the requested inpatient psychiatric 
care is a medical necessity for the enrollee. The Plan denied your request. The Plan says medical necessity 
rules for inpatient psychiatric care have not been met. 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve inpatient psychiatric care. Our reviewer 
says that the requested inpatient psychiatric care is not medically reasonable and necessary in this case. Our 
physician reviewer found that it is not expected that the enrollee will improve in a reasonable period of time 
beyond the date in question as the enrollee is not showing any dangerousness to self or others, auditory or 
visual hallucinations and without aggressive behaviors while not showing any acute threats of safety. It does 
not appear that active treatment is taking place. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve inpatient psychiatric care from May 9, 2022, forward.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) 
provided September 30, 2021. 
 
You asked the Plan to pay for the limited oral exam. You say that this service was necessary to address your 
dental problems. The Plan denied your request. The Plan says you have exceeded the frequency limit for this 
service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the limited or 
periodic oral exam twice per calendar year.  
 
We looked at the file and Medicare rules. The Plan provided documentation showing that a limited exam was 
covered January 13, 2021, and a periodic oral exam was covered May 20, 2021. Based on this information, we decided that the Plan's frequency limit for coverage of the limited oral exam has been exceeded. Therefore, we 
decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) provided 
September 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve extractions, erupted tooth requiring removal of bone 
and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210), alveoloplasty in 
conjunction with extractions - four or more teeth or tooth spaces, per quadrant (D7310), deep sedation/general 
anesthesia  first 15 minutes (D9222), deep sedation/general anesthesia  each subsequent 15 minute increment 
(D9223) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve extractions, alveoloplasty and general anesthesia. You say that the enrollee 
needs these services. The Plan denied your request. The Plan says these services are not covered when provided 
OON. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers extractions, alveoloplasty and general anesthesia when the services are rendered by a provider in the Plans supplemental 
dental network. 
 
We looked at the file and Medicare rules. In this case the services are requested to be provided OON. Based on 
this information, we decided that the Plan's rules for coverage of extractions, alveoloplasty and general 
anesthesia have not been met. Therefore, we decided that the Plan does not have to pre-approve extractions, 
erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal 
flap if indicated (D7210), alveoloplasty in conjunction with extractions - four or more teeth or tooth spaces, per 
quadrant (D7310), deep sedation/general anesthesia  first 15 minutes (D9222), deep sedation/general 
anesthesia  each subsequent 15 minute increment (D9223) to be provided by an out-of-network (OON) 
provider.