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

 
We decided that the Plan does not have to waive the copayments for the ophthalmological medical 
examinations and evaluations, with initiation or continuation of a diagnostic and treatment program (92004, 
92014) provided on March 3, 2021 and September 30, 2021. 
 
You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayments have been applied correctly to 
the services provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that she must pay 
a $35 copayment for Medicare-covered eye exams to diagnose and treat diseases and conditions of the eyes.  
  
The enrollee has been asked to pay $70 ($35 copayment x 2) for the Medicare-covered eye exams provided. 
This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This 
cost sharing is a contractual obligation the enrollee agreed to pay when she enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayments for the ophthalmological medical examinations 
and evaluations, with initiation or continuation of a diagnostic and treatment program (92004, 92014) provided 
on March 3, 2021 and September 30, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on September 29, 
2020. 
 
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 denied code is considered inclusive to another code. 
 
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 49561 is "Repair initial incisional or ventral hernia; 
incarcerated or strangulated." 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found the hernia repair was incorporated 
into the larger procedure which was exploratory laparotomy with small bowel resection and anastomosis. The 
hernia defect was closed during closure of the midline fascial laparotomy incision. It should not be billed as a 
separate procedure code, even though the indication for surgery was incarcerated hernia with strangulated bowel. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for surgical services provided to the enrollee on September 29, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eliquis. 
 
You asked the Plan to pre-approve Eliquis. You say that the enrollee has been stable on this medication. The 
Plan denied your request. The Plan says coverage of this medication is the responsibility of the enrollees 
prescription drug plan. 
 
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 Eliquis.  
 
Benefits for Eliquis 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a vision exam provided on 
November 3, 2021. 
 
You asked the Plan to waive the copayment for the vision exam. The Plan denied your request. The Plan says 
the claim processed 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 $45 
copayment for Vision Care, Medicare Covered Vision Services.  
 
You have been asked to pay a $45 copayment for the vision exam. The vision exam falls within the Vision 
Care, Medicare Covered Vision 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 copayment 
for a vision exam provided on November 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4341) for all 
four mouth quadrants. 
 
You asked the Plan to pre-approve periodontal scaling and root planing. You say that these services are 
necessary. The Plan denied your request. The Plan says this service is not covered by your dental 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 
periodontal scaling and root planing (D4341) for all four mouth quadrants.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a partial lower denture (D5214). 
 
You asked the Plan to pre-approve the lower denture. You say that this denture is necessary for the enrollee. 
The Plan denied your request. The Plan says that this service is covered once every five years. The enrollee 
received a previous partial lower denture in June of 2018, which is less than five years before this request. 
 
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 rules also 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. 
 
We looked at the file and the Plan's rules. The Plan has not made reasonable and diligent efforts to gather and 
forward to us information regarding their decision to deny your request. Although the information submitted 
for review did include documentation that the enrollee had a previous denture provided within five years, the 
record does not include any documentation to further clarify which services require which copayment or which 
services are limited to a frequency of one every 60 months. Based on the contract, not all covered 
prosthodontic services are subject to this frequency limitation. Therefore, we decided that the Plan has to pre-
approve a partial lower denture (D5214).  
 
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 prophylaxis (D1110) provided by a participating provider on 
November 24, 2021. 
 
You asked the Plan to pay for prophylaxis. You say that this should be covered. The Plan denied your request. 
The Plan says you have exceeded the maximum benefit amount of $1,000. 
 
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 dental 
services with a maximum benefit allowance amount of $1,000. 
 
We looked at the file and Medicare rules. Evidence was provided to show that the maximum benefit limit of 
$1,000 has already been met. Based on this information, we decided that the Plan's rules for coverage of 
prophylaxis have already been met. Therefore, we decided that the Plan does not have to pay for prophylaxis 
(D1110) provided by a participating provider on November 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve porcelain fused to high noble metal crowns (D2750) for 
teeth #10 and #11. 
 
You asked the Plan to pre-approve the crowns. You say that you suffered a bad fall which caused injuries to 
your face, mouth, and teeth. These services are necessary to fix your teeth. The Plan denied your request. The 
Plan says the requested crowns are not medically necessary in this case. The documentation provided does not 
demonstrate the need for replacement of the existing crown. Note that an open margin without documented 
presence of active recurrent decay does not meet criteria for crown replacement. 
 
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. The Plan covers the crowns 
when the services are medically necessary and reasonable.  
 
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 crowns. Our reviewer says that the 
requested crowns are not medically necessary. Our physician reviewer found that this request is for 
replacement crowns on teeth #10 and #11 which were damaged during a fall. The Plan criteria provides for 
replacement of old crowns where there is decay that compromises the seal of the crown.  The Plan does not provide coverage for replacement of crowns for cosmetic reasons. In this instance, you suffered a significant fall with reported injuries to the eyes, mouth, lip and face. The existing crowns were fabricated of metal-porcelain materials, so that a fracture of the porcelain which is the white aspect of the crown would not compromise the metal core of the crown. The tooth itself is sealed under the metal core, and although not esthetic, the tooth is still protected. The Plan does not provide coverage where the seal of the tooth 
is not compromised, and in this case the metal core would appear to still be intact. The Plan limitations exclude 
replacement of existing crowns for cosmetic reasons. Given the Plan provisions, there would be no coverage 
for replacement crowns on teeth #10 and #11. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the crowns have not been met. Therefore, we decided that the Plan does not 
have to pre-approve porcelain fused to high noble metal crowns (D2750) for teeth #10 and #11.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on December 8, 
2021. 
 
You asked the Plan to pay for the dental service. You say that you noticed you had a loose crown. You say that 
your dentist referred you to a periodontist. You say that the periodontist found an infection and referred you 
back to your dentist. You also say that you feel that the claim had incorrect information listed. The Plan denied 
your request. The Plan says 1 limited oral evaluation is covered per plan year. The Plan also says that the 
frequency limit has been exceeded. 
 
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 and 1 limited oral evaluation is covered 
per plan year, the frequency limit has been exceeded. The record shows that the Plan paid for a limited oral 
evaluation that you received on December 3, 2021. Therefore, we decided that the Plan does not have to pay 
for the limited oral evaluation (D0140) provided on December 8, 2021.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve the porcelain/ceramic crown and core buildup for tooth #5. We 
decided that the Plan does not have to pre-approve the dental bridge for teeth #12-#15.  
 
You asked the Plan to pre-approve the dental bridge and crown with core buildups. You say that these services 
are necessary. The Plan says that the requested services are not medically necessary. You do not have a 
damaged bridge or decay around the margins of your teeth. 
 
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 dental 
bridges, crowns and core buildups when these services are medically necessary and reasonable. 
 
We decided that the Plan has to pre-approve the porcelain/ceramic crown and core buildup for tooth #5.  
 
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 crown and core buildup for tooth 
#5. Our reviewer says that the requested crown is medically necessary and reasonable. Our physician reviewer 
found that tooth #5 has a large defective restoration. It is the opinion of our reviewer that the core buildup and 
crown are reasonable and necessary to provide adequate masticatory function.  
 
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 crown and core buildup have been met. Therefore, we decided that the Plan 
has to pre-approve the porcelain/ceramic crown and core buildup for tooth #5.  
 
We also decided that the Plan does not have to pre-approve the dental bridge for teeth #12-#15. 
 
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 dental bridge for teeth #12-#15. Our 
reviewer says that the criteria for coverage of a replacement bridge are not met in this case. Our physician 
reviewer found that the current bridge replacing teeth #13 and #15 does not appear defective radiographically, 
and the documentation does not include a narrative indicating why a replacement bridge is necessary. The 
request is not supported as necessary in this case.  
 
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 dental bridge for teeth #12-#15 have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the dental bridge for teeth #12-#15. 
 
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 periapical x-rays (D0220, D0230 x 5) provided on 
November 10, 2021. 
 
You asked the Plan to pay for the dental services. You say that you have not been able to get any preventive 
services due to the coronavirus. You say that these services should be considered preventive and covered. You 
say that you were given incorrect information about the dental rider benefits. You also say that you feel these 
services should be covered as they were emergency services. The Plan denied your request. The Plan says 
periapical x-rays are not listed as 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 periapical x-rays are not among 
those covered under this benefit. Additionally, the record shows that you were not enrolled in the optional supplemental dental rider on the date of service in this case. Therefore, we decided that the Plan does not have 
to pay for the periapical x-rays (D0220, D0230 x 5) provided on November 10, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Providence DTRAX cervical cage system (22842) 
and the i-FACTOR allograft (20930) for the enrollee. 
 
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 these services have not been 
demonstrated. 
 
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. There is limited 
published, large-scale, long-term peer-reviewed literature that shows this request to be an effective and/or safe 
treatment for the noted pathology. Our physician reviewer found that the enrollee's 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 the Providence DTRAX cervical cage system (22842) and the i-FACTOR allograft 
(20930) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the implant (D6010), extraction (D7210), bone graft at time 
of implant placement (D6104), collection and application of autologous blood concentrate product (D7921), 
and sinus augmentation (D7952) provided on November 2, 2021. 
 
You asked the Plan to pay for the dental services. You say that the provider in this case is in network. You also 
say that the services should be paid in full. The Plan denied your request. The Plan says there is a $2,000 
allowance every year for dental services. The Plan also says that the allowance 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, the $2,000 allowance has been 
exhausted. The record shows that the Plan paid $295 for services received on August 31, 2021, and $1,705 for 
services received on the date of service in this case. $295 + $1,705 = $2,000. Therefore, we decided that the 
Plan does not have to pay for the implant (D6010), extraction (D7210), bone graft at time of implant placement 
(D6104), collection and application of autologous blood concentrate product (D7921), and sinus augmentation 
(D7952) provided on November 2, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for BCR/ABL gene analysis (81206) and MLH1 gene analysis 
(81292) provided on August 9, 2021. 
 
You asked the Plan to pay for BCR/ABL and MLH1 gene analysis. You say that this is supported in the 
records. The Plan denied your request. The Plan says the requirements for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that BCR/ABL testing is indicated in patients with 
suspected chronic myeloid leukemia (CML) with either persistent, unexplained leukocytosis or thrombocytosis. MLH1 genetic tests are unlikely to impact therapeutic decision-making, directly impact treatment, outcome 
and/or clinical management in the care of the beneficiary and will be denied as not medically necessary. 
 
We looked at the file and Medicare rules. The records do not show that the enrollee had suspected CML to 
support BCR/ABL testing. MLH1 testing is not covered. Based on this information, we decided that Medicare 
rules for coverage of BCR/ABL and MLH1 gene analysis have not been met. Therefore, we decided that the 
Plan does not have to pay for BCR/ABL gene analysis (81206) and MLH1 gene analysis (81292) provided on 
August 9, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from June 
21, 2021, to June 30, 2021. 
 
You asked the Plan to pay for the SNF care provided from June 21, 2021, to June 30, 2021. You say that the 
services were medically necessary. The Plan denied your request. The Plan says the enrollee did not receive 
skilled care after June 20, 2021. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not 
have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled 
professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, 
knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing 
and/or skilled therapy on an inpatient basis in a SNF 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 the SNF care have not been met. Therefore, we decided that the Plan does not 
have to pay for the skilled nursing facility (SNF) care provided from June 21, 2021, to June 30, 2021.