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

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140), bitewings (D0270), and an 
extraction (D7210) provided by a participating provider on December 1, 2021. 
 
You asked the Plan to pay for a limited oral evaluation, bitewings, and an extraction. You say that you believe 
these services were medically necessary. The Plan denied your request. The Plan says this claim has been 
processed correctly. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan does not cover a 
limited oral evaluation. The Plan covers one set of bitewings per year, and an unlimited number of extractions.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of bitewings have not been met. D0270 was previously provided on May 17, 2021. D0140 is not 
a covered dental benefit. D7210 has been processed correctly with a $129.50 coinsurance. Therefore, we decided 
that the Plan does not have to pay for a limited oral evaluation (D0140), bitewings (D0270), and an extraction 
(D7210) provided by a participating provider on December 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a full mouth x-ray (D0210) provided by an out-of-network 
provider on December 2, 2021. 
 
You asked the Plan to pay for a full mouth x-ray. You say that you were advised that these services would be 
covered 100%. The Plan denied your request. The Plan says the benefit limit for D0210 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. The Plan covers one full 
mouth x-ray every five years.  
 
We looked at the file and Medicare rules. Evidence was provided to show that D0210 was previously provided 
on February 3, 2020. Based on this information, we decided that the Plan's rules for coverage of a full mouth x-
ray have not been met. Therefore, we decided that the Plan does not have to pay for a full mouth x-ray (D0210) 
provided by an out-of-network provider on December 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cone beam computed tomography (CT) capture and 
interpretation with limited field of view  less than one whole jaw (D0364) provided February 1, 2022. 
 
You asked the Plan to pay for the cone beam CT scan. You say that it was necessary to receive service out-of-
network. The Plan denied your request. The Plan says the claim from this date of service has been reprocessed 
as in-network, however the cone beam CT scan is not a covered 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the cone 
beam computed tomography (CT) capture and interpretation with limited field of view  less than one whole 
jaw (D0364) provided February 1, 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 you require this level of care. The Plan denied your 
request. The Plan says that you do not need three hours a day of therapy and her medical illnesses are stable. 
 
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 your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. You were admitted for syncope and a stroke.  Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While you have a need for physical and/or occupational therapy, there is no 
documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that you 
will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an 
IRF. Our physician reviewer found that your 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 pay for the bridge for teeth # 5, 6, 7 and 8 provided on October 28, 2021. 
 
You asked the Plan to pay for the fixed bridge. You say that you need this bridge. The Plan denied your 
request. The Plan says the provided documentation does not support the specific physical or psychological 
condition for the use of a removable prosthesis.  
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 fixed 
bridge 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 pay for the fixed bridge. Our reviewer says that the 
replacement bridge is not medically necessary. Our physician reviewer found the provided documentation 
indicates that this is a replacement bridge required due to recurrent caries. The reviewer also found that the 
documentation was incomplete. The provided documentation does not include radiographs and dental records 
to determine the periodontal status of the abutment teeth and your overall oral health. Therefore, the reviewer 
found that the requested bridge is not medically necessary. 
 
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 fixed bridge have not been met. Therefore, we decided that the Plan does 
not have to pay for the bridge for teeth # 5, 6, 7 and 8 provided on October 28, 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 December 27, 2021. 
 
You asked the Plan to pay for the problem focused limited oral evaluation. You say that this is the first and 
only time you had a root canal procedure done, and you do not understand how the service exceeds the 
frequency limitation. You also say that this was an emergency situation, as the pain and infection needed 
attention immediately. The Plan denied your request. The Plan says this service exceeds the frequency 
limitation in 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, problem focused limited oral 
evaluation (D0140) is limited to one procedure per plan year. The record shows that you received a problem 
focused limited oral evaluation (D0140) with another provider on December 27, 2021, which was covered by 
the Plan, and your problem focused limited oral evaluation (D0140) benefit has been exhausted. Therefore, we 
decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on 
December 27, 2021.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Botox. 
 
You asked the Plan to pre-approve Botox. You say that the records provided support the need for Botox. The 
Plan denied your request. The Plan says that the medical records do not demonstrate that the requested drug is 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Botox. Our reviewer says that the 
criteria for coverage have been met. Our physician reviewer found Botox is FDA approved for use in the 
prevention of chronic migraine. The records provided for review support a diagnosis of chronic migraine 
(based on current diagnostic criteria). Botox is recognized as being safe and effective for use in this condition. 
In this setting it can be said that the use of Botox would be reasonable and 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 Botox have been met. Therefore, we decided that the Plan has to pre-approve 
Botox.  
 
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 cone beam CT capture and interpretation with limited field 
of view (D0364) provided on January 13, 2022. 
 
You asked the Plan to pay for the dental service. You say that you feel this should be covered. You also say 
that you were referred to this dentist by your primary dentist. The Plan denied your request. The Plan says the 
cone beam CT is no listed as a covered service. 
 
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 cone beam CT is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for cone beam 
CT capture and interpretation with limited field of view (D0364) provided on January 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copay for the lab testing provided on February 8, 2022. 
 
You asked the Plan to waive the copay for the services provided. You say that there should be no copay. The 
Plan denied your request.  
 
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 $20 
copay for lab services and diagnostic test performed in an outpatient hospital facility.  
 
The file shows that the Plan received a claim from an outpatient hospital. You have been asked to pay an 
$18.76 copay for the services provided. Because the amount is less than the $20 copay, you were charged the 
lesser amount. The services fall within the outpatient hospital 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 copay for the lab testing provided on February 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided February 8, 2022. 
 
You asked the Plan to pay for the periodontal maintenance. You say that you feel you had a normal cleaning. 
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 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 the 
periodontal maintenance (D4910) provided February 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an epidural injection provided on November 8, 2021. 
 
You asked the Plan to pay for an epidural injection. The Plan denied your request. The Plan says the Health 
Plan has not received the required clinical records to support the medical necessity of the service for the date of 
service requested. The records provided are undated and unsigned. There is insufficient documentation of 
response to prior injections. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of an epidural injection provided on 
November 8, 2021 have been met. The Health Plan has not received the required clinical records to support the 
medical necessity of the service. Therefore, we decided that the Plan does not have to pay for an epidural 
injection provided on November 8, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex procedure (22869, 22870). 
 
You asked the Plan to pre-approve a Vertiflex procedure. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met 
because the requested procedure is experimental/investigational. 
 
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 Vertiflex procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the North American Spine Society and American Orthopedic Association does 
not endorse this procedure. The procedure is considered experimental/investigational. 
 
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 Vertiflex procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Vertiflex procedure (22869, 22870).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81206, 81235, 81292, 81321, and 
81301) provided on April 4, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT code 81479. Therefore, we decided that the Plan does not have 
to pay for the laboratory services (81206, 81235, 81292, 81321, and 81301) provided on April 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the first hour of critical care (99291) provided on October 9, 
2021. 
 
You asked the Plan to pay for the first hour of critical care. You say that you have provided records to support 
the service billed. The Plan denied your request. The Plan says the records do not support the service 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, the CPT Code Manual definition of code 99291 is "Critical care, evaluation and management of 
the critically ill or critically injured patient; first 30-74 minutes." 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, the available medical 
documentation does not record the span of time over which the services at issue were rendered. Based on this 
information, we decided that Medicare rules for coverage of the first hour of critical care have not been met. Therefore, we decided that the Plan does not have to pay for the first hour of critical care (99291) provided on 
October 9, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied 
your request. The Plan says the guidelines for coverage have not been met. The Plan says that the enrollee can 
safely receive the services needed in other settings. 
 
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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for surgical management of perforated intestine. The enrollee's medical problems are stable. 
There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple 
therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 
program. While the enrollee has a need for physical and/or occupational therapy, there is no documentation of a 
need for an intensive rehabilitation program. There is not a reasonable expectation that the enrollee will be able 
to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a battery backup (A9270). 
 
You asked the Plan to pre-approve a battery backup. You say that you would like to appeal this denial for the 
battery backup for your continuous positive airway pressure (CPAP) machine. The Plan denied your request. 
The Plan says alternative power sources are not considered by Medicare as durable medical equipment. The 
Plan also says that Medicare does not allow payment for power generators or alternative power sources needed 
in the event of power outages. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
You are requesting a battery backup for your continuous positive airway pressure (CPAP) machine. A battery 
backup is considered duplicative, and therefore not covered. Therefore, we decided that the Plan does not have 
to pre-approve a battery backup (A9270).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), panoramic x-ray 
(D0330), immediate upper denture (D5130), partial lower denture (D5214), and extractions (D7140 x 2) 
provided on January 17, 2022, by the out of network dentist. 
 
You asked the Plan to pay for the dental services. You say that there was only 1 option for an in network 
dentist. You say that they wanted $2,000 up front for the dental work. You say that you advised you did not 
have that but would try to borrow it. You say that you never heard back from them. You also say that you had 
to find a new dentist as a result. The Plan denied your request. The Plan says the claim denied correctly. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the dental services you received out 
of network are not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pay for the comprehensive oral evaluation (D0150), panoramic x-ray (D0330), immediate upper denture 
(D5130), partial lower denture (D5214), and extractions (D7140 x 2) provided on January 17, 2022, by the out 
of network dentist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the addition of tooth to existing partial denture (D5650) 
provided on February 7, 2022. 
 
You asked the Plan to pay for the dental service. You say that this service is necessary. You say that your teeth 
would not be properly aligned otherwise. You also say that this was not performed for cosmetic reasons. The 
Plan denied your request. The Plan says addition of tooth to existing partial denture is not listed as a covered 
service. 
 
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 addition of tooth to existing partial 
denture is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay 
for the addition of tooth to existing partial denture (D5650) provided on February 7, 2022.