Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a low dose computed tomography (CT) scan of the 
lungs. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee quit smoking 19 years ago. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
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 scan. Our reviewer says that the 
requested scan is not medically reasonable or necessary. Our physician reviewer found that the enrollee would 
qualify for this scan by age and pack year history of smoking. However, the enrollee quit smoking 19 years 
ago. The guidelines specify that a patient must be currently smoking or having quit within the past 15 years. 
 
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 scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a low dose computed tomography (CT) scan of the lungs.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0676). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says items that are 
used for a preventative service or function are excluded from coverage under the Medicare DME benefit. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pre-approve a pneumatic compression device (E0676).
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 requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is not 
medically necessary. 
 
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 admission to a LTACH is not medically necessary. Our physician reviewer found the 
enrollee was admitted for a cardiac arrest. The record indicates that the enrollee still has pneumonia and 
requires ongoing 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. The elements of the coverage rules are not 
satisfied. The requested service cannot be recommended. 
 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 bone grafts at time of implant placement (D6104). 
 
You asked the Plan to pre-approve bone grafts. You say that the enrollee needs this service. The Plan denied 
your request. The Plan says this service is not covered under the enrollee's benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve bone 
grafts at time of implant placement (D6104).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on November 
29, 2021. 
 
You asked the Plan to pay for the dental service. You say that your plan covers this service 3 times per year. 
You also say that this is the third treatment in 2021. The Plan denied your request. The Plan says the annual 
maximum benefit of $1,000 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage and periodontal maintenance is listed as 
covered, the annual maximum benefit of $1,000 has been exhausted. The record shows that the Plan paid $123 
for services received on February 22, 2021, $95 for services received on June 1, 2021, $723 for services 
received on June 23, 2021, and $59 for services received on November 29, 2021. $123 + $95 + $723 + $59 = 
$1,000. Therefore, we decided that the Plan does not have to pay for the periodontal maintenance (D4910) 
provided on November 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown (D2740) provided on June 7, 2021, by the out of 
network provider. 
 
You asked the Plan to pay for the dental service. You say that you do not understand why the plan only paid 
$303.50 on a bill for $1,950. The Plan denied your request. The Plan says since your dentist is out of network, 
the plan pays according to a maximum allowable fee schedule and you are responsible for all the fees in excess 
of this amount from the billed amount. As per the plan benefits, since the provider was out of network, the 
difference of billed amount and paid amount became your responsibility. 
 
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 the service is listed as covered, out 
of network providers may bill you for any amount greater than what the plan pays. The record shows that the 
Plan paid 50% of the allowed amount. Therefore, we decided that the Plan does not have to pay for the crown 
(D2740) provided on June 7, 2021, by the out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the osseous surgery (D4261) provided on September 10, 2021. 
 
You asked the Plan to pay for the dental service. You say that it is difficult for you to pay for this procedure. 
The Plan denied your request. The Plan says osseous surgery 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the osseous surgery is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the osseous surgery 
(D4261) provided on September 10, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the arterial studies rendered on October 21, 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 diagnosis is not supported.
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis code.
We looked at the file and Medicare rules. The file shows that the services were not billed with an appropriate primary diagnosis code. 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 pay for the arterial studies rendered on October 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oximeter. 
 
You asked the Plan to pre-approve an oximeter. You say that an oximeter is medically necessary. The Plan 
denied your request. The Plan says an oximeter is not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that this equipment is precautionary and is not covered by 
Medicare. Therefore, we decided that the Plan does not have to pre-approve an oximeter.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay for the 5 surgical extractions, removal of residual tooth roots, nitrous 
oxide, and limited oral evaluation. We decided that the Plan does not have to pay for .  
 
You asked the Plan to pay for the dental services. You say that you already paid the member cost share. You 
also say that you should not have to pay more. The Plan denied your request. The Plan says the annual 
maximum benefit of $1,500 has been exceeded. The Plan also says that deep sedation services are not listed as 
covered. 
 
We decided that the Plan has to pay for the 5 surgical extractions, removal of residual tooth roots, 
nitrous oxide, and limited oral evaluation.  
 
The Plan must follow Medicare rules. The rules 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. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the file does not include documents that substantiate that the Plan 
has paid $1,500 for dental services prior to the date of service in this case. The file does not include documents 
to substantiate that a limited oral evaluation has been paid for prior to the date of service in this case. This 
documentation was requested but not received. As a result, we cannot determine that the plans annual 
maximum, nor the frequency limit for limited oral evaluation had been satisfied prior to the date of service in 
this case. Therefore, we decided that the Plan has to pay for the 5 surgical extractions, removal of residual tooth 
roots, nitrous oxide, and limited oral evaluation.  
 
We also decided that the Plan does not have to pay for the deep sedation services. 
 
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 deep sedation services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the deep 
sedation services. 
 
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 pre-approve a prefabricated abutment (D6056) and an implant 
supported porcelain/ceramic crown (D6065) for tooth #3, #4, #6, #8, #10, #12, #13 and #14. 
 
You asked the Plan to pre-approve prefabricated abutments and implant supported porcelain/ceramic crowns. 
You say that you cannot wait another week for a decision. You also say you are not eating normal; your gums 
will soon be infected, and this is causing you depression. The Plan denied your request. The Plan says the 
requested services are not a covered benefit with your 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 
prefabricated abutment (D6056) and an implant supported porcelain/ceramic crown (D6065) for tooth #3, #4, 
#6, #8, #10, #12, #13 and #14.
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). 
 
You asked the Plan to pre-approve tooth extractions. You say that the enrollee needs this service. The Plan 
denied your request. The Plan says extractions are 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 pre-approve 
extractions, erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of 
mucoperiosteal flap if indicated (D7210).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral exam (D0120), periodontal maintenance (D4910), 
and unspecified preventive service (D1999) provided on January 8, 2021. 
 
You asked the Plan to pay for the dental services. You say that you were not aware that the services you 
received would not be covered. The Plan denied your request. The Plan says 1 oral exam is covered per 12 
months. The Plan says that the frequency limit has been exceeded. The Plan also says that periodontal 
maintenance and unspecified preventive service are not listed as covered services. 
 
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 oral exam is covered once per 12 
months, the frequency limit has been exceeded. The record shows that the Plan paid for an oral exam that you 
received on April 8, 2021. Additionally, periodontal maintenance and unspecified preventive service are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the oral 
exam (D0120), periodontal maintenance (D4910), and unspecified preventive service (D1999) provided on 
January 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab service provided on June 27, 2021. 
You asked the Plan to pay for the service provided. You say that you provide an important service to the 
enrollee and provider. The Plan denied your request. The Plan says screening testing is not a Medicare benefit. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The Code Manual definition of code 87640 is infectious agent detection by nucleic acid (DNA or RNA); 
Staphylococcus aureus, amplified probe technique.  The test at issue was not ordered due to a specific medical 
condition. Medicare does not cover this test for screening purposes. Therefore, we decided that the Plan does 
not have to pay for the lab service provided on June 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay the full cost for extractions (D7210), a problem focused 
evaluation (D0140), and a ridge preservation graft (D7953) provided from May 11, 2021, to June 10, 2021, by 
an out-of-network provider. 
 
You asked the Plan to pay the full cost for extractions, a problem focused evaluation, and a ridge preservation 
graft. You say that these services should be covered. The Plan denied your request. The Plan says these 
services 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, a problem focused evaluation and a 
ridge preservation graft are not among those covered under this benefit. While extractions are covered, you are 
responsible for a 55% coinsurance when they are received from an out-of-network provider. Therefore, we 
decided that the Plan does not have to pay the full cost for extractions (D7210), a problem focused evaluation 
(D0140), and a ridge preservation graft (D7953) provided from May 11, 2021, to June 10, 2021, by an out-of-
network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bitewing x-rays (D0274) provided on December 6, 2021. 
 
You asked the Plan to pay for the dental service. You say that you had a panoramic x-ray done at your dentist 
appointment 6 months prior. You say that these are 2 different things. You also say that you feel this service 
should not have been denied. The Plan denied your request. The Plan says bitewing x-rays are payable once per 
calendar 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage and bitewing x-rays are listed as 
covered, the frequency limit has been exceeded. The record shows that the Plan paid for bitewing x-rays that 
you received on May 26, 2021. Therefore, we decided that the Plan does not have to pay for the bitewing x-
rays (D0274) provided on December 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator trial. 
 
You asked the Plan to pre-approve a spinal cord stimulator trial. You say that this is medically reasonable and 
necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that patients being selected for a spinal cord stimulator 
trial must not have active substance abuse issues 
 
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 spinal cord stimulator trial. Our 
reviewer says that the requested spinal cord stimulator is not medically reasonable and necessary. Our 
physician reviewer found in this case, the medical records confirm the enrollee has substance abuse issues. 
Substance abuse is a contraindication to spinal cord stimulator use. 
 
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 spinal cord stimulator trial have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a spinal cord stimulator trial.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a core buildup (D2950), and a crown (D2740) provided 
by an out-of-network provider. 
 
You asked the Plan to pre-approve a core buildup and a crown. You say that you are currently feeling a lot of 
discomfort. The Plan denied your request. The Plan says these services have been correctly denied. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
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 a core buildup (D2950), and a crown 
(D2740) to be provided by an out-of-network provider have been met. Specifically, the record submitted does 
not include any clinical information.  There is insufficient documentation to determine if the Plan's criteria for the dental services have been met. 
Therefore, we decided that the Plan does not have to pre-approve a core buildup (D2950), and a crown (D2740) 
provided by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says your needs can be 
met at a lower level of care. 
 
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 that you do not require treatment by multiple therapies at an intensive rehabilitation 
therapy program. Although you continue to have a need for skilled therapy, the documentation doesnt support 
that you would meet criteria for admission to an acute inpatient rehabilitation facility. You can receive further 
services at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.