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

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete 
series x-ray (D0210) provided on April 21, 2021. 
 
You asked the Plan to pay for the dental services. You say that the previous dentist did not do a deep cleaning 
like you were planning. You say that you went to a new dentist because the other one charged too much. You 
also say that the new dentist office did not accept the x-rays from the previous dentist. The Plan denied your 
request. The Plan says 1 comprehensive oral evaluation is covered every 3 plan years. The Plan says that 1 
complete series x-ray is covered every 3 plan years. The Plan also says that the frequency limits have 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. 
 
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of the dental services have not been met. The record shows that the Plan paid for a comprehensive 
oral evaluation and complete series x-ray that you received on April 14, 2021. Therefore, we decided that the 
Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete series x-ray (D0210) 
provided on April 21, 2021.  
 
Your complaint about the previous dental office is not a valid appeal for medical coverage. This part of your 
complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision 
about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more toward the periodontal scaling and root planing (D4341), 
pontic (D6240), retainer crown (D6750) and unspecified periodontal procedure (D4999) provided on May 17, 
2021. 
 
You asked the Plan to pay more toward the periodontal scaling and root planing (D4341), pontic (D6240), 
retainer crown (D6750) and unspecified periodontal procedure (D4999). You say that all the work has to be 
redone and you want to be refunded to fix the problem. You say that insurance should be put back on your 
account due to the poor work and stress. The Plan denied your request. The Plan says the claim 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, the Plan is only obligated to pay 50% 
of the cost for the periodontal scaling and root planing (D4341), pontic (D6240) and retainer crowns (D6750). 
The unspecified periodontal procedure (D4999) is not listed as a covered benefit. Therefore, we decided that 
the Plan does not have to pay more toward the periodontal scaling and root planing (D4341), pontic (D6240), 
retainer crown (D6750) and unspecified periodontal procedure (D4999) provided on May 17, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided by a physical therapist on 
March 26, 2020. You asked the Plan to pay for the physical therapy services. You say that the medical records required to 
reprocess the denied claim are attached. The Plan denied your request. The Plan says the records do not support 
the code billed. 
 
The Plan must follow Medicare rules. Medicare rules say that services of a physical therapist billed as services 
incident to a physician/non-physician practitioner's service must meet all incident requirements.   
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the physical therapy services have not been met. Specifically, the billing provider is a nurse 
practitioner. As such, physical therapy services cannot be paid incident to this provider's professional services. 
Therefore, we decided that the Plan does not have to pay for physical therapy services provided by a physical 
therapist on March 26, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a computed tomography (CT) scan (70450) provided on June
27, 2021.
You asked the Plan to pay for CT scan 70450. You say that you are appealing with records to support this level
of service. The Plan denied your request. The Plan says the denial of payment for this service is correct,
because code 70450 has a procedure-to-procedure (PTP) edit with code 70496 and is not separately payable
without an appropriate modifier.
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 CT scan 70450 is a column II code to column I code 70496. 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 a computed tomography (CT) scan (70450) provided on June 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on July 26, 
2021. 
 
You asked the Plan to pay for the dental service. You say that you were referred to this provider. You say that 
you required special x-rays. 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 limited oral evaluation is listed as 
covered, the frequency limit has been exceeded. The record shows that the Plan paid for a limited oral 
evaluation that you received on July 15, 2021. Therefore, we decided that the Plan does not have to pay for the 
limited oral evaluation (D0140) provided on July 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the implant (D6010) provided on July 2, 2021.
You asked the Plan to reimburse you for the dental services. You say that you called to confirm your dental benefits. You say that you were advised you could see any licensed provider in the United States. You also say that now you are being told that is false. The Plan denied your request. The Plan says the provider in this case has opted out of Medicare. The Plan also says that payment cannot be made for dental services performed by a dentist that has opted out of Medicare. dicare 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, dental services performed by a provider that hast opted out of Medicare are not among those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse you for the implant (D6010) provided on July 2, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital services you received
from October 25, 2020, to October 27, 2020.
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you cannot afford
this copayment. The Plan denied your request. The Plan says you were charged this copayment 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 $350
copayment per day for days 1-5 for inpatient hospital services.
Records show that you were in the hospital for two days. You were charged a $350 copayment per day, for a
total of $700, for these inpatient services. 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 inpatient
hospital services you received from October 25, 2020, to October 27, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for cardiovascular risk assessment testing provided on March 1, 2021.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered service.
The Plan must follow Medicare rules. Medicare rules say that coverage for all CV risk assessment panels, except the basic lipid panel, is denied for symptomatic (with signs and symptoms) patients with suspected or documented CV disease because panel testing is not specific to a given patient's lipid abnormality or disease.
We looked at the file and Medicare rules. Per LCD L36358, the requested cardiovascular risk assessment panel is not a covered service. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for cardiovascular risk assessment testing provided on March 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing amount for the scaling and root planing 
(D4341) for all four quadrants provided from January 20, 2021, to February 19, 2021. 
 
You asked the Plan to waive the cost sharing amount for the dental services. You say that you feel this should 
be covered. You say that this is a gum disease. You also say that it needs to be done. The Plan denied your 
request. The Plan says the claim was processed correctly. The Plan also says there is a 50% coinsurance for 
Class 2 Basic Services, including scaling and root planing. 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 services are listed as covered, 
there is a 50% coinsurance that applies. This is a contractual obligation you agreed to when you enrolled in the 
Plan's dental coverage. Therefore, we decided that the Plan does not have to waive the cost sharing amount for 
the scaling and root planing (D4341) for all four quadrants provided from January 20, 2021, to February 19, 
2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided by a physical therapist on 
February 27, 2020. You asked the Plan to pay for the physical therapy services. You say that plans are required to pay non-
contracted providers at the preferred provider rate if services are not available from preferred providers in the 
service area. You say that the in-network benefits should be honored, and the claim processed for payment. The 
Plan denied your request. The Plan says the records do not support the code billed. 
 
The Plan must follow Medicare rules say that services of a physical therapist billed as services incident to a 
physician/non-physician practitioner's service must meet all incident requirements.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the physical therapy services have not been met. Specifically, the billing provider is a nurse 
practitioner. As such, physical therapy services cannot be paid incident to this provider's professional services. 
Therefore, we decided that the Plan does not have to pay for physical therapy services provided by a physical 
therapist on February 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electronic connection (E2311), expandable controller harness (E2313) and expandable controller (E2377) for the enrollee.
You asked the Plan to pre-approve these items. You say that these items are medically necessary. The Plan denied your request. The Plan says that the member is be able to control the power options using their own switches.
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 items. Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. The documentation does not reveal that the patient requires other types of proportional input devices or non-proportional input devices. The patient does not need a separate display, other electronic devices, or an attendant control.
The wheelchair has multiple power options. The patient's strength of 5 out of 5 in the upper extremities and function with the ability to feed himself supports that the patient can control any power options through their own individual switches. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these items. 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 items have not been met. Therefore, we decided that the Plan does not have to pre-approve an electronic connection (E2311), expandable controller harness (E2313) and expandable controller (E2377) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Procrit (J0885).
You asked the Plan to pre-approve Procrit. You say that the requested treatment is a medical necessity for the enrollee. The Plan denied your request. The Plan says step therapy rules for the requested drug have not been met. dicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Procrit. Our reviewer says that the requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the requested medication is a new start. The provided records do not indicate that the enrollee has tried and failed the Plan's preferred step-one alternative, Retacrit. The record does not indicate that the enrollee has a contraindication to, or would have an adverse effect from, the Plan's preferred step-one alternative. The elements of the coverage criteria are not satisfied. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Procrit have not been met. Therefore, we decided that the Plan does not have to pre-approve treatment with Procrit (J0885).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve immunoglobulin heavy chain locus (IGH) genetic 
testing services. 
 
You asked the Plan to pre-approve IGH genetic testing services. You say that the medical records provided 
support the medical necessity of the requested genetic testing services. The Plan denied your request. The Plan 
says the information provided did not indicate that the requested IGH genetic test would be used to guide 
treatment decisions. 
 
The Plan follows Medicare rules. Medicare rules say that IGH genetic testing services are covered for certain 
clinical indications.  
 
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 IGH genetic testing services. Our 
reviewer says that the criteria for coverage have not been met. Our physician reviewer found the records 
indicate the enrollee does not have Acute Lymphoblastic Leukemia or B-cell lymphoma. The records indicate 
that the enrollee has Chronic Lymphoblastic Leukemia. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IGH genetic testing services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve immunoglobulin heavy chain locus (IGH) genetic testing services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral x-rays (D0220 and D0230) provided on June 17, 2021.
You asked the Plan to pay for the intraoral x-rays (D0220 and D0230). You say that the work performed was an annual exam, x-rays and partial cleaning. You say that you were advised these services were covered by the Plan and the denial should be re-evaluated. The Plan denied your request. The Plan says the services are not covered 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 intraoral x-rays (D0220 and D0230) provided on June 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for sedation services (99152) provided on January 17, 2021.
You asked the Plan to pay for sedation services. You say that this is supported in the records. The Plan denied your request. The Plan says this is not documented.
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 99152 is moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older. We find that CPT code 99152 is not supported in the medical record. Specifically, the submitted records do not document the presence of an independent trained observer. Based on this information, we decided that Medicare rules for coverage of sedation services have not been met. Therefore, we decided that the Plan does not have to pay for sedation services (99152) provided on January 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the out of network cost share for the oral exam (D0120) and prophylaxis (D1110) provided on May 5, 2021.
You asked the Plan to waive the out of network cost share for the dental services. You say that you received a bill from your dentist for the balance of your cleaning. You say that your benefit information indicates that there is a $0 copayment for these services in or out of network. You also say that these services should be covered. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan also says out of network providers may bill you for any amount greater than what the plan pays.
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 oral exam and prophylaxis are listed as covered, out of network providers may bill you for any amount greater than what the plan pays to them. Therefore, we decided that the Plan does not have to waive the out of network cost share for the oral exam (D0120) and prophylaxis (D1110) provided on May 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair.
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied
your request. The Plan says the enrollee is not on a ventilator, and there is no documentation of neurological
problems.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.
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 wheelchair. Our reviewer says that
the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found the
documentation does not support that your mobility deficit cannot be helped using a walker, cane, or manual
wheelchair, as you requested a smaller walker or a stroller to use inside the home at the office visit on 8/25/21.
There is no evidence of a high risk of a pressure ulcer/unable to perform a functional weight shift, utilization of
intermittent catheterization for bladder management, inability to transfer independently from wheelchair to bed,
or a need to increase tone or spasticity. The documentation is insufficient to demonstrate that the enrollee needs
the other accessories.
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 wheelchair have not been met. Therefore, we decided that the Plan does not
have to pre-approve a power wheelchair.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspiration for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says medical studies have not proven that this request is helpful.
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 the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found bone marrow aspiration remains experimental. More research is needed to show safety and efficacy when used as bone graft material in spine surgery. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve bone marrow aspiration for the enrollee.