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

 
We decided that the Plan does not have to pay for the crown (D2740) and sales tax (D9985) provided on March 
9, 2022. 
 
You asked the Plan to pay for the crown and sales tax. You say that you would like a refund for the 
unacceptable crown that was provided. You also say that you would like the coverage to be applied to the 
replacement crown. The Plan denied your request. The Plan says your crowns benefit has been satisfied and the 
frequency limitation has been exceeded. The Plan also says that tax is not paid when the rendering services are 
not paid. 
 
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, sales tax is not covered under this 
benefit. The record shows that you received a crown (D2740) on January 27, 2022, and your crowns benefit has 
been exhausted. Therefore, we decided that the Plan does not have to pay for the crown (D2740) and sales tax 
(D9985) provided on March 9, 2022.  
 
Your complaint about the unacceptable crown you received 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient gastroenterological procedure 
provided on February 22, 2022. 
 
You asked the Plan to waive the copayment for an outpatient GI procedure. You say that this copayment is too 
large and that you did not have a procedure. The Plan denied your request. The Plan says the copayment 
applied was correct. 
 
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 $315 
copayment for outpatient surgery.  
 
You have been asked to pay a $315 copayment for an outpatient GI procedure. An outpatient GI procedure falls 
within the Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and 
Ambulatory Surgical Centers 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 an 
outpatient gastroenterological procedure provided on February 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a vertical pylon feature. 
 
You asked the Plan to pre-approve the requested item. You say that the pylon helps protect the enrollee's 
residual limb from impact forces.  The Plan denied your request. The Plan says the upgraded system exceeds 
the enrollee's needs. 
 
The Plan must follow Medicare rules. Medicare rules say that lower limb prostheses are only covered under 
certain medical indications. 
 
The file shows that a vertical shock reducing pylon feature (L5988) was requested. We looked at the file and 
Medicare rules. The pylon feature was not requested in combination with a complete prosthetic foot. Based on 
this information, we decided that Medicare rules for coverage of the requested item have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a vertical pylon feature.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on December 10, 
2021, and an extraction (D7140) and deep sedation (D9222) provided on January 12, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says these dental services are not covered. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) 
provided on December 10, 2021, and an extraction (D7140) and deep sedation (D9222) provided on January 
12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the power seat elevation system (E2300) attendant 
control (E2331) contoured hand pads (K0108), the microlight (K0108) mini cup (K0108) and egg switches and 
their mounting hardware and/or cables (K0108) the control module display and hardware (K0108) the calf 
panels (K0108) the attendant control mounting hardware (K0108) and the sip and puff mounting hardware 
(K0108). 
 
You asked the Plan to pre-approve the wheelchair accessories. You say that all of the items listed are essential 
to the function of the power char and to the enrollee's overall safety and independence. The Plan denied your 
request. The Plan says these items do not service a primary medical purpose or is unbundled and cannot be 
separately requested. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The seat elevator does not serve a primary medical purpose and 
cannot be approved. The attendant control cannot be approved in addition to the approved member operated 
control (sip and puff). The contoured hand pads do not serve a primary medical need and standard pads are 
included with the approved arm troughs (forearm supports). The microlight, mini cup, and egg switches and 
their mounting hardware and/or cables and the control module display and hardware are covered under the 
approved enhanced electronics and cannot be separately requested. The calf panels would be covered as part of 
the approved basic power wheelchair and cannot be separately requested. The attendant control mounting 
hardware would be covered under the attendant control itself and cannot be separately requested and similarly 
for the sip and puff mounting hardware as it is covered under the approved sip and puff member operated 
control and cannot be separately requested.  Based on this information, we decided that Medicare rules for 
coverage of the wheelchair accessories have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the power seat elevation system (E2300) attendant control (E2331) contoured hand pads (K0108), 
the microlight (K0108) mini cup (K0108) and egg switches and their mounting hardware and/or cables 
(K0108) the control module display and hardware (K0108) the calf panels (K0108) the attendant control 
mounting hardware (K0108) and the sip and puff mounting hardware (K0108).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says that the requested admission to an IRF does not meet 
criteria. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found clinical documentation shows that the enrollee has multiple active comorbidities which would require 
close medical supervision on an inpatient basis. Evaluating therapists state that the enrollee would tolerate and 
significantly benefit from intense therapy (PT, OT and SLP) thus IRF criteria has been met and is medically 
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 IRF care have been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional non-emergent routine transportation trips 
(A0120). 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you need additional trips 
because you had knee surgery and you cannot afford to pay an Uber to visit your provider. The Plan denied 
your request. The Plan says additional trips would exceed your benefit limit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 48 one-way trips per year.  
 We looked at your request, the records in the case file, and the rules. The records show that you have used 
forty-seven (47) one-way transportation trips out of the allowed forty-eight (48) one-way trips approved. Once 
48 trips are used, the benefit will be exhausted. Based on this information, we decided that the Plans rules for 
coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-
approve additional non-emergent routine transportation trips (A0120).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ultrasound on February 09, 2022. 
 
You asked the Plan to waive the copayment for ultrasound. You say that you are appealing because even 
though you did have the tests done you said they were not necessary after false reading from previous tests that 
caused you to have this ultrasound. You feel you should not be liable for this due to the mistake. The Plan 
denied your request. The Plan says the cost-sharing you are being charged is correct. 
 
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 $125 
copayment for Medicare-covered radiological diagnostic services, not including X-rays, performed in a 
physicians office or at a free-standing facility (such as a radiology center or medical clinic). Other outpatient 
diagnostic tests - Radiological diagnostic services, not including x-rays. The provider billed in the amount of 
$990 and the allowed amount is $111.17, which is less than the copayment amount. Therefore, results in the 
total cost-sharing amount of $111.17. You have been asked to pay a $111.17 copayment, which is less than the copayment for ultrasound. Ultrasound 
falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies 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 ultrasound on February 09, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eylea (J0178). 
 
You asked the Plan to pre-approve Eylea. You say that this drug is medically necessary. The Plan denied your 
request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Eylea. Our reviewer says that this drug 
is not medically necessary. Our physician reviewer found there is insufficient support in the compendia or in 
clinical research that appears in a CMS-approved medical journal for the use of Eylea (Aflibercept) for the 
treatment of vitreous hemorrhage in the eye. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Eylea have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Eylea (J0178).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Ossur Proprio microprocessor-controlled ankle foot 
system coded as L5973. 
 
You asked the Plan to pre-approve the requested type of microprocessor ankle foot. You say that you feel that 
this type of foot would be ideal because it will allow you to perform many of the activities that you have not been able to with your current foot. The Plan denied your request. The Plan says there is not clear 
documentation in the physician's medical notes to support the need for this type of foot over other components. 
 
The Plan follows Medicare rules. Medicare rules say that the type of foot described by code L5973 is covered 
when reasonable and necessary for level 3 ambulators.  
 
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 requested type of microprocessor 
ankle foot. Our reviewer says that the documentation does not support the medical necessity of the requested 
type of ankle foot system. Our physician reviewer found the enrollee is noted to now be a level 3 ambulator, 
but the treating medical provider documentation does not indicate extenuating factors that require the Proprio 
Foot which is a microprocessor foot over a standard mechanical level 3 foot. The Proprio Foot exceeds the 
patient's medical need based on the current medical documentation. 
 
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 requested type of microprocessor ankle foot have not been met. Therefore, 
we decided that the Plan does not have to pre-approve the Ossur Proprio microprocessor-controlled ankle foot 
system coded as L5973.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two osseous surgeries (D4261 x2) provided on March 29, 2022. 
 
You asked the Plan to pay for the osseous surgeries. You say that you had a deep scaling last September 2021, 
and this is just an extension of that. You also say that there were two areas that did not do well even with the 
scaling, and you believe these services should be covered. The Plan denied your request. The Plan says this 
service is not a covered benefit under your dental 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, 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 two 
osseous surgeries (D4261 x2) provided on March 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection between wheelchair controller 
and two or more power seating system motors. 
 
You asked the Plan to pre-approve an electronic connection between wheelchair controller and two or more 
power seating system motors. You say that you would like the plan to reconsider their denial. The Plan denied 
your request. The Plan says the enrollee does not meet criteria for the requested item. 
 
The Plan must follow Medicare rules. Medicare rules say that an electronic connection is only covered for 
certain indications. 
 
We looked at the file and Medicare rules. Review of the file shows that the requested power tilt and recline and 
the leg elevation feature include switch controls and the enrollee is able to operate the switch controller, the 
requested expandable controller (electronic connection) is not necessary. There is no documentation in the file 
showing that the enrollee would need to operate these power options through the joy stick. Based on this 
information, we decided that Medicare rules for coverage of an electronic connection between wheelchair 
controller and two or more power seating system motors have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an electronic connection between wheelchair controller and two or more 
power seating system motors.
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 of intraoral x-rays (D0210) provided on February 10, 2022. 
 
You asked the Plan to pay for the dental services. You say that you did not know x-rays are only covered once 
every three years. The Plan denied your request. The Plan says your benefit for the requested item or service 
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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service October 27, 2021.  
 
Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and 
complete series of intraoral x-rays (D0210) provided on February 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantation of a bi-ventricular pacemaker (33208, 
33225). 
 
You asked the Plan to pre-approve an implantation of a bi-ventricular pacemaker. You say that the requested 
procedure is medically necessary. The Plan denied your request. The Plan says the requested procedure does 
not meet criteria. 
 
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 an implantation of a bi-ventricular 
pacemaker. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found there is no history of documented, non-reversible, 
symptomatic bradycardia for which a pacemaker has been indicated. There is no documentation of severe left 
ventricular dysfunction. In summary, there is insufficient documentation to support the medical necessity for 
implantation of a bi-ventricular pacemaker. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an implantation of a bi-ventricular pacemaker have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an implantation of a bi-ventricular pacemaker (33208, 
33225).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service March 16, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
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 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 procedure code 70450 billed for date of service March 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oral hygiene instructions (D1330) provided on March 17, 
2022, and March 18, 2022.  
 
You asked the Plan to pay for hygiene instructions. You say that the services were medically necessary. The 
Plan denied your request. The Plan says oral hygiene instructions (D1330) are not covered by your routine 
dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for oral 
hygiene instructions (D1330) provided on March 17, 2022, and March 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), prophylaxis (D1110), 
and bitewings x-rays (D0274) provided on April 18, 2022. 
 
You asked the Plan to pay for the dental services. You say that you refused to go back to your old dentist, and 
you needed to find a new one. The Plan denied your request. The Plan says the dental services were received 
from an out-of-network provider and are not covered by your supplemental 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. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a periodic oral evaluation (D0120), prophylaxis (D1110), and bitewings x-rays (D0274) provided on 
April 18, 2022.