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

 
We decided that the Plan does not have to pay for the bone replacement graft (D7953) and placement of intra-
socket biological dressing (D7922) provided on October 27, 2021. 
 
You asked the Plan to pay for the dental services. You say that the need for a bone graft was discovered when 
the extraction was performed. You also say that the provider did not tell you it was not a covered service. The 
Plan denied your request. The Plan says the bone graft and placement of intra-socket biological dressing 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, the bone replacement graft and 
placement of intra-socket biological dressing are not among those covered under this benefit. The record shows 
that you signed a financial agreement acknowledging responsibility for services not covered. Therefore, we 
decided that the Plan does not have to pay for the bone replacement graft (D7953) and placement of intra-
socket biological dressing (D7922) provided on October 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pontic (D6245) provided on December 9, 2021. 
 
You asked the Plan to pay for the pontic. You say that you do not understand why this service is not covered 
but an implant is. The Plan denied your request. The Plan says this service is not covered by the 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 pay for the pontic 
(D6245) provided on December 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device. 
 
You asked the Plan to pre-approve the requested device. The Plan denied your request. The Plan says the 
enrollee has not had a trial of an E0650 or E0651 pump. 
 
The Plan follows Medicare rules. Medicare rules say that pneumatic compression devices are only covered 
under certain medical 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 the requested device. Our physician 
reviewer found that the enrollee is diagnosed with recurrent urothelial carcinoma with extensive metastatic 
adenopathy and related lymphedema. A pneumatic compression device w/cal pressure, coded E0652, was 
requested. However, the provided records did not clearly show the enrollee having tried an  E0650 or E0651 
pump or had a contraindication to such to meet criteria for coverage for this item at this time. 
 
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 device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a pneumatic compression device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional supplies and/or clinical staff time required due 
to COVID-19 provided on December 20, 2021, billed with code 99072. 
 
You asked the Plan to pay for the additional supplies and/or clinical staff time. You say that these services 
should be paid due to medical necessity. The Plan denied your request. The Plan says the office visit charge 
was paid; however, separate payment is not allowed for code 99072. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
Code 99072 has a status indicator of "B" on the Medicare Physician Fee Schedule. This means that payment for 
this service is bundled into payment for other services. Based on this information, we decided that Medicare 
rules for coverage of the additional supplies and/or clinical staff time have not been met. Therefore, we decided that the Plan does not have to pay for the additional supplies and/or clinical staff time required due to COVID-19 provided on December 20, 2021, billed with code 99072.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous positive airway pressure (CPAP) device. 
 
You asked the Plan to pay for a CPAP device. You say that this claim should be reprocessed with the 
appropriate cost share applied. The Plan denied your request. The Plan says this provider is not certified with 
Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for a continuous positive airway pressure 
(CPAP) device.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an inpatient admission and stay. 
 
You asked the Plan to pre-approve an inpatient admission and stay. You say that you cannot perform daily 
activities because of the pain you are in and need the surgery right away. The Plan denied your request. The 
Plan says there is no documentation provided to support the expectation you will require a greater than 2 
midnight stay. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
 
  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 inpatient admission and stay. Our 
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this 
case. Our physician reviewer found the record indicates that you are scheduled for a shoulder arthroplasty. Our 
reviewer found that the record does not document that the treating physician has a reasonable expectation of a 
length of stay spanning 2 or more midnights. Our physician reviewer also found that you may be admitted for 
observation. 
 
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 inpatient admission and stay have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an inpatient admission and stay.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mass spectrometry testing provided on July 6, 2021, 
billed with code 83789. 
 
You asked the Plan to pay for the mass spectrometry testing. You say that this was medically necessary drug 
testing which should be reimbursed. The Plan denied your request. The Plan says the drug testing itself was 
approved for payment; however, the code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
We looked at the file and Medicare rules. The services described by code 83789 are considered specimen 
validity testing which cannot be separately paid. Based on this information, we decided that Medicare rules for 
coverage of the mass spectrometry testing have not been met. Therefore, we decided that the Plan does not 
have to pay for the mass spectrometry testing provided on July 6, 2021, billed with code 83789.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing services provided from October 23, 2021, 
to November 7, 2021. 
 
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required 
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee's 
condition no longer required daily skilled services at an inpatient skilled nursing facility level of care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the skilled nursing services. Our reviewer 
says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the 
enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment 
of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the 
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily 
skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the skilled nursing services have not been met. Therefore, we decided that the 
Plan does not have to pay for the skilled nursing services provided from October 23, 2021, to November 7, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve dental implants (D6010) for teeth #24 and #25. 
 
You asked the Plan to pre-approve the implants. You say that the enrollee requires these teeth to be extracted 
and replaced with implants in order for her partial denture to be used. The Plan denied your request. The Plan 
says that they have agreed to pre-approve implants for teeth #23 and #26; however, the Plan can only approve 
one implant (D6010 or D6013) per patient per quadrant per lifetime. 
 
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 denied coverage of implants for teeth #24 and #25, as they approved implants for teeth #23 and #26. 
The Plan states that there is an allowance of one of (D6010, D6013) per lifetime, per patient, per quadrant. 
However, in this case the Evidence of Coverage (EOC) limits this service to one implant per tooth per lifetime. 
Consequently, the Plan's denial is in conflict with the EOC, which is the official contract with 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 implants. Our reviewer says that the 
requested implants are medically reasonable and necessary. Our physician reviewer found the enrollee 
currently has a bottom partial denture. It is documented that the two teeth that are now holding the partial in are 
very mobile, and do not allow the denture to stay in correctly. This is affecting the enrollee's chewing 
capabilities and is causing sores. The dental services in this case are reasonable and 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 implants have been met. Therefore, we decided that the Plan has to pre-
approve dental implants (D6010) for teeth #24 and #25.  
 
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: 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. The Plan denied your request. The Plan says the records do not 
show that you can do 3 or more hours per day of skilled therapy at least 5 days per week. The Plan also says 
that your continued care could be better provided at an alternative level of care such as an outpatient or sub-
acute rehabilitation facility or skilled nursing facility setting. 
 
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 your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer found that 
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. Our physician reviewer 
also found that 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. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Bioventus OsteoAmp Allograft for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that this is medically necessary. The Plan denied 
your request. The Plan says that the clinical value and effectiveness of the Bioventus OsteoAmp Allograft for 
use in spine surgeries has not been demonstrated in the peer-reviewed literature. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. There is limited 
published, large-scale, long-term peer-reviewed literature that shows this request to be an effective and/or safe 
treatment for the noted pathology.  
There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity 
of this request as an exception to guidelines. Our physician reviewer found that the enrollee's condition does 
not meet criteria for coverage of these services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Bioventus OsteoAmp Allograft for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mandibular partial denture (D5212). 
 
You asked the Plan to pre-approve a mandibular partial denture. You say that you lost your lower denture and 
need it to chew and keep your teeth from shifting. The Plan denied your request. The Plan says this service is 
allowed one time every 60 months. The Plan also says that you had this service less than 60 months ago. 
 
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, dentures are limited to once every 60 
months. The record shows that you received a mandibular partial denture (D5212) on December 21, 2020 and 
your mandibular denture benefit has been exhausted. Therefore, we decided that the Plan does not have to pre-
approve a mandibular partial denture (D5212).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custom fabricated abutments (D6057) and abutment 
supported porcelain/ceramic crowns (D6058). 
 
You asked the Plan to pre-approve custom fabricated abutments and abutment supported porcelain/ceramic 
crowns. You say that you cannot eat properly because you cannot chew. The Plan denied your request. The 
Plan says these services are not covered under 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 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 
custom fabricated abutments (D6057) and abutment supported porcelain/ceramic crowns (D6058).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prefabricated abutments (D6056) and implant supported 
porcelain/ceramic crowns (D6065). 
 
You asked the Plan to pre-approve the prefabricated abutments and implant supported porcelain/ceramic 
crowns. You say that you have crews in your mouth and no implants where the screws were placed, and the job 
was not completed. You also say that you cannot eat or live properly with screws where your teeth used to be 
and no implants. The Plan denied your request. The Plan says these services are not covered under 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 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 
prefabricated abutments (D6056) and implant supported porcelain/ceramic crowns (D6065).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial lower denture (D5214). 
 
You asked the Plan to pre-approve a partial lower denture. You say that you have not had this service and 
disagree with the denial. The Plan denied your request. The Plan says you previously received an immediate 
lower denture on February 15, 2022, which was covered by the Plan at that time. Your dental benefit covers 
one removable denture per arch every five years. 
 
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 
removable denture per arch every five years. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the lower denture is requested in a 
frequency that is not covered under this benefit. The documentation shows that the Plan covered a different 
kind of partial denture for this same arch in February 2022. Therefore, we decided that the Plan does not have 
to pre-approve a partial lower denture (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prophylaxis (D1110) provided on December 7, 2021. 
 
You asked the Plan to pay for the prophylaxis. You say that due to your receding gums, you are more 
vulnerable to tooth decay and gum disease. You also say that you should have the benefit of four professional 
cleanings, two with the basic plan and two with the enhanced dental plan. The Plan denied your request. The 
Plan says prophylaxes (cleanings), including periodontal prophylaxes, are payable twice per calendar year. The 
Plan also says that you purchased the enhanced dental package which does not include additional cleanings. 
 
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, you are limited to two cleanings. The 
record shows that you received cleanings on March 24, 2021, and August 2, 2021 and your cleanings benefit 
has been exhausted. Being enrolled in the enhanced dental plan does not include extra cleanings. Therefore, we 
decided that the Plan does not have to pay for the prophylaxis (D1110) provided on December 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a grabber and spray bottle. 
 
You asked the Plan to pre-approve a grabber and spray bottle. You say that these items are medically 
necessary. The Plan denied your request. The Plan says these items are not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a grabber and spray bottle.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a replacement of an implant (D6091) provided by a 
participating provider on December 7, 2021. 
 
You asked the Plan to pay for a replacement of an implant. You say that this is for your denture, not an implant. 
The Plan denied your request. The Plan says D6091 is not a covered dental benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a 
replacement of an implant (D6091) provided by a participating provider on December 7, 2021.