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

 
We decided that the Plan does not have to pay for resin-based composite (D2335) and a first periapical 
radiographic image (D0220) provided on May 31, 2022. 
 
You asked the Plan to pay for the dental services. You say that you have been with the same dentist for over 30 
years. You also say that you are reluctant to invest your dental health to try a new dentist because he is a 
participating provider. 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 resin-based composite (D2335) and a first periapical radiographic image (D0220) provided on May 
31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150) and an 
extraction (D7210) provided by an oral surgeon. 
 
You asked the Plan to pre-approve the dental services. You say that you need these services done. The Plan 
denied your request. The Plan says dental services from an out-of-network provider 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. 
 
You are requesting 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. The referring provider is also out-of-network. Therefore, we decided that the 
Plan does not have to pre-approve a comprehensive oral evaluation (D0150) and an extraction (D7210) 
provided by an oral surgeon.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation services provided on December 14, 
2021, billed with code 99152. 
 
You asked the Plan to pay for the moderate sedation services as billed. You say that these services should be 
paid due to medical necessity. The Plan denied your request. The Plan says the surgical services were approved 
for payment; however, 99152 cannot be paid as the note does not show the presence of an independent 
observer. 
 
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 code requires the 
presence of an independent observer which is not documented in the procedure note. Based on this information, 
we decided that Medicare rules for coverage of the moderate sedation services as billed have not been met. 
Therefore, we decided that the Plan does not have to pay for the moderate sedation services provided on 
December 14, 2021, billed with code 99152.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a dental crown (D2740), provisional crown (D2799), and 
core buildup (D2950) provided on July 19, 2021. 
 
You asked the Plan to pay for the dental services. You say that the Plan was supposed to pay for this. The Plan 
denied your request. The Plan says your benefit for the requested dental crown has already been exhausted, and 
the provisional crown and core buildup are not covered by the Plan's 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, certain limitations apply. The record 
shows your benefit for the requested crown was exhausted on date of service July 19, 2021 as the Plan covered 
one of the crowns provided at this visit. Additionally, the provisional crown and core buildup provided are not 
covered by the Plans dental benefits. Therefore, we decided that the Plan does not have to pay for a dental 
crown (D2740), provisional crown (D2799), and core buildup (D2950) provided on July 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an extraction (D7210). 
 
You asked the Plan to pre-approve an extraction. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says an extraction (D7210) is not covered by your 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 pre-approve an 
extraction (D7210).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional trips for routine transportation beyond the 
Plan's 36-trip limit. 
 
You asked the Plan to pre-approve additional routine transports. You say that you need additional 
transportation to dialysis treatments. The Plan denied your request. The Plan says you have exhausted your 
transportation benefit. 
 
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 36 trips per year.  
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional trips for routine transportation beyond the Plan's 
36-trip limit.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pre-approve JAK2 (Janus kinase 2) targeted sequence analysis (81279). 
 
You asked the Plan to pre-approve genetic testing. You say that the enrollee did a sleep study, but genetic 
testing is needed to rule out polycythemia vera. The Plan denied your request. The Plan says that the enrollee's 
clinical condition does not meet criteria for genetic testing. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 genetic testing. Our reviewer says that 
the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found is documented that an erythropoietin level was normal. A JAK2 V617F mutation was not 
detected. On 7/20/22, the enrollee was seen in follow-up regarding erythrocytosis. It is documented that it was 
most likely that the erythrocytosis is secondary in nature and could be in the setting of possible sleep apnea, for 
which he was awaiting sleep study. The analysis of the specific gene sequences of the JAK2 (Janus kinase 2) 
gene, such as exons 12 and 13, which may be associated with myeloproliferative neoplasms (MPN) in JAK 2 
V617F-negative patients, is determined to be reasonable and necessary for the enrollee in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genetic testing have been met. Therefore, we decided that the Plan has to pre-
approve JAK2 (Janus kinase 2) targeted sequence analysis (81279).  
 
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: 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 the requested spinal cord 
stimulator is medically necessary. The Plan denied your request. The Plan says you do not meet Medicare 
criteria for the requested spinal cord stimulator trial. 
 
The Plan must follow Medicare rules. The rules say that a spinal cord stimulator trial can be covered only for 
patients who have undergone careful screening, evaluation and diagnosis by a multidisciplinary team prior to 
implantation. Such screening must include a psychological evaluation.  
 
The file does not show that a psychological evaluation has been conducted in conjunction with this request for 
a spinal cord stimulator trial. Therefore, we decided that the Plan does not have to pre-approve a spinal cord 
stimulator trial.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to reimburse you for the crown (D2740) provided on January 6, 2022. 
 
You asked the Plan to reimburse you for the crown (D2740). You say that you are appealing the denial of the 
dental claim. You say you are owed $1,000 for your 2022 dental allowance and you did not receive it. The Plan 
denied your request. The Plan says that the claim was paid correctly. 
 
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.  
 
We looked at the Medicare rules. Based on this information, we find that based on the language of your 
contract, you had a reasonable expectation that reimbursement would be made for the services at issue. 
Standard billing practice for dental services would support that payment for a crown would be made only on 
the date of preparation. However, this was not billed directly by the dental provider, but rather payment was 
made out-of-pocket, and reimbursement was requested.  
 
You were reimbursed up to the annual maximum for the amount that you paid for the crown and other dental 
services in 2021, but you did receive a dental service (placement of the crown) in 2022, for which you paid, at 
a time when your 2022 dental benefit was active and had not been exhausted. As such, we find that the Plan is 
obligated to reimburse you for this cost under your 2022 dental benefit, up to the annual maximum. Therefore, 
we decided that the Plan has to reimburse you for the crown (D2740) provided on January 6, 2022.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Baxter NanoBone Allograft (CPT code 20939) and bone 
marrow aspirate (20930 X 2). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the clinical value and effectiveness of the Baxter NanoBone Allograft and Bone Marrow 
Aspirate grafts in the setting of spinal fusion surgery have 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 the services. 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 specific indication provided to support the request for bone marrow aspirate or bone 
allograft for the approved surgery. There is a lack of large-volume, long-term peer-reviewed outcome studies to 
support the use of bone marrow aspirate and allograft for this enrollees medical condition as discussed above. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity 
of this request as an exception. Therefore, the requested Baxter NanoBone allograft and bone marrow aspirate 
grafts in the setting of spinal fusion surgery, in this case, is not medically reasonable or 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Baxter NanoBone Allograft (CPT code 20939) and bone marrow aspirate (20930 X 2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildups, including any pins when required 
(D2950) for tooth #'s 2 and 5 and crowns (D2740) for tooth #'s 2 and 5. 
 
You asked the Plan to pre-approve the core buildups and crowns. The Plan denied your request. The Plan says 
the documentation provided does not demonstrate that there is pathologic destruction to the teeth by caries or 
trauma involving three or more surfaces and at least one cusp. The Plan also says that core buildups are not 
covered under the 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. The Plan covers the core 
buildups and crowns when the services are medically necessary and reasonable.  
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the core buildups and crowns. Our 
reviewer says that crowns for tooth #'s 2 and 5 are not medically reasonable and necessary. Our physician 
reviewer found the provided x-rays show minimally restored tooth #'s 2 and 5. There is no indication of any 
recurrent or new decay present on either tooth. Our reviewer found in order to be considered for crowns, teeth 
must show substantial structural loss such that a full coverage restoration is needed to add support to the tooth. 
Our physician reviewer also found that in this instance, tooth #'s 2 and 5 both have small existing restorations 
and do not demonstrate significant structural damage as to require a crown. 
 
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 core buildups and crowns have not been met. Therefore, we decided that the 
Plan does not have to pre-approve core buildups, including any pins when required (D2950) for tooth #'s 2 and 
5 and crowns (D2740) for tooth #'s 2 and 5.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies 
(K0553, K0554). 
 
You asked the Plan to pre-approve a CGM and supplies. You say that additional medical records have been 
submitted to show medical necessity. The Plan denied your request. The Plan says the enrollee does not meet 
coverage criteria for approval of the CGM and supplies. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections or require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of a CGM and 
supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor (CGM) and supplies (K0553, K0554).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve A ceramic retainer, custom fabricated abutment, and a 
surgical placement of implant body (D6075, D6010, D6057) 
 
You asked the Plan to pre-approve the ceramic retainer, custom fabricated abutment, and a surgical placement 
of implant body. You say that the services should be covered as you disagree with the denial. The Plan denied 
your request. The Plan says the services denied correctly as they do not fall within your 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 pre-approve A 
ceramic retainer, custom fabricated abutment, and a surgical placement of implant body (D6075, D6010, 
D6057)
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a removable unilateral partial denture (D5284) provided 
by a participating provider. 
 
You asked the Plan to pre-approve the dental services. You say that you would like the Plan to approve these 
services. 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 Plans 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 November 6, 2021. 
Therefore, we decided that the Plan does not have to pre-approve a removable unilateral partial denture 
(D5284) provided by a participating 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. You say that the enrollee due to medical needs would benefit from 
IRF. The Plan denied your request. The Plan says the request is not medically necessary; the enrollee can safely 
receive the services they need in other settings. 
 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollees medical problems are stable and there are no complex nursing or rehabilitation needs. There is no documented need for intensive rehabilitation services and medically necessary 
care can be provided in a different 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the vitrectomy chair (E1399) purchased February 
23, 2022. 
 
You asked the Plan to reimburse you for the vitrectomy chair. You say that you had detached retina surgery 
and this chair was essential to your recovery. The Plan denied your request. The Plan says the services was 
rendered by a provider who is not certified with Medicare. If you go to a provider who is not eligible to 
participate in Medicare, you will be responsible for the full cost of the services you receive. 
 
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 reimburse you for the vitrectomy chair (E1399) 
purchased February 23, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the paring or cutting of benign hyperkeratotic lesion (eg, 
corn or callus) (11055) provided June 29, 2022. 
 
You asked the Plan to pay for the foot care services. You say that you have a corn on your foot. It gets big and 
it hurts to put shoes on and to walk. You cannot remedy the corn on your own. The Plan denied your request. 
The Plan says this service is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that routine foot care is not covered. The only exception is 
for those who have a condition that results in severe loss of circulation or areas of poor sensation in the legs or 
feet or have fungal nails.  
 
Records do not show that any of these conditions are present. The services you are asking the Plan to pay for 
are routine foot care services. Based on this information, we decided that Medicare rules for coverage of the 
foot care services have not been met. Therefore, we decided that the Plan does not have to pay for the paring or 
cutting of benign hyperkeratotic lesion (eg, corn or callus) (11055) provided June 29, 2022.