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

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), bone replacement graft for ridge preservation (D7953), deep sedation/general anesthesia services (D9222 and D9223), surgical extraction (D7210), and simple extraction (D7140) provided on December 1, 2021, and December 30, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the problem focused limited oral evaluation, bone replacement graft, deep sedation/general anesthesia services, surgical extraction, and simple extraction. You say that you went to this OON provider because you were in excruciating pain and the other dentist could not render the procedures. The Plan denied your request. The Plan says the problem focused limited oral evaluation, bone replacement graft, and deep sedation/general anesthesia services are not covered expenses under your dental plan.
The Plan also says that services performed by an OON provider are not covered because your healthcare plan does not have OON 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 problem focused limited oral evaluation (D0140), bone replacement graft for ridge preservation (D7953), and deep sedation/general anesthesia services (D9222 and D9223) are not among those covered under this benefit. The contract also says that you are responsible for 100% of the cost for dental services rendered by an OON provider. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), bone replacement graft for ridge preservation (D7953), deep sedation/general anesthesia services (D9222 and D9223), surgical extraction (D7210), and simple extraction (D7140) provided on December 1, 2021, and December 30, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bone replacement graft (D7953) provided by a network 
provider on January 17, 2022. 
 
You asked the Plan to pay for the bone replacement graft (D7953). You say that you were assured that 
extractions and any related necessary medical procedures were covered. The Plan denied your request. The 
Plan says the service is not a covered benefit. The Plan also says an outreach was made to the provider and they 
confirmed that they will write off the $500 charge for the bone graft. 
 
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 bone replacement graft (D7953) is 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
bone replacement graft (D7953) provided by a network provider on January 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lumbar transforaminal epidural steroid injection (ESI). 
 
You asked the Plan to pre-approve the ESI. You say that this should be approved due to medical necessity. The 
Plan denied your request. The Plan says ESIs are limited to four per spinal region per rolling 12 months. 
 
The Plan must follow Medicare rules. Medicare rules say that coverage for ESIs is limited to no more than 4 
per spinal region per rolling 12-month period.  
 
We looked at the file and Medicare rules. Beginning on June 30, 2021, you have received four lumbar ESI 
injections. Another ESI cannot be covered until after June 30, 2022. Based on this information, we decided that 
Medicare rules for coverage of the ESI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a lumbar transforaminal epidural steroid injection (ESI).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on October 19, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are not 
separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that carriers may not pay for the technical component 
(TC) of radiology services furnished to hospital patients.  
 
We looked at the file and Medicare rules. In this case, the non-physician practitioner is not payable for the technical component for these services. 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 pay for the services 
provided on October 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99213), the therapeutic, prophylactic, or 
diagnostic injection (96372), and the unclassified drug injection (J3490) rendered by the out-of-network (OON) 
provider on December 13, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without prior authorization. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. 
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the office visit (99213), the therapeutic, prophylactic, or diagnostic injection 
(96372), and the unclassified drug injection (J3490) rendered by the out-of-network (OON) provider on 
December 13, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chest x-ray rendered on January 31, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable. 
 
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 71045 is a column II code to column I code 36556. 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 the chest x-ray 
rendered on January 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the occlusal guard (D9944) provided on October 7, 2021. 
 
You asked the Plan to pay for the dental item. You say that this item is used for sleep apnea. You also say that 
you feel it should not be considered a dental service. The Plan denied your request. The Plan says the claim 
denied 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.  
Though the Plan offers a dental benefit in excess of Medicare coverage, the occlusal guard is not among those 
covered under this benefit. Additionally, the item you are asking the Plan to pay for involves 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 the occlusal guard (D9944) provided on October 7, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on September 20, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the 
Plan does not have to pay for the laboratory services rendered on September 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the filling (D2332) for tooth # 27 provided on February 15, 2022. 
 
You asked the Plan to pay for the dental service. You say that you do not believe that you have ever had that 
tooth worked on. 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 and fillings are listed as covered, the 
record shows that the Plan paid for a filling for tooth # 27 that you received on November 9, 2021. 
Therefore, we decided that the Plan does not have to pay for the filling (D2332) for tooth # 27 provided on February 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve laboratory services from an out-of-network provider. 
 
You asked the Plan to pre-approve these services. You say that you are in a facility and unable to go to another 
provider. The Plan denied your request. The Plan says the services are available from network providers. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
laboratory services from an out-of-network provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service February 17, 
2022. 
 You asked the Plan to pay for procedure code 76705. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for 
code 93976. 
 
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 76705 
is a column II code to column I code 93976. 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 76705 billed for date of service February 17, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and 
surgical extractions (D7210) of tooth #'s 1, 6, and 11 provided on January 19, 2022. 
 
You asked the Plan to pay for the problem focused limited oral evaluation and surgical extractions of tooth #'s 
1, 6, and 11. You say that you were told you had $2,000 per year to use for dental work. The Plan denied your 
request. The Plan says your problem focused limited oral evaluation and surgical extraction benefits have been 
satisfied and the frequency limitations 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 Plans coverage rules apply in this case. 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, emergency diagnostic exam is limited 
to 1 procedure code per calendar year. The record shows that you received a problem focused limited oral 
evaluation (D0140) on January 4, 2022 and your emergency diagnostic exam benefit has been exhausted. The 
contract also says that extractions are limited to 2 procedure codes per calendar year, and you must pay a $25 
copayment for each covered extraction. The record shows that you received a surgical extraction (D7210) of 
tooth #7 on January 4, 2022 and a surgical extraction (D7210) of tooth #5 on January 19, 2022. You were only 
held responsible for the $25 copayments for each of these extractions, and your extractions benefit has been 
exhausted. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral 
evaluation (D0140) and surgical extractions (D7210) of tooth #'s 1, 6, and 11 provided on January 19, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Opdivo. 
 
You asked the Plan to pre-approve Opdivo. You say that  The Plan denied your request. The Plan says the 
requested drug is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that routine costs associated with a clinical trial are 
not payable by the Plan. 
 
We looked at the file and Medicare rules. Review of the file shows that the enrollee is enrolled in a clinical 
trial. Based on this information, we decided that Medicare rules for coverage of Opdivo have not been met. 
Therefore, we decided that the Plan does not have to pre-approve Opdivo.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that additional routine 
transportation trips are necessary for you. The Plan denied your request. The Plan says the benefit for routine 
transportation has been exhausted. 
 
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 20 one-way 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 routine transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Proton Beam Radiation Treatment Delivery. 
 
You asked the Plan to pre-approve Proton Beam Radiation Treatment Delivery. The Plan denied your request. 
The Plan says based on Medicare guidelines, the Proton Beam Radiation Therapy you and/or your provider are 
requesting does not meet the requirements for approval. 
 
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 Proton Beam Radiation Treatment 
Delivery. Our reviewer says that the requested Proton Beam Radiation Treatment Delivery is not considered 
medically reasonable and necessary in this case. Our physician reviewer found that to date, there are no 
compelling data to suggest that proton therapy is superior to or more beneficial than IMRT/IGRT. The 
generally accepted standard of care for prostate cancer is to only offer proton beam therapy on clinical trials, 
and to not routinely offer it to patients. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Proton Beam Radiation Treatment Delivery have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Proton Beam Radiation Treatment Delivery (77525).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950) 
provided on February 26, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit under 
your contractual policy. 
 
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 service provided in this case is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the core 
buildup, including any pins when required (D2950) provided on February 26, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prednisone 5 mg tablet. 
 
You asked the Plan to pre-approve Prednisone. You say that this is medically necessary for the enrollee's 
condition. The Plan denied your request. The Plan says this drug is not covered under the enrollee's medical 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Prednisone 5 mg tablet.  
 
Benefits for Prednisone may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the treatment simulation using three-dimensional (3D) image 
volume (D0393), adjunctive pre-diagnostic test (D0431), and five localized deliveries of antimicrobial agents 
(D4381 x5) provided on January 3, 2022, and January 18, 2022. 
 
You asked the Plan to pay for the treatment simulation using 3D image volume, adjunctive pre-diagnostic test, 
and localized deliveries of antimicrobial agents. You say that you are on social security, the procedures were 
too expensive, and these services should be covered by the Plan. The Plan denied your request. The Plan says 
these services are not covered. 
 
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 
treatment simulation using three-dimensional (3D) image volume (D0393), adjunctive pre-diagnostic test 
(D0431), and five localized deliveries of antimicrobial agents (D4381 x5) provided on January 3, 2022, and 
January 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950) 
and the intraoral-periapical additional radiographic images (D0230 x 2) provided on January 24, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not payable. 
 
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 case file and the Plans rules. Based on this information, we decided that the Plan's rules for 
coverage of these services have not been met. Specifically, on this day you had three intraoral-periapical 
radiographic images provided. The Plan issued payment for one intraoral x-ray. The Plan contract states that 
intraoral x-rays are covered for one procedure code per calendar year. Therefore, you have exceeded the 
allowable benefit for this service. Additionally, a core build up is not a covered benefit under your contractual 
policy. Therefore, we decided that the Plan does not have to pay for the core buildup, including any pins when 
required (D2950) and the intraoral-periapical additional radiographic images (D0230 x 2) provided on  
January 24, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to be improving but requires short-term additional acute care 
services that can be completed at the current facility until more stable and appropriate for a lower level of care. 
There are no services at the LTACH that the enrollee required that are not already available and covered at the 
current facility. Transfer to LTACH is not medically necessary at this time as it would not be clinically 
advantageous. Completion of treatment in the current facility is recommended. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.