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

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), intraoral 
complete series x-ray (D0210) and adjunctive pre-diagnostic test (D0431) provided on September 1, 2020. 
 
You asked the Plan to pay for the comprehensive oral evaluation (D0150), intraoral complete series x-ray 
(D0210) and adjunctive pre-diagnostic test (D0431). You say that you have $3,000 in available benefits and do 
not know why payment was denied. You say that you are on a limited budget and cannot afford to pay this bill. 
The Plan denied your request. The Plan says the frequency limit for the comprehensive oral evaluation and 
intraoral x-ray have been exceeded. The Plan also says that the adjunctive pre-diagnostic test (D0431) remains 
denied as a non-covered benefit. 
 
  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, you also have a maximum benefit of 
one comprehensive oral evaluation and intraoral x-ray every three plan years. The Plan paid for the 
comprehensive oral evaluation and intraoral x-ray provided on September 4, 2020, which exhausted your 
benefit. The adjunctive pre-diagnostic test remains denied as a non-covered benefit. Therefore, we decided that 
the Plan does not have to pay for the comprehensive oral evaluation (D0150), intraoral complete series x-ray 
(D0210) and adjunctive pre-diagnostic test (D0431) provided on September 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dental surgery procedure (41899), repair of a tooth 
socket (41874) and removal of bony growth (21032). 
 
You asked the Plan to pre-approve dental services. You say that your spouse will proceed with the surgery on 
October 7, 2021. You also say that it is ridiculous that the Plan denied the authorization and it should be 
covered by the Plan since it is a surgical procedure not just a tooth extraction from a regular dental office. The 
Plan denied your request. The Plan says service at issue in this appeal is not a covered benefit. 
 
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 pre-approve a 
dental surgery procedure (41899), repair of a tooth socket (41874) and removal of bony growth (21032).
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pay for the self-administered drugs provided from July 8, 2021, to July 11, 2021.  You asked the Plan to pay for the self-administered drugs. You say that you had a total knee replacement, and the drugs were administered to you by a nurse from their pharmacy, as ordered by your doctor. You also say that hospitals do not allow patients to keep oral drugs at their bed side to self-administer. The Plan denied your request. The Plan says self-administered drugs are not covered under Part B of Original Medicare.  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 pay for the self-administered drugs provided from July 8, 2021, to July 11, 2021.   Benefits for the self-administered drugs 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 problem focused limited oral evaluation (D0140) provided on August 5, 2021.  You asked the Plan to pay for the problem focused limited oral evaluation. You say that you do not understand where the $94.00 you owe for this service is coming from. The Plan denied your request. The Plan says your full annual dental allowance amount of $1,000 has already been paid 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 Plan's coverage rules apply in this case.  Though the Plan offers a dental benefit in excess of Medicare coverage, the Plan offers a $1,000 combined allowance for supplemental preventive and comprehensive dental services every year. The contract says that you are responsible for any amount over and above the allowance amount. The record shows that you met the annual maximum benefit on July 20, 2021 and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on August 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve replacement eyeglasses. 
 
You asked the Plan to pre-approve replacement eyeglasses. You say that you lost your eyeglasses, and you are 
in need of a replacement. The Plan denied your request. The Plan says you have exhausted your eyeglasses 
benefit for the 2021 plan year. 
 
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear 
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  
 
We looked at the file and the Plan's rules. The file shows that you used your routine eyeglasses benefit on September 14, 2021, and you have exhausted the benefit for this year. Therefore, we decided that the Plan does 
not have to pre-approve replacement eyeglasses.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continued Skilled Nursing Facility (SNF) services 
after November 24, 2021 
 
You asked the Plan to pre-approve the continued SNF services. You say that you would like reconsideration 
because the SNF services are medically necessary. The Plan denied your request. The Plan says the member 
does not meet Medicare coverage criteria for continued SNF services.  
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 pre-approve the continued SNF services. Our 
reviewer says that daily skilled services are not necessary. Our physician reviewer found daily skilled services 
do not appear to be required as of November 24, 2021. The member does not require the services on an 
inpatient basis, only in a skilled nursing facility 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 continued SNF services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the continued Skilled Nursing Facility (SNF) services after November 24, 
2021
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an automatic blood pressure monitor (A4670) provided on 
February 25, 2021. 
 
You asked the Plan to pay for an automatic blood pressure monitor. You say that the Plan needs to pay for the 
item at issue since their representative said they would. The Plan denied your request. The Plan says rules for 
payment have not been met.  
The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only 
for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require 
ABPM to confirm a diagnosis of hypertension.  
 
The records do not show that this monitor is requested in the setting of home dialysis services, or that this 
request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home 
may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation. 
Therefore, we decided that the Plan does not have to pay for an automatic blood pressure monitor (A4670) 
provided on February 25, 2021.  
 
Your complaint about receiving erroneous or incomplete information about your benefits from a representative 
of the Plan 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex interspinous spacer procedure for the 
enrollee. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says thisis considered experimental and investigational. 
 
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 procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this device is experimental. More research is needed to show the safety and efficacy of the 
device. 
 
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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Vertiflex interspinous spacer procedure for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says your request does not show you have skilled nursing or therapy needs that need to be provided on a daily basis as an inpatient only status. The services you require can safely be received at a different setting, for example, home with home health, in residential care, or home with close follow-up with your doctor.
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 pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not qualify for SNF coverage. The enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee is ambulating household distances and tending to activities of daily living (ADLs) with minimal supervision. The enrollee's care needs, as a practical matter, can be provided at a lower 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services provided on April 15, 2021, coded as 
01230 and 99100. 
 
You asked the Plan to pay for the anesthesia services. You say that this claim should be paid for medically 
necessary anesthesia. The Plan denied your request. The Plan says the diagnosis codes reported on this claim 
are not appropriate. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report diagnosis codes in 
accordance with the ICD-10-CM guidelines.  The guidelines indicate that a diagnosis code should not be reported with another code that has an Excludes1 
note. 
 
In this case, both diagnosis codes S72.91XA and S72.001A were reported. Diagnosis codes in the S72.9 family 
have an excludes1 note for diagnosis codes within the S72.00 family. This means that the two reported 
diagnosis codes cannot be reported on the same claim. Therefore, we decided that the Plan does not have to pay 
for the anesthesia services provided on April 15, 2021, coded as 01230 and 99100.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve a second diagnostic injection. 
 
You asked the Plan to pre-approve a second diagnostic injection. You say that the services are necessary. The 
Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not 
been met. 
 
The Plan follows Medicare rules. Medicare rules say that facet joint injections are covered when specific 
criteria are met. 
 
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 a second diagnostic injection. Our 
reviewer says that the services are medically necessary. Our physician reviewer found in this case; the enrollee 
had a first cervical MBB which provided 100% pain relief. The review has determined that the enrollee meets 
the coverage criteria for the requested service. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a second diagnostic injection have been met. Therefore, we decided that the 
Plan has to pre-approve a second diagnostic injection.  
 
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 an oxygen concentrator and a portable concentrator for 
the enrollee. 
 
You asked the Plan to pre-approve the items. You say that this is medically necessary. The Plan denied your 
request. The Plan says the blood gas study received does not support the medical necessity of this request. 
 
The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet 
the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would 
benefit from the use of portable oxygen in the home. Portable oxygen is not covered for patients who qualify 
for oxygen solely based on blood gas studies obtained during sleep.   
 
To qualify for home oxygen, the patient must meet one of the following blood gas levels: 
 
1. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, at rest; 
 
2. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, taken during 
sleep for a patient who have hypoxia symptoms during sleep;  
 
3. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88%, taken during exercise for 
patients who have hypoxia symptoms during exercise; 
 
4. Arterial PO2 between 56 and 59 mmHg and arterial O2 saturation is 89% on room air if there is evidence of 
dependent edema, pulmonary hypertension, or erythrocythemia. 
 
For patients with arterial PO2 at or above 60 mm Hg or arterial O2 saturation at or above 90% on room air, 
there is a rebuttable presumption of non-coverage. 
 
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 items. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found based on the 
medical records provided, there is no documentation that the coverage criteria for home oxygen therapy has 
been met as records do not document improvement in the enrollee's hypoxemia with supplemental oxygen at 
the time of the testing on 10/04/2021. The records do not clarify if the enrollee's recovery to 94% oxygen 
saturation after the exercise test was on oxygen or room air. 
 
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 items have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an oxygen concentrator and a portable concentrator for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an angiography (75716-XU) provided on February 12, 2021. 
 
You asked the Plan to pay for an angiography. You say that this was performed before the other procedure. The 
Plan denied your request. The Plan says this is 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 75716 
is a column II code to column I code 37225. Although this code was billed with modifier XU to bypass the edit, 
the records do not show that this service provided the information needed to decide whether to proceed with the 
therapeutic procedure, meaning the use of XU is not supported. Based on the claim submitted, Medicare billing 
criteria have not been met. Therefore, we decided that the Plan does not have to pay for an angiography 
(75716-XU) provided on February 12, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for tissue exam by pathologist (88305) provided on May 24, 
2021. 
 
You asked the Plan to pay for pathology 88305. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the denial of payment for this service is correct, because code 88305 
has a procedure-to-procedure (PTP) edit with code 88323 and is not separately payable without an appropriate 
modifier. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 
pathology 88305 is a column II code to column I code 88323. 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 tissue exam by pathologist (88305) provided 
on May 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) 
provided July 22, 2021. 
 
You asked the Plan to pay for the limited oral exam. You say that you were told at the time of service that there 
would be no cost. The Plan denied your request. The Plan says this service is not covered under your benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
limited oral evaluation - problem focused (D0140) provided July 22, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuation of SNF care from November 21, 2021, 
forward. 
 
You asked the Plan to pre-approve continuation of SNF care. You say that the stay is medically necessary. The 
Plan denied your request. The Plan says the stay is not medically necessary. 
 
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 pre-approve continuation of SNF care. Our reviewer 
says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled 
nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require 
skilled nursing or therapy services on a daily basis. This enrollee does not meet severity of illness or intensity 
of service criteria for 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 continuation of SNF care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve continuation of SNF care from November 21, 2021, forward.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intravenous moderate (conscious) sedation/analgesia 
(D9239, D9243) provided on July 5, 2021. 
 
You asked the Plan to pay for the moderate sedation/analgesia. You say that these services were medically 
necessary. The Plan denied your request. The Plan says sedation/analgesia is not covered by your dental 
benefit. 
 
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 
intravenous moderate (conscious) sedation/analgesia (D9239, D9243) provided on July 5, 2021.