Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical medicine mechanical traction modality (97012), 
electrical stimulation (G0283) and established patient office or other outpatient visit (99212) provided on 
December 16, 2021. 
 
You asked the Plan to pay for physical medicine mechanical traction modality, electrical stimulation and 
established patient office or other outpatient visit. The Plan denied your request. The Plan says the services 
were carried out by chiropractor and per your EOC, only manual manipulation of the spine for the treatment of 
subluxation is covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for physical medicine mechanical traction modality (97012), electrical 
stimulation (G0283) and established patient office or other outpatient visit (99212) provided on  
December 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an upper partial denture. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the criteria for coverage are not met. 
 
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 an upper 
partial denture when there are less than eight teeth in biting contact.  
 
We looked at the file and the Plans rules. The file shows that you have 10 teeth in biting contact. Based on this 
information, we decided that the Plan's rules for coverage of these services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an upper partial denture.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve porcelain/ceramic crowns (D2740) for teeth #22, #23, #24 and 
#25. 
 
You asked the Plan to pre-approve crowns. You say that your teeth are fracturing, and you feel it is because 
your teeth are missing a significant level of structure. The Plan denied your request. The Plan says that the 
criteria for coverage of these services are not met. Crowns are only covered when there is extensive loss of 
tooth structure due to caries and/or fracture. 
 
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 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 crowns. Our reviewer says that the 
criteria for coverage of crowns are met for the requested teeth. Our physician reviewer found a review of the 
documentation indicates that these teeth appear to have significant coronal breakdown which affects the proper 
function. Crown restorations are medically necessary and reasonable in this case to return these teeth to proper 
function. 
 
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 crowns have been met. Therefore, we decided that the Plan has to pre-approve 
porcelain/ceramic crowns (D2740) for teeth #22, #23, #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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic radiology services provided on  
December 10, 2021. 
 
You asked the Plan to pay for diagnostic radiology services. The Plan denied your request. The Plan says the 
Plan requires utilization of network providers when possible and available and requires authorization for 
certain services. No medical necessity for an out-of-network provider such as an urgent or an emergent 
situation that has been documented.   
 
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 requested provider in this case is not a network provider with the Plan. 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 diagnostic radiology services provided on December 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chimeric antigen receptor T-Cell (CAR-T) therapy. 
 
You asked the Plan to pre-approve CAR-T therapy. You say that this procedure is medically necessary. The 
Plan denied your request. The Plan says this therapy is not medically reasonable and necessary. 
 
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 CAR-T therapy. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has been diagnosed with relapsed diffuse large B-cell lymphoma. As of December 
2021, there appears to be no evidence of disease. As there is no evidence of recurrence and head and neck 
pathology have not been addressed, this service will be denied per the National Comprehensive Cancer 
Network. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CAR-T therapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve chimeric antigen receptor T-Cell (CAR-T) therapy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve MyoPro Motion G device. 
 
You asked the Plan to pre-approve MyoPro Motion G device. You say that this equipment is medically 
reasonable and necessary for the enrollee's condition. The Plan denied your request. The Plan says the 
requested device is considered experimental/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 MyoPro Motion G device. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the MyoPro is not known to be effective, based on scientific evidence, 
professional standards and expert opinion, in improving health outcomes in stroke patients. The MyoPro is not 
in widespread use based on scientific evidence. There is insufficient evidence in the literature that the MyoPro 
Orthosis will improve the long-term outcomes for this patient, improve hemiparetic arm function, or be safe for 
long term use. There is insufficient evidence in the literature that this device will increase participation in 
bimanual activities. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MyoPro Motion G device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve MyoPro Motion G device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve addition to lower extremity, above knee or knee 
disarticulation, acrylic socket (L5631). 
 
You asked the Plan to pre-approve a special prosthetic part. You say that the enrollee is highly motivated and 
has expressed her desire to be ambulatory again with a prosthesis. The Plan denied your request. The Plan says 
the special prosthetic part (acrylic material) cannot be used with the approved preparatory prosthesis L5590. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a special prosthetic part have not been met. Therefore, we decided that the Plan does not have to 
pre-approve addition to lower extremity, above knee or knee disarticulation, acrylic socket (L5631).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mandibular partial denture - cast metal framework with 
resin denture bases (including retentive/clasping materials, rests and teeth) (D5214) provided January 24, 2022. 
 
You asked the Plan to pay for the lower partial denture. You say that your original dentures were not made 
correctly, and you cannot afford the cost of the new dentures. The Plan denied your request. The Plan says you 
have exceeded the frequency limit for this service. 
 
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 lower 
partial denture once every 5 calendar years. 
 
We looked at the file and Medicare rules. The Plan provided documentation showing that a lower partial 
denture was previously covered on January 10, 2020. Based on this information, we decided that the Plan's 
frequency limit for coverage of the lower partial denture has been exceeded. Therefore, we decided that the 
Plan does not have to pay for the mandibular partial denture - cast metal framework with resin denture bases 
(including retentive/clasping materials, rests and teeth) (D5214) provided January 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140) and cone beam CT 
(D0364) provided on October 12, 2021. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered. The Plan denied 
your request. The Plan says 1 limited oral evaluation is covered per plan year. The Plan says that the frequency 
limit has been exceeded. The Plan also says that cone beam CT is not listed as a covered service. 
 
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 and limited oral evaluation is covered 
once per plan year, the frequency limit has been exceeded. The record shows that the Plan paid for a limited oral evaluation that you receive on October 11, 2021. Additionally, the cone beam CT is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the limited oral 
evaluation (D0140) and cone beam CT (D0364) provided on October 12, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Lumbar Decompression surgery (22867, 22869). 
 
You asked the Plan to pre-approve the Lumbar Decompression surgery=. You say that the service is medically 
necessary. The Plan denied your request. The Plan says the service is experimental 
 
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 Lumbar Decompression surgery=. 
Our reviewer says that the requested services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found this service is experimental and more research is needed to show the safety 
and efficacy for the enrollee's diagnosis. 
 
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 Lumbar Decompression surgery= have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the Lumbar Decompression surgery (22867, 22869).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on August 9, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
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 the laboratory 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 provided on August 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye exam provided on November 22, 2021. 
 
You asked the Plan to pay for an eye exam. The Plan denied your request. The Plan says you have already 
received the maximum amount of coverage allowed for this type of service. 
 
Medicare generally does not cover routine vision services. However, the Plan offers a routine vision benefit 
that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers 
these services every 12 months. 
 
We looked at the file and the Plan's rules. The file shows that you have received the maximum amount of 
coverage allowed for this type of service. Based on this information, we decided that the Plan's rules for 
coverage of an eye exam have not been met. Therefore, we decided that the Plan does not have to pay for an 
eye exam provided on November 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Debridement of nail(s) by any method(s); 6 or more 
(11721) provided on February 9, 2022. 
 
You asked the Plan to pay for code 11721. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered as billed.  
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 11721 
is a column II code to column I code 11042. 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 Debridement of nail(s) by any method(s); 6 or more (11721) 
provided on February 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral exam (D0150) and panoramic x-ray 
(D033) provided on August 23, 2021. 
 
You asked the Plan to pay for the dental services. You say that you were told these services were necessary 
before your valve replacement procedure. The Plan denied your request. The Plan says the requested services 
are purely dental in nature and are not covered by Medicare or the Plan. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for the comprehensive oral exam 
(D0150) and panoramic x-ray (D033) provided on August 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gum medication (D4381) to be provided by a 
participating provider. 
 
You asked the Plan to pre-approve gum medication. You say that you would like the Plan to approve this 
dental work. The Plan denied your request. The Plan says D4381 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 pre-approve gum 
medication (D4381) to be provided by a participating provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head and neck 
(70450) provided on December 16, 2021. 
 You asked the Plan to pay for the CT scan services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says an appropriate modifier was not billed with 
this claim as required by Medicare coding regulations. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the computed tomography (CT) scan of the head and neck 
(70450) provided on December 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infrared therapy provided on October 11, 2021. 
 
You asked the Plan to pay for infrared therapy. The Plan denied your request. The Plan says infrared therapy is 
noncovered for all indications. 
 
The Plan must follow Medicare rules. Medicare rules say that infrared therapy is non-covered for all 
indications. 
 
We looked at the file and Medicare rules. Medicare says infrared therapy is non-covered for all indications. 
Therefore, we decided that the Plan does not have to pay for infrared therapy provided on October 11, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a physical therapy services (97110, 97161, 
97140) provided February 1, 2022, to February 24, 2022. 
 
You asked the Plan to waive the deductible for the physical therapy services. You say that the services should 
be covered as you disagree with the charges. The Plan denied your request. The Plan says the deductible 
applied correctly based on the services provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $150 
deductible for outpatient rehabilitation services.  
 
 You have been asked to pay a $150 deductible for the physical therapy services. Physical therapy services fall 
within the outpatient rehabilitation services benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the deductible 
for a physical therapy service (97110, 97161, 97140) provided February 1, 2022, to February 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the bone replacement grafts for ridge preservation - per 
site (D7953). 
 
You asked the Plan to pre-approve the bone replacement grafts. You say that you feel this should be covered. 
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 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 the 
bone replacement grafts for ridge preservation - per site (D7953).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675). 
 
You asked the Plan to pay for a pneumatic compression device. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism is a preventive service. The rules also say that a PCD coded 
as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental codes D6058 and D6057 provided on January 24, 
2022, and January 25, 2022. 
 
You asked the Plan to pay for dental codes D6058 and D6057. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says dental codes D6058 and 
D6057 are not covered under the Plan's supplemental 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, dental codes D6058 and D6057 are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for dental 
codes D6058 and D6057 provided on January 24, 2022, and January 25, 2022.