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

 
We decided that the Plan does not have to pre-approve a filling on tooth #5, 11, 26, and 29 (D2950), a crown 
on tooth #5, 11, 26, and 29 (D2740), deep gum and root cleaning (D4341 x 4), and nerve treatment on tooth #5, 
11, 26, and 29 (D3320). 
 
You asked the Plan to pre-approve fillings, crowns, deep cleaning, and nerve treatments. You say that these 
dental services are medically necessary. The Plan denied your request. The Plan says these services (D2950, 
D2740, D4341, D3320 are 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 a 
filling on tooth #5, 11, 26, and 29 (D2950), a crown on tooth #5, 11, 26, and 29 (D2740), deep gum and root 
cleaning (D4341 x 4), and nerve treatment on tooth #5, 11, 26, and 29 (D3320).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Retacrit (Q5106). 
 
You asked the Plan to pre-approve Retacrit. You say that the requested drug is medically necessary for the 
enrollee's condition. The Plan denied your request. The Plan says this drug is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Retacrit. Our reviewer says that the 
requested drug is not medically reasonable and necessary. Our physician reviewer found the enrollee is a 76-
year-old male with a medical history of chronic kidney disease. Based on the medical records provided and the 
Medicare-approved major drug compendia there is no documentation that Retacrit is medically reasonable and 
necessary for the patient. Provided records (from January 12, 2022, and January 13, 2022) document a 
hemoglobin level greater than 10.0 grams/dL and a low iron saturation of 17%; there are no other related lab 
results provided in this case showing anemia. The criteria for coverage of Retacrit have not been satisfied 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 Retacrit have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Retacrit (Q5106).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve six abutment supported cast metal crowns (D6063 x6). 
 
You asked the Plan to pre-approve the abutment supported cast metal crowns. The Plan denied your request. 
The Plan says this service is not covered under your benefit plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve six 
abutment supported cast metal crowns (D6063 x6).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Critical care services (99291) provided on May 26, 2021. 
 
You asked the Plan to pay for code 99291. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the records do not support the services 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, the CPT Code Manual definition of code 99291 is Critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, code 99291 is a time-based 
code. In order to bill CPT code 99291, the documentation must note that the first 30-74 minutes was spent 
providing services to the enrollee. The progress notes for May 26, 2021, does not note how much time was spent providing services to the enrollee. As such, the provided documentation does not support the billing of 
code 99291. Based on this information, we decided that Medicare rules for coverage of code 99291 have not 
been met. Therefore, we decided that the Plan does not have to pay for the Critical care services (99291) 
provided on May 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on February 2, 2022. 
 
You asked the Plan to pay for an evaluation. You say that both evaluations were medically necessary. The Plan 
denied your request. The Plan says a limited oral evaluation (D0140) is covered by the Plan's dental benefit; 
however, your benefit for one procedure per year has been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers one limited 
oral evaluation (D0140) per year. 
 
We looked at this case file, the Plan's rules, and Medicare rules. The record shows the Plan paid for a limited 
oral evaluation provided on January 20, 2022; therefore, the benefit for a limited oral evaluation has been 
exhausted. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) 
provided on February 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the toilet rails provided on January 27, 2022. 
 
You asked the Plan to pay for the services provided. You say that the item was purchased for use during 
recovery from surgery. The Plan denied your request. The Plan says the provider is not certified by Medicare. 
 
The Plan covers all items that Medicare covers. Medicare rules state that grab bars are not covered because 
they are not primarily medical in nature.  
 
We looked at the file and the rules. While a grab bar may be appropriate in this case, neither the Plan nor 
Medicare offers coverage of this item. The provider at issue is also not enrolled in the Medicare program. 
Therefore, we decided that the Plan does not have to pay for the toilet rails provided on January 27, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan provided on February 
9, 2022. 
 You asked the Plan to pay for the CT scan. You say that the enrollee had multiple exams on this date of 
service. The Plan denied your request. The Plan says an appropriate modifier was not 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 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 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 evaluation (D0150) and the intraoral-
complete series of radiographic images (D0210) provided on February 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 you have exceeded the allowable benefit for 
these services. 
 
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 a 
comprehensive oral evaluation and an intraoral-complete series of radiographic images once every three years.  
 
 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, the Plan covers a comprehensive oral evaluation 
and an intraoral-complete series of radiographic images once every three years. These services were received 
by you on October 19, 2021 and were subsequently paid for by the Plan on October 21, 2021. Therefore, you 
have exceeded the allowable benefit for these services. Therefore, we decided that the Plan does not have to 
pay for the comprehensive oral evaluation (D0150) and the intraoral-complete series of radiographic images 
(D0210) provided on February 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the endosteal implants (D6010 x 6), crown (D2740) and 
fixed prosthodontic service (D6999) provided on September 23, 2021, by the out of country provider. 
 
You asked the Plan to pay for the dental services. You say that you saved $18,000 by going to this provider. 
You also say that you should be reimbursed. The Plan denied your request. The Plan says the dental 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the implants, crown, and fixed 
prosthodontic service are not among those covered under this benefit when performed outside of the United 
States. Additionally, there is no documentation indicating the services were urgent or emergent in nature. 
Therefore, we decided that the Plan does not have to pay for the endosteal implants (D6010 x 6), crown 
(D2740) and fixed prosthodontic service (D6999) provided on September 23, 2021, by the out of country provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment provided on October 7, 2021. 
 
You asked the Plan to pay for the provided services. You say that the chairs from the medical supply firms 
were not compatible with your body. The Plan denied your request. The Plan says the provider is not certified 
with Medicare. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that 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 provider in this case is not eligible to provide services under Original Medicare. The Plan did not pre-
approve the services at issue from this provider. 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 durable medical equipment 
provided on October 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core buildup, including any pins when required (D2950) 
provided on February 8, 2022. 
 
You asked the Plan to pay for the core buildup, including any pins when required. You say that the services 
should be covered as you were told they were. 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 pay for core 
buildup, including any pins when required (D2950) provided on February 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CxBladder testing provided on December 7, 2021. 
 
You asked the Plan to pay for the testing services. You say that the testing provides actionable results. The Plan 
denied your request. The Plan says the testing is non-covered. 
 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. In this case, there were no medical records from the treating 
physician to show that the results of testing would impact clinical management. Based on this information, we 
decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that 
the Plan does not have to pay for the CxBladder testing provided on December 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement power wheelchair. 
 
You asked the Plan to pre-approve a replacement power wheelchair. You say that this new power operated 
wheelchair is medically reasonable and necessary. The Plan denied your request. The Plan says there is no 
documentation provided to show medical necessity for the specific wheelchair being requested. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you currently have a power wheelchair. This device serves the same purpose as a 
replacement power wheelchair. There is no documentation that the current power wheelchair is not able to meet 
your needs or that an evolving medical condition requires a new power wheelchair at this time. Therefore, we 
decided that the Plan does not have to pre-approve a replacement power wheelchair.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing provided on November 23, 2021. 
 
You asked the Plan to pay for the services provided. You say that the provider told you that Medicare would 
cover the testing. The Plan denied your request. The Plan says there is no documentation that your symptoms 
had been appropriately worked up. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover naturopathic services.  
 
We looked at the file and the services. There are insufficient medical records to show the testing was ordered 
for a specific medial problem or treatment strategy. It appears this testing was used as a screening tool.  
 Based on this information, we decided that the Medicare rules for coverage have not been met. Therefore, we 
decided that the Plan does not have to pay for the lab testing provided on November 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair and accessories. 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that this device is medically 
reasonable and necessary. The Plan denied your request. The Plan says Medicare does not cove durable 
medical equipment in a skilled nursing facility. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that a power wheelchair and accessories is being requested for use in a SNF or hospital. 
Therefore, we decided that the Plan does not have to pre-approve a power wheelchair and accessories.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a resin-based composite filling on tooth #16 (D2394) 
provided on March 17, 2022. 
 
You asked the Plan to pay for a composite filling. You say that the filling on tooth #16 should have been 
processed and paid first. The Plan denied your request. The Plan says this service is covered by the Plan's 
dental benefits; however, your benefit for two fillings per year has 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. The Plan covers two fillings 
per year. 
 
We looked at this case file, the Plans rules, and Medicare rules. The record shows the Plan paid for a filling 
provided on January 17, 2021; therefore, the benefit for fillings has been exhausted. The record also shows that 
the filling on tooth #17 was processed first since it was listed first on the claim submission form. Therefore, we 
decided that the Plan does not have to pay for a resin-based composite filling on tooth #16 (D2394) provided 
on March 17, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for enteral nutrition services (S9343) provided on November 4 
to December 3, 2021. 
 You asked the Plan to pay for enteral nutrition services. You say that the services at issue were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code S9343 has a Status Indicator of I on the Physician Fee Schedule. This means that CPT 
code S9343 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for 
coverage of enteral nutrition services have not been met. Therefore, we decided that the Plan does not have to 
pay for enteral nutrition services (S9343) provided on November 4 to December 3, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on October 13, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the billed code 
cannot be verified. 
 
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. The claim in this case was billed with the laboratory POS code. The 
records do not support that the sample was taken in a laboratory setting. Based on this information, we decided 
that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan 
does not have to pay for the lab services provided on October 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an extraction (D7210) provided by an oral surgeon. 
 
You asked the Plan to pre-approve an extraction. You say that you disagree with how the request was handled 
and you do not think it was done properly. The Plan denied your request. The Plan says dental services 
performed by an oral surgeon 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 
covered under this benefit when performed by an oral surgeon. Therefore, we decided that the Plan does not 
have to pre-approve an extraction (D7210) provided by an oral surgeon.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hereditary cardiovascular gene testing provided on June 
25, 2021. 
 
You asked the Plan to pay for the testing services. You say that the documentation substantiates the claim The 
Plan denied your request. The Plan says the screening panel was initiated by the laboratory. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
We looked at the file and the rules. The test at issue in this appeal was requested for screening purposes. 
Screening services such as pre-symptomatic genetic tests and services used to detect an undiagnosed disease or 
disease predisposition are not a Medicare benefit. Therefore, we decided that the Plan does not have to pay for 
the hereditary cardiovascular gene testing provided on June 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator. 
 
You asked the Plan to pre-approve a portable oxygen concentrator. You say that the requested portable oxygen 
concentrator is a medical necessity for the enrollee. The Plan denied your request. The Plan says medical 
necessity rules for a portable oxygen concentrator have not been met. 
 
The Plan must follow Medicare rules. The rules say that patients who are mobile in the home and would benefit 
from the use of portable oxygen in the home, may qualify for coverage of a portable oxygen system either by 
itself, or to use in addition to a stationary oxygen system. Oxygen is coverable when medically necessary for 
patients with hypoxemia who meet certain blood gas evidence requirements. In reviewing the arterial PO2 
levels and the arterial oxygen saturation percentages, variations in oxygen measurements that may result from 
such factors as the patient's age, the patients skin pigmentation, the altitude level, or the patient's decreased 
oxygen carrying capacity, must be taken into account. For patients who do not exhibit hypoxemia according to 
the above criteria, oxygen may be coverable when medically reasonable and necessary for patients who do not 
have a non-covered indication.  
 
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 portable oxygen concentrator Our 
reviewer says that the requested portable oxygen concentrator is not medically reasonable and necessary in this 
case. Our physician reviewer found that the enrollee has portable tanks and is requesting a portable oxygen 
concentrator because dexterity issues make it difficult to operate the tank regulator. It is unclear how the 
controls of a portable oxygen concentrator would be easier to use than the regulator for someone with dexterity 
issues. In addition, the records do not include evidence that the oxygen saturation can be maintained at 90% or 
above using an oxygen conserving device, which is a Medicare criterion for coverage. 
 
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 portable oxygen concentrator have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a portable oxygen concentrator.