Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an evaluation visit provided by a Licensed Professional 
Counselor (LPC) on April 11, 2022. 
 
You asked the Plan to pay for evaluation visit. You say that you believe that you are covered for this service. 
The Plan denied your request. The Plan says this provider does not participate in the Medicare program and is 
not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that Licensed Professional Counselors (LPCs) are not 
eligible to enroll in the Medicare program. Medicare rules also say that a provider must be enrolled in the 
Medicare program in order to receive payment for covered services.  
 
We looked at the file and Medicare rules. This service was performed by a Licensed Professional Counselor 
(LPC). An LPC is not eligible to enroll in the Medicare program and is therefore not payable. Based on this 
information, we decided that Medicare rules for coverage of evaluation visit have not been met. Therefore, we 
decided that the Plan does not have to pay for an evaluation visit provided by a Licensed Professional 
Counselor (LPC) on April 11, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex device insertion. 
 
You asked the Plan to pre-approve the Vertiflex device insertion. You say that the enrollee has suffered from 
this condition for 14 months and has failed greater than 12 months of conservative approaches to treatment. 
You say that this treatment is safe and effective and should be approved. The Plan denied your request. The 
Plan says there are not enough studies on Vertiflex Superion to show it is safe and effective. 
 
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 Vertiflex device insertion. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that the Vertiflex device is considered experimental. 
 
 
  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 Vertiflex device insertion have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the Vertiflex device insertion.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for chiropractic services on March 24, 2022. 
 
You asked the Plan to waive the cost share for chiropractic services. You say that you are requesting 
reconsideration and to please cover all services from the provider. The Plan denied your request. The Plan says 
the cost sharing you are being charged is correct. 
 
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 $20 
copayment for out-of-network Medicare-covered chiropractic services at specialists office. Covered services 
include: we cover only manual manipulation of the spine to correct subluxation. Other services performed by a 
chiropractor are not covered. There is a $20 copayment and $200 for other services. $20 + $200 = $220. 
Therefore, results in the total cost sharing amount of $220. 
 
 
 
 You have been asked to pay a $20 copayment and $200 for chiropractic services. Chiropractic services fall 
within the Chiropractic 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 cost share for 
chiropractic services on March 24, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nail debridement provided on February 22, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for nail debridement. You say that you are appealing the claim payment denial. The 
Plan denied your request. The Plan says the services were provided out-of-network and were not approved in 
advanced. 
 
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 had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for nail debridement provided on February 22, 2022, 
by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve procedure code A9276. 
 
You asked the Plan to pre-approve procedure code A9276. You say that the items are necessary. The Plan 
denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code A9276 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code A9276 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of disposable sensors have not been met. Therefore, we decided that the Plan does not have 
to pre-approve procedure code A9276.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for occupational therapy provided on January 
19, 2022. 
 
You asked the Plan to waive the copayment for occupational therapy. You say that you cannot afford the 
copayment each time you go to therapy. The Plan denied your request. The Plan says the copayment applied is 
correct. 
 
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 $35 
copayment for each Medicare-covered occupational therapy visit.  
 
You have been asked to pay $35 copayment for occupational therapy. Occupational therapy falls 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 copayment for 
occupational therapy provided on January 19, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacroiliac joint fusion. 
 
You asked the Plan to pre-approve a sacroiliac joint fusion. You say that you confirmed the sacroiliac joint is 
the primary pain generator and the enrollee has failed multiple conservative treatments. You say that a joint 
fusion is deemed medically necessary since all non-operative treatment approaches have failed to alleviate 
pain. The Plan denied your request. The Plan says this service is considered investigational and not medically 
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 sacroiliac joint fusion. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Linq fusion system and a sacroiliac joint fusion for degenerative back pain is 
experimental. 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of sacroiliac joint fusion have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a sacroiliac joint fusion.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for blood pressure machine provided on January 23, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for blood pressure machine. You say that you were advised that if you purchased a 
blood pressure machine, you would be reimbursed. The Plan denied your request. The Plan says the service 
could be provided by an in-network supplier. 
 
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 had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for blood pressure machine provided on January 23, 
2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bilateral repeat therapeutic facet joint injections. 
 
You asked the Plan to pre-approve bilateral repeat therapeutic facet joint injections. You say that this is 
medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for 
coverage have not been satisfied. 
 
The Plan must follow Medicare rules. Medicare rules say that in order for therapeutic facet joint injections to 
be covered, there must be documentation of why the patient is not a candidate for radiofrequency ablation 
(such as established spinal pseudarthrosis, implanted electrical device). 
 
We looked at the file and Medicare rules. In this case, no documentation was received as to why the enrollee is 
not a candidate for radiofrequency ablation. Based on this information, we decided that Medicare rules for 
coverage of bilateral repeat therapeutic facet joint injections have not been met. Therefore, we decided that the 
Plan does not have to pre-approve bilateral repeat therapeutic facet joint injections.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dental surgery procedure (41899) and alveoloplasty 
(41874). 
 
You asked the Plan to pre-approve the surgery procedure and alveoloplasty. You say that you have an infection 
and need to be treated. The Plan denied your request. The Plan says these services are not a covered benefit 
under your dental 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 a 
dental surgery procedure (41899) and alveoloplasty, each quadrant (41874).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that the services are necessary. The Plan denied 
your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found based on the medical records 
provided there is no documentation that the ventilator at issue meets Medicare criteria for medically necessary 
and reasonable for you. As stated in the Medicare rules: "Claims for ventilators used to provide continuous 
positive airway pressure (CPAP) or bi-level CPAP therapy for conditions described in this RAD policy will be 
denied as not reasonable and necessary."   
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for eye exam provided on April 6, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for eye exam. You say that you are appealing the claim payment denial. The Plan 
denied your request. The Plan says the services were provided out-of-network and were not approved in 
advanced. 
 
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 had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for eye exam provided on April 6, 2022, by an out-of-
network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a resin-based composite filling on tooth #27 (D2331) and a 
resin-based composite filling on tooth #29 (D2391) provided on April 5, 2022. 
 
You asked the Plan to pay for fillings. You say that these services should be fully covered. The Plan denied 
your request. The Plan says resin-based composite fillings (D2331, D2391) are not covered by your preventive 
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 a resin-
based composite filling on tooth #27 (D2331) and a resin-based composite filling on tooth #29 (D2391) 
provided on April 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pontic-porcelain fused to high noble metal (D6240) and 
the retainer crown-porcelain fused to high noble metal (D6750 x 2) provided on April 13, 2022. 
 
You asked the Plan to pay for these dental items. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these dental items are not covered 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 dental items provided in this case 
are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
the pontic-porcelain fused to high noble metal (D6240) and the retainer crown-porcelain fused to high noble 
metal (D6750 x 2) provided on April 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99239 billed for date of service September 9, 
2021. 
 
You asked the Plan to pay for code 99239. You say you have provided medical records to support payment. 
The Plan denied your request. The Plan says this code is not supported in the medical record. 
 
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 99239 is Hospital Discharge Day Management Services; 
more than 30 minutes.  Because this is a time-specific code, the actual number of minutes spent with the patient must be documented in the medical record. The medical records from September 9, 2021, do not document the 
number of minutes spent with the patient. Without this documentation, this code cannot be confirmed.  
Therefore, we decided that the Plan does not have to pay for procedure code 99239 billed for date of service 
September 9, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for bitewings - four radiographic images (D0274) provided on October 25, 
2021. 
 
You asked the Plan to pay for the bitewings. The Plan denied your request. The Plan says that this service is 
denied due to frequency limitation. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan did not submit documentation showing that your benefit 
for bitewings has already been provided. This means that we cannot determine if your benefit for the 
bitewings-four radiographic images (D0274)  has already been exhausted. It is the burden of the Plan to 
substantiate their decision with evidence. In this case, the decision has not been substantiated so we must find 
in your favor. Therefore, we decided that the Plan has to pay for bitewings - four radiographic images (D0274) 
provided on October 25, 2021.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the alveoloplasty in conjunction with extractions - four or 
more teeth or tooth spaces, per quadrant (D7310) and alveoloplasty not in conjunction with extractions - four or 
more teeth or tooth spaces, per quadrant (D7320) provided February 10, 2022. 
 
You asked the Plan to pay for the alveoloplasties. You say that it was not your fault that you needed this 
procedure. 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 pay for the 
alveoloplasty in conjunction with extractions - four or more teeth or tooth spaces, per quadrant (D7310) and alveoloplasty not in conjunction with extractions - four or more teeth or tooth spaces, per quadrant (D7320) 
provided February 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve complete denture (D5110) and crown - 
porcelain/ceramic substrate (D2740) provided on March 3, 2022. 
 
You asked the Plan to pre-approve the dental services. You say that you were advised by the dental provider 
that this dentist is in-network. The Plan denied your request. The Plan says dental services from an out-of-
network provider are not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
You are requesting dental services from an out-of-network provider. Though the Plan offers a dental benefit in 
excess of Medicare coverage, the requested items or services are not covered under this benefit when received 
from an out-of-network provider. Therefore, we decided that the Plan does not have to pre-approve complete 
denture (D5110) and crown - porcelain/ceramic substrate (D2740) provided on March 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the application of caries arresting medicaments on tooth #4 
(D1354) provided on March 2, 2022. 
 You asked the Plan to pay for application of medicament. You say that you disagree with the denial of dental 
services. The Plan denied your request. The Plan says the application of caries arresting medicaments (D1354) 
is not covered by your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
application of caries arresting medicaments on tooth #4 (D1354) provided on March 2, 2022.