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

 
We decided that the Plan does not have to pre-approve a root canal to be rendered by an endodontist. 
 
You asked the Plan to pre-approve the root canal. You say that it has not been determined that a root canal is 
needed. You also say that the dentist indicated you may need a root canal, and feel the Plan should approve this 
so you can be evaluated by an endodontist. The Plan denied your request. The Plan says while your contract 
offers a supplemental dental benefit in excess of Medicare coverage, there is no listed benefit for a root canal to 
be performed by an endodontist. 
 
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. Dental services are also not covered when they are rendered by anyone 
other than a participating general dentist. Therefore, we decided that the Plan does not have to pre-approve a 
root canal to be rendered by an endodontist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown (D2740) and core buildup, including any pins 
when required (D2950) provided on February 10, 2022. 
 
You asked the Plan to pay for the crown and core buildup. You say that the provider did not advise you that 
these services were not covered. You also say that according to a plan representative you spoke with, you 
should be eligible for a 20% discount since you went to a participating provider. The Plan denied your request. 
The Plan says these services are not covered expenses under your dental plan. The Plan also says that you were 
educated by the call center concerning the 20% discount. 
 
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 crown 
(D2740) and core buildup, including any pins when required (D2950) provided on February 10, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Ilumya. 
 
You asked the Plan to pre-approve Ilumya. You say that you are appealing this denial. The Plan denied your 
request. The Plan says the denial of authorization for this drug is correct, because the Plan requires a trial of at 
least two of Cosentyx, Enbrel, Humira, Renflexis, Skyrizi, or Stelara before it will approve Ilumya. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Ilumya. Our reviewer says that you do 
not meet the Medicare criteria for a step therapy exception for Ilumya. Our physician reviewer found the 
enrollee has not tried and failed at least 2 of the Plan's preferred drugs of Cosentyx, Enbrel, Humira, Renflexis, 
Skyrizi, or Stelara. The record does no show that these drugs would likely be less effective and/or have adverse 
effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Ilumya have not been met. Therefore, we decided that the Plan does not have to 
pre-approve use of Ilumya.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve local delivery of antimicrobial agent (D4381), and 
gingival irrigation (D4921) to be provided by a participating provider. 
 
You asked the Plan to pre-approve local delivery of antimicrobial agent and gingival irrigation. You say that 
you would like approval for these services. The Plan denied your request. The Plan says D4381 and D4921 are 
not covered dental 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 pre-approve local 
delivery of antimicrobial agent (D4381), and gingival irrigation (D4921) to be provided by a participating 
provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950) 
and endodontic therapy (D3310) provided on January 4, 2022. 
 
You asked the Plan to pay for the core buildup and endodontic therapy. You say that due to the length of time 
to receive the approval for predetermination, the condition of the tooth worsened, and you had to see another 
provider nearer to your home. You also say that the requested claim fro the root canal treatment was previously 
approved. The Plan denied your request. The Plan says these services are not covered expenses under your 
dental plan. The Plan also says that you did not contact the Plan prior to receiving these services to verify 
benefits or the treating provider's participation status. 
 
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. The record shows that the predetermination was processed under your 
previous plan with a different servicing provider. You had these services performed by another provider and 
after the benefit plan change from your previous plan to your current plan. Therefore, we decided that the Plan 
does not have to pay for the core buildup, including any pins when required (D2950) and endodontic therapy 
(D3310) provided on January 4, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 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 you do not have any parental medication; 
complex wound care or nutrition given via a feeding tube. You are medically stable without any acute 
exacerbations of chronic medical problems. Your physical function is at or near your new baseline. Although 
further rehab services would be appropriate to improve function, as a practical matter, the intermittent skilled 
services can be provided at a lower level of care than a skilled nursing facility. 
 
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 skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the adjunctive pre-diagnostic test (D0431) provided on 
January 11, 2022. 
 
You asked the Plan to pay for the adjunctive pre-diagnostic test. You say that you would like this service to be 
covered. The Plan denied your request. The Plan says this service is 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 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 
adjunctive pre-diagnostic test (D0431) provided on January 11, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that status is slowly improving, but given this 
level of assessment and intervention, care needs to occur under direct supervision of highly skilled specialized 
therapy, i.e., MD assessment daily, access to daily specialist assessment. The Plan denied your request. The 
Plan says the enrollee is receiving appropriate inpatient care at the current hospital and can safely receive this 
care in another setting, such as a Skilled Nursing Facility (SNF) or at home with home health services. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to be more stable and improving with current treatment and 
should only require short-term additional acute care services that can safely be administered at the current 
facility until appropriate for 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the facet joint injections (64494) provided on November 24, 
2021.  You asked the Plan to pay for the facet joint injections (64494). You say that the attached medical records 
support the level of service provided. You say that both 64494 lines and both 64495 lines should be 
reconsidered for payment. The Plan denied your request. The Plan says CPT codes 64493 and 64495 were paid. 
The Plan also says CPT code 64494 exceeded the allowable units. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 64494 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the facet 
joint injections (64494) have not been met. Therefore, we decided that the Plan does not have to pay for the 
facet joint injections (64494) provided on November 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator (SCS) trial. 
 
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 services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that an SCS trial is 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has polyneuropathy. She 
has psychological clearance for the SCS trial. There is no detail of trial and failure of other therapies. She does 
not have an evidence-based indication for the SCS trial. The services are therefore not reasonable or medically 
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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a spinal cord stimulator (SCS) trial.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement skin protection wheelchair seat cushion. 
 
You asked the Plan to pre-approve a replacement skin protection wheelchair seat cushion. You say that this 
equipment lasts approximately 2 years before it is unable to be used. The Plan denied your request. The Plan 
says the reasonable useful lifetime of this equipment has not been exceeded. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of a replacement skin protection 
wheelchair seat cushion. have been met. In this case, no documentation has been provided that details the 
current state of the skin protection wheelchair seat cushion. Therefore, we decided that the Plan does not have 
to pre-approve a replacement skin protection wheelchair seat cushion.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periapical x-ray (D0220) provided on December 7, 2021. 
 
You asked the Plan to pay for the dental service. You say that this service was automatically performed due to 
the emergency nature of the problem. You say that you did not use your bitewing x-ray benefit this year. You 
also say that this should be covered. The Plan denied your request. The Plan says periapical x-ray exceeds the 
bitewing x-ray 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 periapical x-ray is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the periapical x-ray 
(D0220) provided on December 7, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for continuous intraoperative neurophysiology monitoring 
(95941) provided on October 1, 2021. 
 
You asked the Plan to pay for continuous intraoperative monitoring. You say that this service was billed 
correctly and is supported in the record. The Plan denied your request. The Plan says this service was billed 
with a code that is not valid 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 CPT code. 
 
We find that CPT code 95941 has a Status Indicator of I on the Physician Fee Schedule. This means that CPT 
code 95941 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for 
coverage of continuous intraoperative monitoring have not been met. Therefore, we decided that the Plan does 
not have to pay for continuous intraoperative neurophysiology monitoring (95941) provided on October 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950) 
provided on January 7, 2022. 
 
You asked the Plan to pay for the core buildup. You say that you feel you should not have to pay an extra $250 
when the core buildup should be part of receiving a crown. The Plan denied your request. The Plan says your 
plan does not cover this procedure. 
 
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 core 
buildup, including any pins when required (D2950) provided on January 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for the comprehensive oral evaluation 
(D0150) and complete series x-ray (D0210) provided on August 10, 2021, by the out of network provider. 
 
You asked the Plan to pay an additional amount for the dental services. You say that the booklet indicates there 
is no difference in coverage for in and out of network providers. You say that the office advised they were out 
of network after you received the services. You say that the dental office staff was rude. You also say that you 
expect to be fully reimbursed for this bill. The Plan denied your request. The Plan says since the provider was 
out of network, the difference of the billed amount and allowed amount are the enrollee's responsibility. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
Though the Plan offers a dental benefit in excess of Medicare coverage and the services are listed as covered, 
out of network providers may bill you for any amount greater than what the plan pays. Therefore, we decided 
that the Plan does not have to pay an additional amount for the comprehensive oral evaluation (D0150) and 
complete series x-ray (D0210) provided on August 10, 2021, by the out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extractions (D7140 x 2), and addition of tooth to existing 
partial denture (D5650 x 2) provided on February 10, 2022. 
 
You asked the Plan to pay for the dental services. You say that your tooth broke in half. You say that you had a 
decaying tooth too. You say that you needed 2 teeth added to your partial as a result. You also say that this was 
all necessary dental work. The Plan denied your request. The Plan says extraction is not listed as a covered 
service. The Plan says that addition of tooth to existing partial denture is not listed and therefore is not a 
covered service either. 
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 extractions and addition of teeth to 
an existing partial denture are not among those covered under this benefit. Additionally, dental services 
received out of network are not covered under this benefit. Therefore, we decided that the Plan does not have to 
pay for the extractions (D7140 x 2), and addition of tooth to existing partial denture (D5650 x 2) provided on 
February 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided by a participating 
provider on December 7, 2021. 
 
You asked the Plan to pay for a limited oral evaluation. You say that you just had a regular cleaning. You say 
that this should be covered. The Plan denied your request. The Plan says D0140 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 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 a limited 
oral evaluation (D0140) provided by a participating provider on December 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two prefabricated abutments (D6056 x2) and two 
abutment supported cast metal crowns (D6062 x2). 
 
You asked the Plan to pre-approve the prefabricated abutments and abutment supported cast metal crowns. You 
say that you need these services for your dental health. The Plan denied your request. The Plan says these 
services are 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 two 
prefabricated abutments (D6056 x2) and two abutment supported cast metal crowns (D6062 x2).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
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 services are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee presented with low back 
pain radiating to the legs. She reports stabbing pain in the back that keeps her up at night. The formal magnetic 
resonance imaging (MRI) report was not provided for review to corroborate the noted pathology at the 
requested procedure levels of L3 to L5. The non-radiating midline back pain, the noted pain-aggravating and 
pain-relieving factors, and intact neurologic exam were/are all non-specific to any pathologic entities. There are 
multiple plausible pathologic sources of significant pain generation. The Intracept procedure is therefore not 
reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an Intracept procedure.