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

 
We decided that the Plan does not have to pay for the prophylaxis (D1110) provided on July 20, 2021. 
 
You asked the Plan to pay for the prophylaxis. You say that you were told that you could have 2 cleanings per 
year. You also say that you had not had any cleanings last year, and you did not exceed the limit. The Plan 
denied your request. The Plan says this service exceeds the frequency limitation in 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, prophylaxis (D1110) is limited to two 
procedures per plan year. The record shows that you received prophylaxes (D1110) on April 5, 2021, and 
November 19, 2021 and your prophylaxis (D1110) benefit has been exhausted. Therefore, we decided that the 
Plan does not have to pay for the prophylaxis (D1110) provided on July 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on 
January 31, 2022. 
 
You asked the Plan to pay for the comprehensive oral evaluation. You say that you are appealing because you 
were at the need of the dentist due to your broken tooth and time for a dental period maintenance. You also say 
that it was the beginning of a new year and the dentist needed to know the condition of your teeth. The Plan 
denied your request. The Plan says this service exceeds the frequency limitation in 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, comprehensive oral evaluation 
(D0150) and is limited to one procedure every three plan years. The record shows that you received a 
comprehensive oral evaluation (D0150) on March 4, 2020 and your comprehensive oral evaluation (D0150) 
benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive 
oral evaluation (D0150) provided on January 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional intraoral periapical x-ray (D0230) provided on 
March 8, 2022. 
 
You asked the Plan to pay for the additional intraoral periapical x-ray. You say that your dentist only takes x-
rays once per year, and it is a normal annual preventive service. The Plan denied your request. The Plan says 
your benefits for this service have been satisfied and the frequency limitation has been exceeded. 
 
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, intraoral x-rays are limited to 1 
procedure code per calendar year. The record shows that you received a first intraoral periapical x-ray (D0220) 
on March 8, 2022 and your intraoral x-rays benefit has been exhausted. Therefore, we decided that the Plan 
does not have to pay for the additional intraoral periapical x-ray (D0230) provided on March 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) and 
incisional biopsy of oral tissue (D7286) provided on February 9, 2022. 
 
You asked the Plan to pay for the comprehensive periodontal evaluation and incisional biopsy of oral tissue. 
You say that you went to the dentist for a cleaning and the dentist found extensive bone loss also with 
generalized tissue sloughing. The Plan denied your request. The Plan says these services are not covered 
benefits 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 pay for the 
comprehensive periodontal evaluation (D0180) and incisional biopsy of oral tissue (D7286) provided on 
February 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for the porcelain crown (D2740) for tooth 
# 5 provided on January 5, 2022. 
 
You asked the Plan to pay an additional amount for the dental service. You say that you purchased the extra 
dental coverage. You also say that the crown should be covered. The Plan denied your request. The Plan says if 
a method of treatment is more costly than is customarily provided, benefits will be paid on the least costly 
method of treatment. The Plan also says you will be responsible for the remaining balance. 
 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 crowns are listed as covered, the 
service was paid at the rate of an alternate benefit. The record shows that a porcelain crown was used. The 
record also shows that the claim was paid at the rate of a mental crown since this is the least costly treatment. 
You are responsible for the difference in the allowed amounts. Therefore, we decided that the Plan does not 
have to pay an additional amount for the porcelain crown (D2740) for tooth # 5 provided on January 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by a participating provider on 
December 9, 2021. 
 
You asked the Plan to pay for dental services. You say that you were in a lot of pain, and you needed these 
services done. The Plan denied your request. The Plan says this claim has been correctly denied. 
 
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 up to a $1,000 
maximum benefit allowance for covered dental services. 
 
We looked at the file and Medicare rules. Evidence was provided to show that the dental benefit maximum 
allowance has already been met and exhausted. Based on this information, we decided that the Plan's rules for coverage of dental services have not been met. Therefore, we decided that the Plan does not have to pay for 
dental services provided by a participating provider on December 9, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMs device. 
 
You asked the Plan to pre-approve a CardioMEMs device. You say that the requested device is medically 
necessary due to the enrollee's worsening heart condition. The Plan denied your request. The Plan says the 
requested device is 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 a CardioMEMs device. Our reviewer 
says that a CardioMEMs device is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there remains a dearth of randomized, blinded clinical studies examining long-term 
clinical outcomes establishing the value of CardioMEMS in patient management. As a result, at this time the 
CardioMEMS system would not be considered medically appropriate and necessary in this enrollee's clinical 
management. 
 
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 CardioMEMs device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMs device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the sales tax (S9999), from a purchase on December 22, 
2021. 
 
You asked the Plan to pay for the sales tax. You say that this should be covered. The Plan denied your request. 
The Plan says sales tax is not covered under any condition. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare does not reimburse separately for sales 
tax. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the sales tax have not been met. Therefore, we decided that the Plan does not have to pay for the 
sales tax (S9999), from a purchase on December 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene panel provided on March 8, 2021. You asked the Plan to pay for the gene panel. You say that the panel will be useful at initial diagnosis or with 
refractory disease. The Plan denied your request. The Plan says one code must be submitted for the panel. 
 
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 the gene panel was billed with multiple codes. Based on this information, we decided that 
Medicare rules for coverage of the gene panel have not been met. Therefore, we decided that the Plan does not 
have to pay for the gene panel provided on March 8, 2021.
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 the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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 is currently undergoing treatment at an ACH for pneumonia. The 
enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not 
currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no 
advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such 
time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for 
any ongoing LTC needs. 
 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional physical therapy provided by an out-of-
network provider. 
 
You asked the Plan to pre-approve physical therapy. You say that physical therapy helps with neuropathy. The 
Plan denied your request. The Plan says additional physical therapy sessions are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 physical therapy. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the documentation does not reveal a progression towards specific 
functional goals. The requested services are not part of a maintenance program, and the specialized skill, 
knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a program to 
maintain the enrollee's current condition or to prevent or slow further deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of physical therapy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve additional physical therapy provided by an out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator. 
 
You asked the Plan to pre-approve a spinal cord stimulator. You say that you are in a lot of pain and have been 
for years. The Plan denied your request. The Plan says the request is not medically necessary because the 
records do not show that this procedure option is being used as a last resort to treat your pain. 
 
The Plan follows Medicare rules. Medicare rules say that payment may be made for the implantation of dorsal 
column or depth brain stimulators when specific conditions have been met.  
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a spinal cord stimulator. Our reviewer 
says that the criteria for coverage have not been met. Our physician reviewer found the enrollee has chronic 
low back pain. His magnetic resonance imaging (MRI) shows L4-L5 foraminal stenosis. He has had an Intra-
thecal pump which was removed after when the enrollee thought it was not helpful. He had Dorsal root 
ganglion stimulator placed, revised and then removed. He had a psychological evaluation where unrealistic 
expectations were stated. There is no documentation of recent physical therapy, home exercise program, 
Chiropractic care or Acupuncture. There is no surgical consultation as to why the enrollee is not a candidate for 
foramenotomy. The requested procedure is not medically reasonable or 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 spinal cord stimulator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a spinal cord stimulator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic office visit (99202), provided on December 
3, 2021. 
 
You asked the Plan to pay for the chiropractic office visit. You say that the service should be covered. The Plan 
denied your request. The Plan says this is not a covered service. 
 
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 the chiropractic office visit (99202), provided on December 3, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency 
transport (A0428) and ground mileage (A0425) provided on October 15, 2021. 
 
You asked the Plan to pay for the ambulance services. You say that the ambulance services were medically 
necessary. The Plan denied your request. The Plan says the records do not show that the enrollee could not 
have been transported in a wheelchair van or an automobile. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
  
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 pay for the ambulance services. Our reviewer says 
that the ambulance services are not medically necessary. Our physician reviewer found the provided 
documentation does not support that other means of transport (such as stretcher van, wheelchair van, taxi, 
private car, or other type of vehicle) were contraindicated for the enrollee on October 15, 2021. The reviewer 
found that the documentation does not support that the enrollee needed the expertise, services and lifesaving 
and life-sustaining equipment that only a fully-equipped ambulance can provide for safe transport on October 
15, 2021. Therefore, the reviewer found that the ambulance transport on October 15, 2021 was not medically 
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 the ambulance services have not been met. Therefore, we decided that the Plan 
does not have to pay for the ambulance service, basic life support, non-emergency transport (A0428) and 
ground mileage (A0425) provided on October 15, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing provided on December 30, 2021. 
You asked the Plan to pay for the services provided. You say that the services were performed in good faith. 
The Plan denied your request. The Plan says the testing is unlikely to impact therapeutic decisions. 
 
The Plan must follow Medicare rules. Medicare rules say that by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation. 
 
We looked at the file and Medicare rules. The records in the case file does not show that the hematology profile 
will change the management of the enrollees medical conditions. Based on this information, we decided that 
Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan 
does not have to pay for the lab testing provided on December 30, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve therapeutic procedure, 1 or more areas, each 15 
minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility (97110) and 
application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes (97032) to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve physical therapy and electrical stimulation. You say that this service is 
medically necessary. The Plan denied your request. The Plan says while this service may be medically 
necessary, the services are not covered when provided OON. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and 
endurance, range of motion and flexibility (97110) and application of a modality to 1 or more areas; electrical 
stimulation (manual), each 15 minutes (97032) to be provided by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency 
transport (A0428) and ground mileage (A0425) provided on November 24, 2021. 
 
You asked the Plan to pay for the ambulance services. You say that the ambulance services were medically 
necessary. The Plan denied your request. The Plan says the enrollee could have been transported in a 
wheelchair van or an automobile. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
 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 pay for the ambulance services. Our reviewer says 
that the ambulance services were not medically necessary. Our physician reviewer found the provided 
documentation does not support that other means of transport (such as stretcher van, wheelchair van, taxi, 
private car, or other type of vehicle) were contraindicated for the enrollee. The reviewer found that there were 
no acute medical issues and the reason for transport was for a routine physician appointment for eye exam. The 
reviewer found that the documentation does not support that the patient needed the expertise, services and 
lifesaving and life-sustaining equipment that only a fully-equipped ambulance can provide for safe transport. 
Therefore, the reviewer found that the ambulance services were not medically reasonable or 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 the ambulance services have not been met. Therefore, we decided that the Plan 
does not have to pay for the ambulance service, basic life support, non-emergency transport (A0428) and 
ground mileage (A0425) provided on November 24, 2021.