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

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a complete lower 
denture (D5120). 
 
You asked the Plan to pre-approve the dental items. You say that your denture fell out when you were sleeping. 
You say that your dog chewed it up. You also say that your dentist confirmed it could not be repaired and you 
would need a new set. The Plan denied your request. The Plan says dentures are covered once every 5 plan 
years. The Plan also says that the frequency limit has been reached. 
 
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 dentures are covered once every 5 
plan years, the frequency limit has been reached. The record shows that the Plan paid for a complete upper and 
complete lower denture that you received on January 15, 2020. Therefore, we decided that the Plan does not 
have to pre-approve a complete upper denture (D5110) and a complete lower denture (D5120).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transforaminal epidural of the right lumbar or sacral 
level (64484RT). 
 
You asked the Plan to pre-approve a transforaminal epidural. You say that the requested service is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for the 
requested service have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that no more than two transforaminal injections may 
be performed at a single setting (e.g. single level bilaterally or two levels unilaterally). 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a transforaminal epidural have not been met. Specifically, the Plan has already agreed to pre-
approve two transforaminal injections at the same setting. Therefore, we decided that the Plan does not have to 
pre-approve a transforaminal epidural of the right lumbar or sacral level (64484RT).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an apicoectomy (D3421), retrograde filling (D3430), 
collection and application of autologous blood concentrate product (D7921), intravenous moderate sedation 
(D9239, D9243), therapeutic parenteral drugs (D9610) and a bone graft (D3428) for tooth #4. 
 
You asked the Plan to pre-approve the dental services. You say that you have an infected tooth and these 
services are medically necessary. The Plan denied your request. The Plan says these services are not covered by 
your 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 pre-approve an apicoectomy (D3421), retrograde filling (D3430), collection and application of autologous blood concentrate product (D7921), intravenous moderate sedation (D9239, D9243), therapeutic parenteral drugs (D9610) and a bone graft (D3428) for tooth #4.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrocardiogram (ECG) report. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable. 
 
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 93010 
is a column II code to column I code 31500. 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 electrocardiogram (ECG) report.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the local anesthesia not in conjunction with operative or 
surgical procedures (D9210) provided on December 22, 2021. 
 
You asked the Plan to pay for the local anesthesia. You say that you are very hyper at the dental office and that 
you are more comfortable receiving routine dental work when the anesthetic is applied. The Plan denied your 
request. The Plan says this service is 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 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 local 
anesthesia not in conjunction with operative or surgical procedures (D9210) provided on December 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the three core buildups, including any pins when required 
(D2950 x3), two pontics (D6245 x2), and three retainer crowns (D6740 x3) provided on January 8, 2022. 
 
You asked the Plan to pay for the core buildups, pontics, and retainer crowns. You say that you cannot afford 
this dental work with the Plan's coverage helping to pay for this care. The Plan denied your request. The Plan 
says these services are not covered expenses 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 three 
core buildups, including any pins when required (D2950 x3), two pontics (D6245 x2), and three retainer 
crowns (D6740 x3) provided on January 8, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy evaluation provided on December 20, 
2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the physical therapy evaluation. You say that the provided records substantiate 
the medical necessity for the services rendered. The Plan denied your request. The Plan says the treating 
provider is not a network provider with the Plan. The Plan also says that these services are not urgent or 
emergent, nor were they approved in advance. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
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 the physical therapy evaluation provided on 
December 20, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower bench.

You asked the Plan to pre-approve these services. You say that you need the item to help keep you safe. The Plan denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. 

While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower bench.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation feature represented by code E2300. 
 
You asked the Plan to pre-approve code E2300. You say that you are unable to walk or lift yourself. You say 
that your wife cannot lift you to transfer you from the wheelchair to a bed or car. The Plan denied your request. 
The Plan says the item in dispute is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature is non-covered 
because it is not primarily medical in nature.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code E2300 have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
power seat elevation feature represented by code E2300.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for the lidocaine injection rendered on December 2, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says that the services are not separately payable. 
 
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. The Plan states that code J2001 is a column II code with a modifier indicator of 
1 when billed with column I code 20611; however, there are no National Correct Coding Initiative (NCCI) 
procedure-to-procedure (PTP) edits for this code pair for the date of service at issue. The Plan has not provided 
any documentation or Medicare rules to support that code J2001 is not payable as billed. Therefore, we decided 
that the Plan has to pay for the lidocaine injection rendered on December 2, 2020.  
 
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 provide additional payment for the custom fabricated abutment - 
includes placement (D6057) and crowns - porcelain fused to high noble metal (D2750) provided January 21, 2022. 
 
You asked the Plan to provide additional payment for the custom fabricated abutment and crowns. You say that 
an implant or abutment is covered every 60 months. The Plan denied your request. The Plan says you have 
exceeded your maximum dental allowance. 
 
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 the custom 
fabricated abutment and crown up to a $1,000 maximum annual allowance.  
We looked at the file and Medicare rules. The Plan provided documentation showing that your full $1,000 
dental allowance was applied towards the services provided on January 21, 2022. Therefore, we decided that 
the Plan does not have to provide additional payment for the custom fabricated abutment - includes placement 
(D6057) and crowns - porcelain fused to high noble metal (D2750) provided January 21, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the problem focused limited oral evaluation (D0140) and incisional 
biopsy of oral tissue (D7286) provided on January 4, 2022. 
 
You asked the Plan to pay for the problem focused limited oral evaluation and incisional biopsy of oral tissue. 
You say that the biopsy you received was a form of surgery which was covered. The Plan denied your request. 
The Plan says that these dental services, unless related to a surgery of the jaw/facial bone, is not covered by 
your medical plan. The Plan also says that if you have dental coverage, you should submit to that dental plan 
for coverage determination. 
 
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. The Plan did not provide a copy of the applicable 2022 Evidence of Coverage 
for this case. Without this information we cannot determine that the Plan's coverage rules support the denial of 
payment in this case, or that the enrollee has been adequately notified of the Plan's coverage rules and benefits. 
Consequently, the Plan has not substantiated their denial of payment in this case. Therefore, we decided that 
the Plan has to pay for the problem focused limited oral evaluation (D0140) and incisional biopsy of oral tissue 
(D7286) provided on January 4, 2022.  
 
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 pre-approve scaling and root planing (D4341) for all 4 quadrants. 
 
You asked the Plan to pre-approve the dental services. You say that the services are medically necessary. The 
Plan denied your request. The Plan says the scaling and root planing are not medically necessary. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the dental 
services when the services are medically necessary and reasonable.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the dental services. Our reviewer says 
that the requested dental services are not medically necessary. Our physician reviewer found the provided 
documentation does not indicate evidence of noticeable bone loss on four or more teeth in any one quadrant 
despite abnormal periodontal charting measurements.  As abnormal pocket readings may be due to gingival 
inflammation or other conditions and not necessarily periodontal disease, the lack of evidence of attachment 
loss on four or more teeth in a quadrant precludes the use of D4341. Therefore, the reviewer found that there is 
no necessity for the requested scaling and root planing.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve scaling and root planing (D4341) for all 4 quadrants.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Genvisc. 
 
You asked the Plan to pre-approve Genvisc. You say that this drug is medically necessary for the enrollee's 
condition. The Plan denied your request. The Plan says step therapy criteria have not been met. 
 
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 Genvisc. Our reviewer says that the 
requested drug is not medically reasonable and necessary. Our physician reviewer found the Plan requires a 
trial of Orthovisc, Synvisc, or Synvisc-One before they will approve the requested drug. In this case, the patient 
has not tried and failed the required drug(s). There is no documentation provided indicating that the Plans 
required drug(s) would likely be less effective and/or likely 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 Genvisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Genvisc.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections-cervical medial branch block at the 
third level. 
 
You asked the Plan to pre-approve facet joint injections-cervical medial branch block injections. The Plan 
denied your request. The Plan says the third level exceeds the number of injections allowed in a 12-month 
rolling period. The Plan follows Medicare rules. Medicare rules say that for each covered spinal region no more than two (2) 
radiofrequency sessions will be reimbursed per rolling 12 months. 
 
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 facet joint injections-cervical medial 
branch block, third level. Our reviewer says that facet joint injections-cervical medial branch block, third level 
is considered not medically reasonable or necessary. Our physician reviewer found that the utilization criteria 
limit the repeat block to 2 levels only. The third level is considered 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 facet joint injections-cervical medial branch block, third level have not been 
met. Therefore, we decided that the Plan does not have to pre-approve facet joint injections-cervical medial 
branch block, third level.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the three periodontal scalings and root planings (D4342 x3), 
four gingival irrigations (D4921 x4), two drugs or medicaments dispensed in the office for home use (D9630 
x2), and two additional intraoral periapical x-rays (D0230 x2) provided on November 17, 2021, and December 
1, 2021. 
 
You asked the Plan to pay for the scalings and planings, gingival irrigations, drugs or medicaments, and 
additional intraoral periapical x-rays. You say that this should not be looked at as a dental claim because you 
feel it is a medical claim. The Plan denied your request. The Plan says the scalings and planings, gingival 
irrigations, and drugs or medicaments are not covered expenses under your dental plan. The Plan also says that 
your benefits for the intraoral periapical x-rays 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, periodontal scaling and root planing 
(D4342), gingival irrigation (D4921), and drugs or medicaments dispensed in the office for home use (D9630) 
are not among those covered under this benefit. The contract says that intraoral x-rays are limited to one 
procedure code per calendar year. The record shows that you received a first intraoral periapical x-ray (D0220) 
on November 17, 2021 and your intraoral x-rays benefit has been exhausted. Therefore, we decided that the 
Plan does not have to pay for the three periodontal scalings and root planings (D4342 x3), four gingival 
irrigations (D4921 x4), two drugs or medicaments dispensed in the office for home use (D9630 x2), and two 
additional intraoral periapical x-rays (D0230 x2) provided on November 17, 2021, and December 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81404 and 81479) provided on 
September 20, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Specifically, this claim was billed with the laboratory 
POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided 
that the Plan does not have to pay for the laboratory services (81404 and 81479) provided on September 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on November 14, 2021. 
You asked the Plan to pay for lab tests. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of payment for this testing is correct, because the documentation 
submitted does not support the Place of Service (POS) code billed on this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of lab tests have not been met. Specifically, this claim was billed with the laboratory POS code. The 
records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the Plan 
does not have to pay for laboratory testing provided on November 14, 2021.