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

 
We decided that the Plan does not have to pay for a retainer crown (D6750) and a pontic (D6240) provided by 
a participating provider on May 17, 2022. 
 
You asked the Plan to pay for a retainer crown and a pontic. You say that you think the Plan should pay for 
this. The Plan denied your request. The Plan says the rendered dental services are not covered 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 retainer 
crown (D6750) and a pontic (D6240) provided by a participating provider on May 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve addition to lower limb prosthesis, multiaxial ankle with 
swing phase active dorsiflexion feature (CPT code L5968) and all lower extremity prostheses, flex-walk system 
or equal (L5981). 
 
You asked the Plan to pre-approve the prosthesis. You say that the prosthesis is necessary. The Plan denied 
your request. The Plan says the K3 foot does not meet Medicare criteria as reasonable and necessary. 
 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the prosthesis. Our physician reviewer 
found although records from the device vendor argue that you are a K3 ambulator and that the requested device 
is medically necessary, no records from the enrollees actual treating provider clarify that the enrollee is a K3 
ambulator and why the requested device is the most appropriate treatment for the enrollees condition. 
 
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 prosthesis have not been met. Therefore, we decided that the Plan does not 
have to pre-approve addition to lower limb prosthesis, multiaxial ankle with swing phase active dorsiflexion 
feature (CPT code L5968) and all lower extremity prostheses, flex-walk system or equal (L5981).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 83789 billed for date of service April 11, 
2022. 
 
You asked the Plan to pay for procedure code 83789. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 83789 is bundled into payment for code G0481. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules also say that that providers may bill 
services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service. 
   
In this case, we have confirmed that code 83789 is a column II code to column I code G0481.  
While this claim was billed with modifier -59, the medical records provided do not show that the service billed 
with the -59 modifier is a distinct procedural service. Based on this information, we decided that Medicare 
rules for coverage of services billed with a -59 modifier have not been met. Based on the claim submitted, 
Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 83789 billed for date of service April 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two dimensional (2D) oral/facial photographic image 
(D0350), comprehensive oral evaluation (D0150), complete series of intraoral x-rays (D0210), and panoramic 
x-ray (D0330) provided on July 11, 2022. 
 
You asked the Plan to pay for the 2D oral/facial photographic image, comprehensive oral evaluation, complete 
series of intraoral x-rays, and panoramic x-ray. You say that you were not advised that these services would not 
be covered. The Plan denied your request. The Plan says the 2D oral/facial photographic image (D0350) is not 
a covered expense under your dental plan. The Plan also says that your benefits for the comprehensive oral 
evaluation, complete series of intraoral x-rays, and panoramic x-ray have already been exhausted. 
 Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. 2D oral/facial 
photographic image (D0350) is not a covered supplemental benefit. The record shows your benefits for the 
comprehensive oral evaluation (D0150), complete series of intraoral x-rays (D0210), and panoramic x-ray 
(D0330) were exhausted on date of service December 14, 2020. Therefore, we decided that the Plan does not 
have to pay for the two dimensional (2D) oral/facial photographic image (D0350), comprehensive oral 
evaluation (D0150), complete series of intraoral x-rays (D0210), and panoramic x-ray (D0330) provided on 
July 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and 
first intraoral periapical x-ray (D0220) provided on June 9, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the dental services. You say that you spoke with a Plan representative who 
advised you have an embedded dental benefit. You also say that you believe these services should be covered. 
The Plan denied your request. The Plan says the dental services were received from an OON provider and 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. 
 
 
 The record shows you received the requested dental services from an OON 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 OON provider. Therefore, we decided that the Plan does not have to pay for the 
problem focused limited oral evaluation (D0140) and first intraoral periapical x-ray (D0220) provided on June 
9, 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 cone beam imaging (D0364) and a bitewing x-ray (D0270) 
provided on June 6, 2022. 
 
You asked the Plan to pay for imaging and x-ray. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says cone beam imaging (D0364) and a bitewing x-ray (D0270) are not 
covered by your dental benefits when received 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 when received by an endodontist. Therefore, we decided that the Plan 
does not have to pay for cone beam imaging (D0364) and a bitewing x-ray (D0270) provided on June 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (code D0140) provided on  
June 15, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were referred to this network specialist, 
however you did not know that the provider would need further testing to perform the root canal. The Plan 
denied your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested service was exhausted on date of service February 9, 2022. Therefore, we 
decided that the Plan does not have to pay for a limited oral evaluation (code D0140) provided on 
June 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 85027 billed for date of service August 17, 
2020. 
 You asked the Plan to pay for procedure code 85027. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 85027 is bundled into payment for code 85025. 
 
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 85027 
is a column II code to column I code 85025. 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 procedure code 85027 billed for date of service August 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377), expandable controller 
harness (E2313) and electronic connection (E2311). 
 
You asked the Plan to pre-approve these items. You say that these items are medically necessary. The Plan 
denied your request. The Plan says that your upper limb strength and function are adequate for you to be able to 
control the power options using their own switches which are included in the allowance of these power options. 
 
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 items. Our reviewer says that the 
requested items are not considered medically reasonable and necessary in this case. These items exceed your 
requirements to meet your needs as you have full upper body limb function. Our physician reviewer found that 
your condition does not meet criteria for coverage of these services.  
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 items have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an expandable controller (E2377), expandable controller harness (E2313) and electronic 
connection (E2311).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing procedures (83789) billed for date of service 
April 1, 2022. 
 
You asked the Plan to pay for validity testing. You say that the validity testing at issue was a medical necessity 
for the enrollee. The Plan denied your request. The Plan says validity testing is not separately reportable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of validity testing have not been met. Specifically, we find that the testing described by the billed 
code is considered specimen validity testing which is not separately payable. Therefore, we decided that the 
Plan does not have to pay for validity testing procedures (83789) billed for date of service April 1, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the cost sharing for an office visit provided on April 28, 2022. 
 
You asked the Plan to waive the cost sharing for an office visit. You say that this service should have been paid 
for as a wellness visit. The Plan denied your request. The Plan says that the cost sharing applied was correct. 
 
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 records do not show a breakdown of the deductible to confirm it was met 
with the processing of this claim. If we cannot determine you met your deductible with the processing of this 
claim, this means that we cannot confirm the deductible and coinsurance you are being asked to pay is correct. 
Therefore, we decided that the Plan has to waive the cost sharing for an office visit provided on April 28, 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: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Leqvio (J1360). 
 
You asked the Plan to pre-approve Leqvio. You say that the requested drug is necessary for the enrollee. The 
Plan denied your request. The Plan says that the criteria for coverage have not been met. 
 
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 file indicates that the requested drug had been denied due to 
criteria having not been met. There were no records provided with the case file. We requested records, but we 
did not receive them. Without the records, we cannot determine that the criteria have not been met. Therefore, 
we decided that the Plan has to pre-approve Leqvio (J1360).  
 
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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. 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 Prolia. Our reviewer says that the 
requested drug is not medically reasonable and necessary. Our physician reviewer found the Plan requires a 
trial of bisphosphonate drugs for a year before they will approve the requested drug. In this case, the patient has 
not tried and failed the required drugs. There is no documentation provided indicating that the plans required 
drugs 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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Coolief genicular radiofrequency ablation provided to the 
enrollee on May 10, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the clinical value and effectiveness of a genicular nerve radiofrequency ablation in the setting of 
knee osteoarthritis have not been demonstrated in the peer-reviewed literature. 
 
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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that this is an experimental/ investigational procedure. Therefore, the procedure is deemed as 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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for Coolief genicular radiofrequency ablation provided to the enrollee on May 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the recliner chair with seat lift received on December 24, 
2021. 
 
You asked the Plan to pay for the recliner chair with seat lift. You say that your doctor told you to make sure 
you got a chair that was the right size. The Plan denied your request. The Plan says the item received is not a 
covered benefit when provided by an unauthorized Medicare provider. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the recliner chair with seat lift received 
on December 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept intraosseous ablation of the basivertebral 
nerve. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee has tried conservative 
treatment without relief. The Plan denied your request. The Plan says it has not been shown to be safe and 
effective in long term studies. 
 
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 requested services. Our physician 
reviewer found that the Intracept procedure is experimental. More research is needed to show safety and 
efficacy. Therefore, the request 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept intraosseous ablation of the basivertebral nerve.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on November 8, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the services rendered are not a covered benefit. 
 
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 the office visit provided on November 8, 2021 by 
an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiation therapy provided on May 11, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the radiation therapy. You say that the services were medically necessary and 
were authorized. The Plan denied your request. The Plan says the services were provided out-of-network and 
were not 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 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 the radiation therapy provided on May 11, 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 the chiropractic services. 
 
You asked the Plan to pre-approve the chiropractic services. You say that the services are necessary. The Plan 
denied your request. The Plan says excluded from Medicare coverage is any service other than manual 
manipulation for the treatment of subluxation. 
 
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 pre-approve the 
chiropractic services.