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

 
We decided that the Plan does not have to pay for the pulp vitality tests (D0460), and to pay more for the first 
intraoral periapical x-ray (D0220) and endodontic therapy (D3330) provided on September 7, 2021 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the pulp vitality tests, or pay more for the first intraoral periapical x-ray and 
endodontic therapy. You say that you are low income and cannot pay for these services. The Plan denied your 
request. The Plan says pulp vitality tests are not a covered benefit under your dental plan. The Plan also says 
that your member liability was applied correctly for the first intraoral periapical x-ray and endodontic therapy. 
 
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, pulp vitality tests (D0460) are not 
among those covered under this benefit. The contract says that you are responsible for the difference between 
the billed amount and allowed amount for covered dental services received OON. Therefore, we decided that 
the Plan does not have to pay for the pulp vitality tests (D0460), and to pay more for the first intraoral 
periapical x-ray (D0220) and endodontic therapy (D3330) provided on September 7, 2021 by an out-of-
network (OON) provider.
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 
removal of residual tooth roots (D7250) provided on September 7, 2021. 
 
You asked the Plan to pay for the problem focused limited oral evaluation and removal of residual tooth roots. 
You say that you were not advised that these services would not be covered, and you cannot afford to pay the 
bill. 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 the date of service to verify 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 pay for the 
problem focused limited oral evaluation (D0140) and removal of residual tooth roots (D7250) provided on 
September 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the facet joint injections. 
 
You asked the Plan to pre-approve the facet joint injections. You say that the service is necessary. The Plan 
denied your request. The Plan says the Medicare rules have not 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 the facet joint injections. Our physician 
reviewer found the enrollee has non-facet pathology demonstrated on radiology studies that could explain the 
source of the enrollee's pain. On magnetic resonance imaging (MRI), the enrollee has evidence of L5 burst 
fracture. Therefore, the request is deemed 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 facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the facet joint injections.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D6740), and a pontic (D6245) provided by a 
participating provider on January 5, 2022. 
 
You asked the Plan to pre-approve a crown and a pontic. You say that these services are needed. The Plan 
denied your request. The Plan says the requested 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 pre-approve a 
crown (D6740), and a pontic (D6245) provided by a participating provider on January 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) and 
preventive procedure (D1999) provided on January 28, 2022. 
 
You asked the Plan to pay for the comprehensive periodontal evaluation and preventive procedure. You say 
that you would like to be reimbursed $100. The Plan denied your request. The Plan says these services are not 
Medicare covered benefits and are excluded from coverage. 
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 
comprehensive periodontal evaluation (D0180) and preventive procedure (D1999) provided on January 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a K3 microprocessor knee and a K3 foot (L8428, 
L5848, L5856, L5845, L5981, L5986). 
 
You asked the Plan to pre-approve these items. You say that these are medically necessary. The Plan denied 
your request. The Plan says that there are no medical records from the physician/practitioner to show that you 
are a K3 ambulator. 
 
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. The requested K3 
microprocessor knee and K3 foot exceeds your medical needs and are not medically necessary. You use an 
assistive device of walker and wheelchair which is not consistent with a K3 level of ambulation. Your 
activities/hobbies do not require the advanced K3 knee and foot. Our physician reviewer found that your 
condition does not meet criteria for coverage of these items. 
 
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 a K3 microprocessor knee and a K3 foot (L8428, L5848, L5856, L5845, L5981, L5986).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS device (CPT code 33289). 
 
You asked the Plan to pre-approve the CardioMEMS device. You say that the service is necessary. The Plan 
denied your request. The Plan says the CardioMEMS device at this point should only be approved for enrollee's 
enrolled in a clinical trial. The Plan states there is no indication that this enrollee is enrolled in a clinical trial of 
the device. 
 
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 CardioMEMS device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found 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 the CardioMEMS device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the CardioMEMS device (CPT code 33289).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the coinsurance for outpatient clinic services provided on  
October 20, 2021 and October 21, 2021. 
 
You asked the Plan to waive the coinsurance for outpatient clinic services. You say that you met your 
out of pocket maximum as of July 2021. The Plan denied your request. The Plan says that you did not meet 
your out-of-pocket maximum until November 11, 2021. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says if you reach the maximum out-of-pocket amount of $7,000, you will not have to pay 
any out-of-pocket costs for the rest of the year for in-network covered Part A and Part B services. 
 
We looked at the file and the Plans rules. The file shows that you met your out-of-pocket maximum prior to 
the dates of services at issue in this case. Therefore, we decided that the Plan has to waive the coinsurance for 
outpatient clinic services provided on October 20, 2021 and October 21, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wheelchair accessory, power seat elevation system 
(E2300). 
 
You asked the Plan to pre-approve power seat elevation system. You say that the power seat elevation system 
is necessary for your condition. The Plan denied your request. The Plan says the requested accessory is not 
covered because it is not primarily medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a wheelchair accessory, power seat elevation system 
(E2300).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the readmission services provided from August 20, 2021, to August 22, 
2021. 
 
You asked the Plan to pay for the readmission services. The Plan denied your request. The Plan says that the 
readmission was not reasonable or necessary because the enrollee was not readmitted. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 readmission services. Our reviewer says 
that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the patient was admitted on August 20, 2021 for nausea, vomiting and abdominal pain. 
Evaluation revealed partial small bowel obstruction. Our reviewer found that the admitting physician well 
documented multiple past hospitalization and detailed treatment options that were limited due to other medical 
conditions. She was discharged on August 23, 2021. Our physician reviewer also found that the record shows 
that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary 
hospital care (including earlier emergency department and/or observation care) would span two midnights and 
medically necessary care did span more than two midnights. 
 
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 readmission services have been met. Therefore, we decided that the Plan has 
to pay for the readmission services provided from August 20, 2021, to August 22, 2021.  
 
 
 
 
 
 
 
 If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that you need the short-term rehab to walk and 
regain strength. The Plan denied your request. The Plan says that the services you require, such as additional 
therapy services, can safely be received at a different setting. 
 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 services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that your condition does not meet 
Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
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 
December 8, 2021. 
 
You asked the Plan to pay for the additional intraoral periapical x-ray. You say that you were told that these 
services would be billed under your medical insurance, not your dental insurance. You also say that if you had 
been told nothing was found that the services would be billed under your dental insurance, and you would be 
responsible for the bill. The Plan denied your request. The Plan says periapical radiographic image is limited to 
one procedure code per calendar year. The Plan also says that reimbursement has already issued for one 
periapical image.  
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 one 
procedure code per calendar year. The record shows that you received a first intraoral periapical x-ray (D0220) 
on December 8, 2021 which was covered by the Plan, 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 December 8, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care, first hour (99291) provided on November 5, 
2021, and the hospital discharge day management (99239) provided on November 8, 2021. 
 
You asked the Plan to pay for critical care and discharge management. You say that these services were billed 
appropriately. The Plan denied your request. The Plan says these services are not supported in the record. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. The CPT Code Manual definition of code 99239 is 
hospital discharge day management; more than 30 minutes.  
 
We find that CPT codes 99291 and 99239 are not supported in the medical record for the dates in question. 
Specifically, the records do not note the time spent providing these services. Based on this information, we 
decided that Medicare rules for coverage of critical care and discharge management have not been met. 
Therefore, we decided that the Plan does not have to pay for critical care, first hour (99291) provided on 
November 5, 2021, and the hospital discharge day management (99239) provided on November 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bone graft at time of implant placement (D6104) 
provided on November 10, 2021. 
 
You asked the Plan to pay for the bone graft. You say that you would like to appeal this service which you are 
requesting reimbursement for. The Plan denied your request. The Plan says this service is not a covered 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 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 bone 
graft at time of implant placement (D6104) provided on November 10, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Eliquis for the enrollee.

You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not covered under Part B.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Eliquis for the enrollee. 

Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), bitewing x-rays 
(D0274), and prophylaxis (D1110) provided on January 11, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the periodic oral evaluation, bitewing x-rays, and prophylaxis. You say that you 
were unable to find a participating dentist with the Plan. You also say that the treating provider advised you 
that they would try to become contracted with the Plan. The Plan denied your request. The Plan says these 
services were not rendered by an in-network provider. The Plan also says that you must receive services at a 
participating provider. 
 
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 
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the periodic 
oral evaluation (D0120), bitewing x-rays (D0274), and prophylaxis (D1110) provided on January 11, 2022 by 
an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on March 2, 2021. 
 
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 were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.  
 
 
 We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and 
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on March 2, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on March 23, 2021. 
 
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 were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.  
 
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and 
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on March 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services (77073) provided November 12, 2021. 
 
You asked the Plan to pay for the radiology services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the code billed is not eligible for separate payment. 
 
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 77073 is not supported in the medical record. Specifically, this service has a status 
indicator of "N" and payment is packaged into another service. Based on this information, we decided that 
Medicare rules for coverage of the radiology services have not been met. Therefore, we decided that the Plan 
does not have to pay for radiology services (77073) provided November 12, 2021.