Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home infusion therapy (S9500) provided from October 7, 
2021, through October 14, 2021. 
 
You asked the Plan to pay for home infusion therapy (S9500). You say that the provider is contracted and falls 
under network status for the services. You say that the claim processed incorrectly as out-of-network and the 
claim should be reprocessed under the correct network status. The Plan denied your request. The Plan says the 
billed code is not valid for Medicare purposes. 
  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code S9500 has a Status Indicator of I on the Physician Fee Schedule. This means that CPT 
code S9500 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for 
coverage of home infusion therapy (S9500) have not been met. Therefore, we decided that the Plan does not 
have to pay for home infusion therapy (S9500) provided from October 7, 2021, through October 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a PureWick catheter system. 
 
You asked the Plan to pre-approve these services. You say that you have been using this for about seven 
months and it works well. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve a PureWick catheter system.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the freeing of intestinal adhesion (44005) provided on March 
4, 2021. 
 
You asked the Plan to pay for the freeing of intestinal adhesion (44005). You say that the operative report 
details the services and provides proof of necessity. You say that you have not been properly reimbursed and 
additional payment should be made. The Plan denied your request. The Plan says this edit has a modifier 
indicator of 0, which indicates there are no modifiers that are allowed with this code pair. 
  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 44005 
is a column II code to column I code 44204 with a modifier indicator of 0. The column II code is therefore not 
payable. 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 freeing of intestinal adhesion (44005) provided on March 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex Superion device. 
 
You asked the Plan to pre-approve the Vertiflex Superion device. You say that the enrollee has suffered from 
this condition for many years and has failed many months of conservative approaches to treatment. You say 
that you recommend this minimally invasive procedure as a safer alternative when conservative treatment has 
failed. The Plan denied your request. The Plan says Medicare does not cover experimental and investigational 
services. 
 
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 Vertiflex Superion device. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that the Vertiflex device is experimental, and more research is needed. 
 
 
  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 Vertiflex Superion device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the Vertiflex Superion device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an alignable system and flexible protective outer surface 
covering system. 
 
You asked the Plan to pre-approve an alignable system and flexible protective outer surface covering system. 
You say that the services are necessary. The Plan denied your request. The Plan says based on the 
documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that prosthetic knees are considered for coverage when 
specific criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an alignable system and flexible 
protective outer surface covering system. Our reviewer says that the services are not medically necessary. Our 
physician reviewer found the requested items exceed your medical need as the documentation does not reveal 
that your current approved alignable system is damaged or unable to be used. The documentation does not 
support that you require protection against unusually harsh environmental situations where it is necessary to 
protect the lower limb prosthesis beyond the level of protection that is afforded by a standard cover. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an alignable system and flexible protective outer surface covering system have 
not been met. Therefore, we decided that the Plan does not have to pre-approve an alignable system and 
flexible protective outer surface covering system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that you cannot afford the items on your 
own. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an epidural injection provided on November 15, 2021. 
 
You asked the Plan to pay for an epidural injection. The Plan denied your request. The Plan says the Health 
Plan has not received the required clinical records to support the medical necessity of the service for the date of 
service requested. The records provided are undated and unsigned. There is insufficient documentation of 
response to prior injections. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of an epidural injection provided on 
November 15, 2021 have been met. The Health Plan has not received the required clinical records to support 
the medical necessity of the service for the date of service requested. Therefore, we decided that the Plan does 
not have to pay for an epidural injection provided on November 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aid services (V5257, V5181) provided on 
October 5, 2020. 
 
You asked the Plan to pay for hearing aid services. You say that you cannot afford this bill, and it is your 
understanding that these services should have been covered by your out-of-network benefits. The Plan denied 
your request. The Plan says hearing aids are only covered when received through the specified hearing vendor. 
Out-of-network hearing aids are not covered. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when they are received through the Plans specified routine hearing vendor.  
 
We looked at the file and the Plan's rules. The hearing aids in this case were received from a provider outside 
the Plans specified routine hearing vendor network. Based on this information, we decided that the Plan's rules for coverage of hearing aid services have not been met. Therefore, we decided that the Plan does not have to 
pay for the hearing aid services (V5257, V5181) provided on October 5, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene panel provided on August 20, 2021. 
 
You asked the Plan to pay for the testing services. You say that the system connects physician with the most 
up-to-date treatment options. 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 looked at the file and the rules. The Tempus gene panel at issue was billed with multiple codes. If a single 
procedure is performed, only one code with one unit of service may be reported for the procedure. Based on 
this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we 
decided that the Plan does not have to pay for the gene panel provided on August 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene panel provided on August 18, 2021. 
 
You asked the Plan to pay for the testing services. 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 multiples codes. If a single procedure is performed, only one code 
with one unit of service may be reported for the procedure. Based on this information, we decided that 
Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does 
not have to pay for the gene panel provided on August 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve mandibular partial dentures for the enrollee. 
 
You asked the Plan to pre-approve the dentures. You say that this is medically necessary. The Plan denied your 
request. The Plan says dentures are only covered when there is a medical need for them. 
 
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 dentures 
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 dentures. Our reviewer says that the 
requested dentures are not medically reasonable or necessary. Our physician reviewer found that the copies of 
the dental x-rays available in the case file are of poor quality, and along with limited clinical documentation, do 
not support that mandibular partial dentures are reasonable and necessary in this case. 
 
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 dentures have not been met. Therefore, we decided that the Plan does not 
have to pre-approve mandibular partial dentures for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve osseous surgery (D4260) and gingival irrigation 
(D4921). 
  You asked the Plan to pre-approve osseous surgery (D4260) and gingival irrigation (D4921). The Plan denied 
your request. The Plan says the services remain 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the osseous surgery (D4260) and 
gingival irrigation (D4921) are not among those covered under this benefit. Therefore, we decided that the Plan 
does not have to pre-approve osseous surgery (D4260) and gingival irrigation (D4921).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home health skilled nursing visit (CPT code G0299). 
 
You asked the Plan to pre-approve the home health skilled nursing visit. You say that the enrollee has not met 
goals and is debilitated due to chronic illness. The Plan denied your request. The Plan says the approved visit 
should be enough for the provider to start care and complete an assessment.  
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health skilled nursing visit. 
Our physician reviewer found the health plans denial should be upheld. The enrollee does not have 
documented skilled nursing needs (i.e. IVs, complex wound care, new ostomy, new TFs). As such, the enrollee 
does not have documented skilled therapy 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 home health skilled nursing visit have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the home health skilled nursing visit (CPT code G0299).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services (D4212, D2740, D2950). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this 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. D2950 and D4212 have no benefit under your contract. Additionally, 
you have exhausted the benefit for crowns (D2740), as you were approved for one crown already for April 13, 
2022. Therefore, we decided that the Plan does not have to pre-approve dental services (D4212, D2740, 
D2950).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom abutment (D6057) and implant supported 
crown (D6066). 
 
You asked the Plan to pre-approve the dental services. You say that you are halfway through the procedure. 
You say that implants were covered last year. You also say that you are missing a tooth and in need of approval 
to finish the implant process. The Plan denied your request. The Plan says dental implants and all associated 
services 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested implant related services 
are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-
approve a custom abutment (D6057) and implant supported crown (D6066).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crowns (D2740) and core buildups, including any pins 
when required (D2950). 
 
You asked the Plan to pre-approve the crowns and core buildups. You say that you have not been able to eat 
solid foods for a number of months and you cannot keep doing a liquid diet. The Plan denied your request. The 
Plan says records were not provided that show a very large loss of tooth structure and not enough tooth left to 
hold the crown. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of crowns (D2740) and core buildups, 
including any pins when required (D2950) have been met. Medical records were not provided showing that the 
crowns and core buildups are necessary. Therefore, we decided that the Plan does not have to pre-approve 
crowns (D2740) and core buildups, including any pins when required (D2950).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services to be provided by an out of network 
dentist. 
 
You asked the Plan to pre-approve out of network dental services. You say that you have been seeing this 
dentist for 9 years. You say that you do not want to change dentists now. You say that you have anxiety when 
getting dental work done. You also say that you are comfortable with this provider. The Plan denied your 
request. The Plan says the requested provider is out of network. The Plan also says that dental services are 
covered with providers in the Dental Plan's preferred provider organization (PPO) network only. 
 
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 provider is not in the 
Dental Plan's PPO network. Services you receive from this provider are not among those covered under this 
benefit. Therefore, we decided that the Plan does not have to pre-approve dental services to be provided by an 
out of network dentist.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the transit system (CPT code K0108). 
 
You asked the Plan to pre-approve the transit system. You say that there is a need for this durable medical 
equipment (DME). The Plan denied your request. The Plan says the transit system is not covered by Medicare 
or the health plan. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home. The transit kit is used to strap the wheelchair to a vehicle to travel outside 
the home. The item at issue in this appeal is for use outside of the home. Although this item may be helpful, 
neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan 
does not have to pre-approve the transit system (CPT code K0108).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an immediate maxillary partial denture (D5223) and 
removable prosthodontic procedure (D5899). 
 
You asked the Plan to pre-approve an immediate maxillary partial denture and removable prosthodontic 
procedure. You say that the enrollee requires a new maxillary immediate cast partial. The Plan denied your 
request. The Plan says these services are not covered under the enrollee's benefit package. 
 
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 
immediate maxillary partial denture (D5223) and removable prosthodontic procedure (D5899).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implant supported porcelain/ceramic crown (D6065). 
 
You asked the Plan to pre-approve an implant supported porcelain/ceramic crown. You say that you would like 
this service to be reconsidered for coverage because you were halfway through with the treatment when your 
insurance was canceled without notice. The Plan denied your request. The Plan says this service is not covered 
under your benefit package. 
 
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 an 
implant supported porcelain/ceramic crown (D6065).