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

 
We decided that the Plan does not have to pay for Complete dentures on August 31, 2021. 
 
You asked the Plan to pay for Complete dentures. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the member's plan excludes coverage for this service and 
the cost share is correct. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for Complete dentures on August 31, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral - complete series of radiographic images (code 
D0210) provided on February 16, 2022. 
 
You asked the Plan to pay for the intraoral x-rays. You say that the x-rays should be paid for by the plan. The 
Plan denied your request. The Plan says the service was denied due to the coverage limitations. The enrollee is 
allowed a complete intraoral series once every 60 months but received this service again before 60 months have 
passed (April 3, 2017). 
 
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 intraoral x-
rays when the services are medically necessary and reasonable once every 60 months.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of intraoral x-rays have not been met. Therefore, we decided that the Plan does not have to pay for the 
intraoral - complete series of radiographic images (code D0210) provided on February 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve adapter interface plate (K0108) expandable controller 
(k0108) cellphone holder (K0108) Gatlin midline mount (K0108) height adjustable mount with flat fixed 
bracket (K0108) Gatlin mount (K0108) satellite twister black (K0108) satellite twister red (K0108). 
 You asked the Plan to pre-approve the wheelchair accessories. You say that the medical records provided will 
show proof of medical necessity. The Plan denied your request. The Plan says these items either do not serve a 
medical purpose, is not for use inside the home and not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at this the file, and Medicare rules. Code K0108 must not be used for any component or feature of 
an expandable controller at the time of initial issue. Based on this information, we decided that Medicare rules 
for coverage of the wheelchair accessories have not been met. Therefore, we decided that the Plan does not 
have to pre-approve adapter interface plate (K0108) expandable controller (k0108) cellphone holder (K0108) 
Gatlin midline mount (K0108) height adjustable mount with flat fixed bracket (K0108) Gatlin mount (K0108) 
satellite twister black (K0108) satellite twister red (K0108).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of leg without 
contrast. 
 
You asked the Plan to pre-approve a CT scan. You say that the requested CT scan is necessary when 
performing a robotic assisted hip replacement. The Plan denied your request. The Plan says the requested CT 
scan is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically 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 a CT scan. Our reviewer says that the 
requested CT scan is not medically necessary. Our physician reviewer found there is no compelling rationale 
presented or extenuating circumstances noted to support the medical necessity of this request as an exception. 
Therefore, the request for CT scan of the left without contrast (pre-operative for MAKO robotic assisted hip 
arthroplasty) is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a CT scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a computed tomography (CT) scan of leg without contrast.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic activities coded 97530 provided on 
September 9, 2020. 
 
You asked the Plan to pay for the therapeutic activities. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation. 
 
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 97530 is therapeutic activities, direct (one-on-one) 
patient contact (use of dynamic activities to improve functional performance), each 15 minutes. 
 
 
 We find that CPT code 97530 is not supported in the medical record. Specifically, the submitted medical 
records indicate that a certified occupational therapy assistant performed the therapeutic procedure in a home 
health or hospice setting. There is a more appropriate code to be billed for the services provided. Based on this 
information, we decided that Medicare rules for coverage of the therapeutic activities have not been met. 
Therefore, we decided that the Plan does not have to pay for the therapeutic activities coded 97530 provided on 
September 9, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for the Transcutaneous Electrical Nerve Stimulators (TENS) supply
(A4595), provided on February 8, 2022.
You asked the Plan to pay for the TENS supply. You say that the items are medically necessary. The Plan
denied your request. The Plan says that the items are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item
or service, then that item or service will be covered when it is medically 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 pay for the TENS supply. Our reviewer says that the
requested items are considered medically reasonable and necessary in this case. Our physician reviewer found
this member meets LCD criteria for coverage of this item.
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 TENS supply have been met. Therefore, we decided that the Plan has to pay
for the Transcutaneous Electrical Nerve Stimulators (TENS) supply (A4595), provided on February 8, 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 a fixed bridge for tooth #'s 23, 24, 25, 26 (D6241) and 
retainer crowns for tooth #'s 22 and 27 (D6751). 
 
You asked the Plan to pre-approve a fixed bridge and crowns. You say that you received approval to have the 
teeth removed and need the bridges completed. The Plan denied your request. The Plan says these services 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 a fixed bridge 
and crowns 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 a fixed bridge and crowns. Our 
reviewer says that the criteria for coverage are not met. Our physician reviewer found that a fixed bridge may 
be covered if two mandibular anterior teeth are missing, and no other teeth are missing in the arch.   In this case, four mandibular anterior teeth are missing (#'s 23, 24, 25 and 26) and other teeth in the arch are 
missing (#'s 18 and 31). 
 
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 a fixed bridge and crowns have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a fixed bridge for tooth #'s 23, 24, 25, 26 (D6241) and retainer crowns for 
tooth #'s 22 and 27 (D6751).
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the occlusal orthotic device (D7880) provided by an out-of-network provider on September 13, 2021.

You asked the Plan to pay for the occlusal orthotic device (D7880). You say that the device is not for your teeth, it is for your jaw. The Plan denied your request. The Plan says that the diagnosis of temporomandibular joint dysfunction (TMJ) has not been established and the claim denied.

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 occlusal orthotic device (D7880) 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 pay for the occlusal orthotic device (D7880). Our reviewer says that the service is medically necessary. Our physician reviewer found the documentation provided meets the criteria for coverage for an occlusal orthotic appliance (D7880) for treatment of the patient's Temporomandibular joint (TMJ) Dysfunction. The record shows a diagnosis of Bilateral Disc Disorder, Bilateral Arthralgia and Myalgia of the associated muscles. This diagnosis is medical in nature and not related to any treatment of the teeth or supporting structures of the teeth. 

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 occlusal orthotic device (D7880) have been met. Therefore, we decided that the Plan has to pay for the occlusal orthotic device (D7880) provided by an out-of-network provider on September 13, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Laminectomy/Discectomy, Lumbar (CPT code 
62380). 
 
You asked the Plan to pre-approve the surgery. You say that you are in a lot of pain and were told by your 
doctor that you could have this surgery. You state you have been through twenty (20) or more physical therapy 
visits with no relief. The Plan denied your request. The Plan says more research is needed to show safety and 
efficacy. The Plan states open laminectomy remains the gold standard for laminectomy decompression. The 
Plan states this procedure is considered experimental/investigational and cannot be approved. 
 
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 surgery. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is limited published, large-scale, long-term peer-reviewed literature that shows this 
request to be an effective and/or safe treatment for the noted pathology. Further studies are needed to support 
this surgical procedure over a more standard laminectomy/discectomy procedure(s). There is no compelling 
rationale presented or extenuating circumstances noted to support the medical necessity of this request as an 
exception. Therefore, the request for laminectomy/discectomy of the lumbar spine at L4-5 (CPT code 62380) 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 surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Laminectomy/Discectomy, Lumbar (CPT code 62380).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral x-rays (D0220, D0230) provided on March 23, 2022. 
 
You asked the Plan to pay for the intraoral x-rays. You say that the services should be covered as you disagree 
with the charges. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental 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 services have exceeded 
your annual benefit limit. Therefore, we decided that the Plan does not have to pay for intraoral x-rays (D0220, 
D0230) provided on March 23, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve six (6) HH OT services (CPT code G0152 x 6) and eight 
(8) HH PT services (CPT code G0151 x 8). 
 
You asked the Plan to pre-approve the home health services. You say that the services are necessary. The Plan 
denied your request. The Plan says the services are not necessary.  
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 services. Our physician 
reviewer found the health plans denial should be upheld. The enrollee does not have documented, ongoing, 
HH PT needs. The enrollee is functioning at a level commiserate with their injury. The enrollee has an 
available caregiver. The additionally approved HH OT is appropriate. The denied, ongoing, HH PT and HH OT 
services are not medically necessary or reasonable. 
 
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 services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve six (6) HH OT services (CPT code G0152 x 6) and eight (8) HH PT services 
(CPT code G0151 x 8).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drugs dispensed in the office for home use (D9630) provided 
on November 8, 2021. 
 
You asked the Plan to pay for office dispensed drugs. You say that you disagree with the denial for denial 
services. The Plan denied your request. The Plan says that drugs dispensed in the office for home use (D9630) 
are not covered by your Plan's supplemental dental 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 drugs 
dispensed in the office for home use (D9630) provided on November 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for palliative emergency treatment (D9110) provided on 
November 23, 2021. 
 
You asked the Plan to pay for palliative treatment. You say that the palliative care was needed for a 
deteriorating tooth under a cap, and it was medically necessary to prevent pain and potential further damage. 
The Plan denied your request. The Plan says that palliative emergency treatment (D9110) is not covered by 
your preventive dental 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 palliative 
emergency treatment (D9110) provided on November 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a root canal treatment (D3346-) provided on February 21, 2022. 
 
You asked the Plan to pay for the root canal treatment. You say that the services should be covered as you 
disagree with the charges. The Plan denied your request. The Plan says the services denied correctly as they do 
not fall within your dental 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, you have exceeded the frequency limit 
for root canals, the Plan's contract states that these services may only be performed once per lifetime per tooth. 
The record indicates that your previous root canal was in 2017. Therefore, we decided that the Plan does not 
have to pay for a root canal treatment (D3346-) provided on February 21, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that an admission to an IRF is medically necessary. The 
Plan denied your request. The Plan says your needs can be met at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found your medical problems are stable and there are no complex nursing or rehabilitation 
needs.  While you have a need for physical or occupational therapy, there is no documentation of a need for an 
intensive rehabilitation program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
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 the SNF services. You say that SNF services are medically necessary 
because the enrollee's wife can no longer care for them at home. The Plan denied your request. The Plan says 
the enrollee does not meet criteria for SNF services, their needs can be met at a lower level of care like home 
health services. 
 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 the SNF services. Our reviewer says 
that the requested SNF care is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee does not qualify for SNF coverage. The enrollee does not have documented skilled 
nursing or therapy needs.  Daily skilled services are not shown to be required to establish a maintenance 
program or to prevent deterioration of the enrollees condition. The enrollees care needs, custodial and 
intermittent, can be provided at a lower level of care. 
 
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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar ESI (CPT code 62323). 
 
You asked the Plan to pre-approve the ESI's. You say that you are requesting this due to spinal stenosis, lumbar 
region without neurogenic claudication. 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 ESI's. Our physician reviewer found 
the review has determined that the requested ESI's are 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 ESI's have not been met. Therefore, we decided that the Plan does not have 
to pre-approve lumbar ESI (CPT code 62323).