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

 
We decided that the Plan does not have to pay for the two custom fabricated abutments (D6057 x2), two 
abutment supported porcelain/ceramic crowns (D6058 x2), and two pontics (D6245 x2) provided on October 5, 2021. 
 
You asked the Plan to pay for the custom fabricated abutments, abutment supported porcelain/ceramic crowns, 
and pontics. You say that you received these services due to an accident you were in. You also say that you feel 
these services should be covered. The Plan denied your request. The Plan says you had dental services for the 
treatment of your oral injuries with implants. The Plan also says that you do not meet the conditions for 
payment of these services as your Evidence of Coverage does not provide a benefit for the services requested. 
 
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 the two custom fabricated 
abutments (D6057 x2), two abutment supported porcelain/ceramic crowns (D6058 x2), and two pontics (D6245 
x2) provided on October 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the full mouth x-ray (D0210) provided on January 12, 2022. 
 
You asked the Plan to pay for the x-ray. You say that your dentist said you needed these x-rays, and they 
should be covered. The Plan denied your request. The Plan says you previously had a panoramic x-ray (D0330) 
provided and covered for December 8, 2021. Your benefit covers one panoramic or one full mouth x-ray every 
36 months. 
 
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 can cover one full 
mouth or panoramic x-ray every 36 months. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the x-ray is requested in a frequency 
that is not covered under this benefit. Therefore, we decided that the Plan does not have to pay for the full 
mouth x-ray (D0210) provided on January 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the reline of a complete mandibular denture (D5751) 
provided on December 14, 2021. 
 
You asked the Plan to pay for the reline of a complete mandibular denture. You say that you were not advised 
that the Plan was not going to pay the whole bill, and were not told that the Plan was only going to pay for one 
alignment. You also say that you thought the $2,000 benefit you have was for any service as long as you do not 
go over $2,000. The Plan denied your request. The Plan says your benefits for this service have been satisfied 
and the frequency limitation has been exceeded. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, denture reline is limited to one 
procedure code per calendar year. The record shows that you received a reline of a complete maxillary denture 
(D5750) on December 14, 2021, which was covered by the Plan, and your denture reline benefit has been 
exhausted. Therefore, we decided that the Plan does not have to pay for the reline of a complete mandibular 
denture (D5751) provided on December 14, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the SNF admission. You say that the requested admission to a SNF is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a SNF is not 
medically necessary. 
 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 admission. Our reviewer says 
that the requested services are not medically necessary. Our physician reviewer found you require continued 
care in the hospital at this time. Until you have stabilized medically there is no indication for transfer into a 
skilled nursing facility. 
 
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 admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care after January 16, 
2022. 
 
You asked the Plan to pre-approve SNF care after January 16, 2022. You say that the continued admission to a 
SNF is medically necessary. The Plan denied your request. The Plan says the continued admission to a SNF is 
not medically necessary. 
 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 care after January 16, 2022. Our 
reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not have daily 
skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional 
nurse. You do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment 
of a skilled professional therapist. You do not require daily skilled nursing and/or skilled therapy on an 
inpatient basis in a SNF setting. 
 
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 care after January 16, 2022, have not been met. Therefore, we decided that 
the Plan does not have to pre-approve skilled nursing facility (SNF) care after January 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine PCR panel testing coded as 87799, 87798, 87482, 
87150 provided December 23, 2021 by an out of network provider. 
 You asked the Plan to pay for the laboratory services. You say that please review and reprocess the claim 
following the CMS guidance. The Plan denied your request. The Plan says PCR testing is considered unproven 
and not medically necessary. Experimental or investigational services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered. 
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay 
for the urine PCR panel testing coded as 87799, 87798, 87482, 87150 provided December 23, 2021 by an out 
of network provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa (J7323). 
 
You asked the Plan to pre-approve Euflexxa. You say that this is supported in the records. The Plan denied 
your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise 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 Euflexxa. Our reviewer says that the 
requested use of Euflexxa is not medically necessary. Our physician reviewer found Euflexxa indicated for 
osteoarthritis pain in patients who have not responded to conservative nonpharmacologic therapy and simple 
analgesics, such as acetaminophen. The case file does not contain documentation that the enrollee has not 
responded to simple analgesics. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa (J7323).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prophylaxis - adult (D1110) provided October 27, 2021, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the dental cleaning. You say that this should not have been billed as OON. The 
Plan denied your request. The Plan says this service is not covered when provided OON. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the dental 
cleaning when provided in-network.  
 
We looked at the file and Medicare rules. 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. Based on this information, we decided that the Plan's rules for coverage of 
the dental cleaning have not been met. Therefore, we decided that the Plan does not have to pay for the 
prophylaxis - adult (D1110) provided October 27, 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 tooth extraction (D7140) provided on January 11, 2022. 
 
You asked the Plan to pay for the extraction. You say that this service was necessary as your tooth was cracked 
and causing you pain. The Plan denied your request. The Plan says you did not have dental benefits with your 
plan at the time of services. 
 
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 the tooth extraction (D7140) 
provided on January 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 1 heavy duty power operated vehicle for the 
enrollee. 
 
You asked the Plan to pre-approve a Group 1 heavy duty power operated vehicle. You say that this is medically 
necessary. The Plan denied your request. The Plan says that the enrollee does not meet criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that a power operated vehicle (POV) can be covered 
if the beneficiarys weight is less than or equal to the weight capacity of the POV that is provided and greater 
than or equal to 95% of the weight capacity of the next lower weight class. A Heavy Duty POV is covered for a 
beneficiary weighing 285  450 pounds. 
 
We looked at the file and Medicare rules. The file indicates the enrollee's weight does not fall within the 
required weight range. Based on this information, we decided that Medicare rules for coverage of a Group 1 
heavy duty power operated vehicle have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a Group 1 heavy duty power operated vehicle for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance (D4910) provided by a participating 
provider on December 30, 2021. 
 
You asked the Plan to pay for periodontal maintenance. You say that you do not understand why the Plan is not 
paying for this. The Plan denied your request. The Plan says D4910 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 
periodontal maintenance (D4910) provided by a participating provider on December 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided at 24-hour facility, in addition to basic 
service (99053) provided on August 26, 2021. 
 
  You asked the Plan to pay for the services provided at 24-hour facility, in addition to basic service (99053). 
You say that the correct CPT code and ICD10 were assigned, and no coding changes are required. You say that 
the attached medical records support the claim as originally submitted. The Plan denied your request. The Plan 
says procedure code 99285 has been overturned and procedure code 99053 remains denied as bundled services 
are 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 99053 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99053 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of the services provided at 24-hour facility, in addition to basic service (99053) have not been met. Therefore, 
we decided that the Plan does not have to pay for the services provided at 24-hour facility, in addition to basic 
service (99053) provided on August 26, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on June 28, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were 
billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample 
was taken in a laboratory setting. Therefore, we decided that the Plan does not have to pay for the lab services 
provided on June 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete denture - maxillary (D5110) and complete 
denture - mandibular (D5120) provided December 15, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the complete upper and lower dentures. You say that you believed that the 
provider would be covered. The Plan denied your request. The Plan says dentures are not covered when 
provided OON. 
 
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 complete 
upper and lower dentures when provided in-network.  
 
We looked at the file and Medicare rules. 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. Based on this information, we decided that the Plan's rules for coverage of 
the complete upper and lower dentures have not been met. Therefore, we decided that the Plan does not have to 
pay for the complete denture - maxillary (D5110) and complete denture - mandibular (D5120) provided 
December 15, 2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve an MRI of the lumbar spine. 
 
You asked the Plan to pre-approve an MRI of the lumbar spine. You say that an MRI is medically necessary. 
The Plan denied your request. The Plan says that the member had an MRI in mid-November of 2021, and there 
is no expectation of any major change. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 an MRI of the lumbar spine. Our 
reviewer says that an MRI of the lumbar spine is medically necessary. Our physician reviewer found that the 
records indicate a pedicle screw was removed in February 2022. Given the recent intervention since the 
previous MRI, a repeat MRI seems in order. 
 
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 MRI of the lumbar spine have been met. Therefore, we decided that the Plan 
has to pre-approve an MRI of the lumbar spine.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that all attending physicians have agreed that 
the enrollee is stable for transfer to the LTACH. In addition, they determined that the enrollee requires 
prolonged and intensive skilled services that are not available at a lower level of care. The Plan denied your 
request. The Plan says the requested LTACH services do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to be improving and more stable and should only require short-
term additional acute care services that can be safely administered at the current facility until more appropriate 
for a lower level of care. The enrollee does not require services at the LTACH that are not already available at 
the current facility. There are no services at the LTACH that the enrollee requires that are not already available 
and covered at the current facility. Transfer to an LTACH is not medically necessary as it would not be 
clinically advantageous. Transfer to a lower level of care may be considered when treatment has completed.  
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intraosseous Ablation of the Basivertebral Nerve 
Procedure (intracept device) (64628). 
 
You asked the Plan to pre-approve the intracept device. You say that the service is medically necessary. The 
Plan denied your request. The Plan says the service is experimental. 
 
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 intracept device. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this service is experimental and more research is needed on its safety and efficacy. 
 
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 intracept device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the Intraosseous Ablation of the Basivertebral Nerve Procedure (intracept device) 
(64628).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an MRI of the breast. 
 
You asked the Plan to pre-approve an MRI of the breast. You say that an MRI of the breast is medically 
necessary. The Plan denied your request. The Plan says the necessity of a breast MRI was dependent on the 
findings of the subsequent mammogram. The mammogram was read as a negative study with recommendation 
to repeat a screening mammogram in one year. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 an MRI of the breast. Our reviewer says 
that an MRI of the breast is not medically reasonable and necessary. Our physician reviewer found that you 
have a left breast lump, which has not been properly evaluated. The first step would be a left diagnostic 
mammogram followed by a targeted left breast ultrasound. At that point, pending the results, an MRI may be 
considered if still deemed necessary. You have no increased risk of breast cancer using the Gail model. 
 
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 MRI of the breast have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an MRI of the breast.