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

 
We decided that the Plan does not have to pre-approve a self-administered drug, Vyzulta Sol 0.024%. 
 
You asked the Plan to pre-approve a self-administered drug. You say that the requested drug is medically 
necessary. The Plan denied your request. The Plan says the requested medication does not fall under Part B 
coverage. The enrollee does not have pharmacy (drug) benefits administered by the Plan. 
 
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. The records show that this medication falls under Part D coverage and the enrollee does not 
have Part D coverage with the Plan. Therefore, we decided that the Plan does not have to pre-approve a self-
administered drug, Vyzulta Sol 0.024%.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services (G0483) provided on October 21, 
2021. 
 
You asked the Plan to pay for the drug testing services. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says the documentation received does not 
include definitive laboratory results for 22 or more drug classes to support the coding criteria for code G0483. 
 
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 G0483 is drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or 
more drug class(es), including metabolite(s) if performed  
 
We find that CPT code G0483 is not supported in the record. Specifically, the documentation submitted does 
not support that 22 or more drug classes were tested. Based on this information, we decided that Medicare rules 
for coverage of the drug testing services have not been met. Therefore, we decided that the Plan does not have 
to pay for the drug testing services (G0483) provided on October 21, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray services provided on September 2, 2021. 
 
You asked the Plan to pay for the services provided. You say that the radiology reports verify the services 
rendered. The Plan denied your request. The Plan says no modifiers are allowed with this code pair. 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
In this case, the CPT Code Manual definition of code 74220 is radiologic examination, esophagus, including 
scout chest radiograph(s) and delayed image(s), when performed; single-contrast (e.g., barium) study. 
 
We find that CPT code 74220 was billed on the same date of service as code 74230. We find that there is a 
correct coding modifier indicator of 0 for this code pair. This means that the column two code, 74220, is not 
eligible for payment. Based on this information, we decided that Medicare rules for coverage have not been 
met. Therefore, we decided that the Plan does not have to pay for the x-ray services provided on September 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the sacroiliac (SI) 
joint. 
 
You asked the Plan to pre-approve RFA of the SI joint. You say that this is not investigational. The Plan denied 
your request. The Plan says the denial of authorization for this service is correct, because this is 
experimental/investigational. 
 
The Plan follows Medicare rules. Medicare rules state that certain facet joint interventions are considered not 
medically 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 RFA of the SI joint.  Our reviewer says that the enrollee does not meet the Medicare criteria for the requested radiofrequency 
ablation. Our physician reviewer found according to the medical literature, sacral lateral nerve branch blocks 
and/or ablations for the diagnosis or treatment of sacroiliac joint mediated pain is considered experimental and 
investigational. Radiofrequency ablation for denervation, whether performed using traditional, cooled, or 
pulsed radiofrequency, is considered investigational and not medically 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 RFA of the SI joint have not been met. Therefore, we decided that the Plan does 
not have to pre-approve radiofrequency ablation (RFA) of the sacroiliac (SI) joint.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the 4 fillings provided on January 10, 2022. 
 
You asked the Plan to pay for the dental services. You say that you thought the $1,000 benefit noted in the 
Evidence of Coverage was for all dental work, not only covered (allowed) dental services. The Plan denied 
your request. The Plan says 2 fillings are covered per calendar year. The Plan also says that 
 
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 and fillings are listed as covered, there 
is a frequency limit of 2 per year with a 50% coinsurance that applies. This is a contractual obligation you 
agreed to when you enrolled in the Plans dental coverage. The record shows that the Plan paid 50% of the 
allowed amount for the fillings for teeth # 11 and 19. Therefore, we decided that the Plan does not have to pay 
for the 4 fillings provided on January 10, 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 these services are medically necessary. The Plan 
denied your request. The Plan says that ongoing skilled therapy and nursing needs can be provided 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. You 
are medically stable and do not need physical medicine and rehabilitation physician close supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical 
conditions. There are no rehab nursing needs identified or documented in the record. At the current functional 
level, you do not need 3 hours a day five days a week of IRF therapies with interdisciplinary management and 
your rehab needs can be met in an alternate and lower setting. Our physician reviewer found that your 
condition does not meet Medicare criteria for IRF 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 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the consultation (D9310), two non-autogenous connective 
tissue grafts (D4275 x2), and two combined connective tissue and pedicle grafts (D4276 x2) provided from 
July 10, 2021, to November 13, 2021. 
 
You asked the Plan to pay for the consultation, non-autogenous connective tissue grafts, and combined 
connective tissue and pedicle grafts. You say that you believe that the situation is a medical issue rather than 
cosmetic and you are appealing the denial of insurance. The Plan denied your request. The Plan says these 
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 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 
consultation (D9310), two non-autogenous connective tissue grafts (D4275 x2), and two combined connective 
tissue and pedicle grafts (D4276 x2) provided from July 10, 2021, to November 13, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chest x-ray (71045) provided on December 3, 2021. 
 
You asked the Plan to pay for the chest x-ray. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the documentation submitted does not support the 
service billed. 
 
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 the chest x-ray (71045) provided on 
December 3, 2021. have been met. Specifically, the record shows that the Plan processed and paid one unit of 
CPT code 7145. The documentation submitted does not show that this service was rendered more than once on 
the billed date of service. Therefore, we decided that the Plan does not have to pay for the chest x-ray (71045) 
provided on December 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom fabricated abutment (D6027) for tooth #14 to 
be provided by an out-of-network provider. 
 
You asked the Plan to pre-approve a custom fabricated abutment. You say that you are missing two teeth. The 
Plan denied your request. The Plan says the benefit limit for D6027 has been exhausted. 
 
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 one custom 
fabricated abutment per calendar year.  
 
We looked at the file and Medicare rules. D6027 is approved for tooth #13, but not tooth #14. Based on this 
information, we decided that the Plan's rules for coverage of a custom fabricated abutment have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a custom fabricated abutment (D6027) for 
tooth #14 to be provided by the provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140), panoramic x-ray 
(D0330), bitewing x-rays (D0274), and periapical x-ray (D0230) provided on December 13, 2021. 
 
You asked the Plan to pay for the dental services. You say that this visit was for a second opinion. You say that 
your goal is to save your tooth. You also say that you feel an exception should be made in this particular case in 
recognition of a serious medical necessity. The Plan denied your request. The Plan says the claim denied 
correctly. 
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 and the services are listed as covered, 
the frequency limits have been exceeded. The record shows that the Plan paid for oral exams that you received 
on September 7, 2021, and October 28, 2021. The record shows that the Plan paid for a complete series x-ray 
that you received on October 29, 2019. The record shows that the Plan paid for bitewing x-rays that you 
received on October 28, 2021. The record also shows that the Plan paid for the initial periapical x-ray that you 
received on the date of service in this case. Therefore, we decided that the Plan does not have to pay for the 
limited oral evaluation (D0140), panoramic x-ray (D0330), bitewing x-rays (D0274), and periapical x-ray 
(D0230) provided on December 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a rebase for a maxillary partial denture (D5720) provided by 
a participating provider on January 14, 2022. 
 
You asked the Plan to pay for a rebase for a maxillary partial denture. You say that you needed this dental work 
done. The Plan denied your request. The Plan says D5720 is not a covered dental 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 a rebase 
for a maxillary partial denture (D5720) provided by a participating provider on January 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve partial dentures (D5120 and D5110) to be provided by a 
participating provider. 
 
You asked the Plan to pre-approve partial dentures. You say that you need these dentures. The Plan denied 
your request. The Plan says the benefit limit for a partial denture has already been met. 
 
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 one partial 
denture every five years.  
 
We looked at the file and Medicare rules. Partial dentures were provided on June 14, 2019. Based on this 
information, we decided that the Plan's rules for coverage of partial dentures have not been met. Therefore, we 
decided that the Plan does not have to pre-approve partial dentures (D5120 and D5110) to be provided by a 
participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete mandibular and maxillary denture (D5120 and D5110) to be provided by a participating provider.

You asked the Plan to pre-approve a complete mandibular and maxillary denture. You say that you would like the Plan to approve the dentures. The Plan denied your request. The Plan says the benefit limit for D5120 or D5110 has already been exhausted.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a complete mandibular and maxillary denture once every five years. 

We looked at the file and Medicare rules. Evidence was provided to show that D5120 and D5110 were provided on January 20, 2020. Based on this information, we decided that the Plan's rules for coverage of a complete mandibular and maxillary denture have not been met. Therefore, we decided that the Plan does not have to pre-approve a complete mandibular and maxillary denture (D5120 and D5110) to be provided by a participating provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the home health services provided to the 
enrollee on September 29, 2021. 
 
You asked the Plan to waive the coinsurance. The Plan denied your request. The Plan says the claim processed 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay a 30% coinsurance for out-of-network home health services.  
 
Review of the file shows that the enrollee was provided out-of-network home health services on September 29, 
2021. The enrollee has been asked to pay a 30% coinsurance for the services. The services fall within the home 
health services benefit category. This means that the enrollee has been asked to pay the correct amount based 
on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon 
enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the home 
health services provided to the enrollee on September 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prophylaxis (D1110) provided on February 15, 2022 by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the prophylaxis. You say that you were not aware that the treating provider was 
non-participating. The Plan denied your request. The Plan says this procedure is not a covered benefit when 
rendered by a dentist who does not participate in this program. 
 
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 
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the 
prophylaxis (D1110) provided on February 15, 2022 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the simple extraction (D7140) or pay more for the periodic 
oral evaluation (D0120), bitewing x-rays (D0274), and prophylaxis (D1110) provided on September 21, 2021, 
and October 8, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the simple extraction and to pay more for the periodic oral evaluation, bitewing 
x-rays, and prophylaxis. You say that these claims should be paid. The Plan denied your request. The Plan says 
the $57 you were charged for the simple extraction was applied to your deductible correctly. The Plan says that 
the periodic oral evaluation, bitewing x-rays, and prophylaxis were covered at 100% of the Plan's allowance. 
The Plan also says that the treating provider can balance bill you the difference between what he billed and 
what was paid because he is a non-participating provider.  
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, you are responsible for a $100 
deductible for the extraction, plus the difference between the billed amount and allowed amount for dental 
services that are received OON. Therefore, we decided that the Plan does not have to pay for the simple 
extraction (D7140) or pay more for the periodic oral evaluation (D0120), bitewing x-rays (D0274), and 
prophylaxis (D1110) provided on September 21, 2021, and October 8, 2021 by an out-of-network (OON) 
provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2750) for tooth #3. 
 
You asked the Plan to pre-approve the crown. You say that the crown is broken and needs to be replaced. The 
Plan denied your request. The Plan says this service is allowed one time every 60 months. The Plan also says 
that you received this service less than 60 months ago. 
 
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, crowns are limited to once per 60 
months. The record shows that you received a crown (D2750) on tooth #3 on December 17, 2018 and your 
crown benefit for tooth #3 has been exhausted. Therefore, we decided that the Plan does not have to pre-
approve a crown (D2750) for tooth #3.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve peripheral nerve stimulation of the right suprascapular 
nerve. 
 
You asked the Plan to pre-approve peripheral nerve stimulator. You say that this is medically necessary. The 
Plan denied your request. The Plan says the denial of authorization for this service is correct, because studies 
have not shown that this is helpful for treatment of the enrollee. 
 
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 peripheral nerve stimulator. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found this procedure is experimental/investigational. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of peripheral nerve stimulator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve peripheral nerve stimulation of the right suprascapular nerve.