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

 
We decided that the Plan does not have to pay for an occlusal guard (D9944), adjunctive pre-diagnostic test 
(D0431), periodontal scaling and root planing (D4342), and gingival irrigation (D4921), provided by a 
participating provider on March 2, 2022, to March 3, 2022. 
 
You asked the Plan to pay for an occlusal guard, adjunctive pre-diagnostic test, periodontal scaling and root 
planing, and gingival irrigation. You say that you feel like this should be covered. The Plan denied your 
request. The Plan says the services provided are not covered 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 an occlusal guard (D9944), adjunctive pre-diagnostic test (D0431), periodontal scaling and root planing (D4342), 
and gingival irrigation (D4921), provided by a participating provider on March 2, 2022, to March 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve four semi-precision attachment abutments (D6052 x4), 
maxillary interim complete denture (D5810), and mandibular interim complete denture (D5811). 
 
You asked the Plan to pre-approve the semi-precision attachment abutments and interim complete dentures. 
The Plan denied your request. The Plan says these services are not covered under the enrollee's benefit plan. 
 
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 four 
semi-precision attachment abutments (D6052 x4), maxillary interim complete denture (D5810), and 
mandibular interim complete denture (D5811).
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 the LTACH services are medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
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 records show the patient is currently not stable for transfer with worsening kidney 
function. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bone replacement graft (D4263) and osseous surgery 
(D4261), provided by an out-of-network provider on April 26, 2022. 
 
You asked the Plan to pay for a bone replacement graft and osseous surgery. You say that this should be 
covered. The Plan denied your request. The Plan says the rendered dental work are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a bone 
replacement graft (D4263) and osseous surgery (D4261), provided by an out-of-network provider on April 26, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (81455) provided December 23, 2021. 
 
You asked the Plan to pay for the genetic testing. You say that the services were medically necessary. The Plan 
denied your request. The Plan says this is not a covered procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that genetic testing procedures submitted with code 
81455 are unlikely to impact therapeutic decision-making in the clinical management of the patient and will be 
denied automatically as not medically necessary. 
 
We looked at the file and Medicare rules. This procedure is not covered. Based on this information, we decided 
that Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan 
does not have to pay for genetic testing (81455) provided December 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for resin-based composite - one surface, anterior (D2330), add 
clasp to existing partial denture - per tooth (D5660), add tooth to existing partial denture (D5650), and resin-
based composite - two surfaces, anterior (D2331) on February 4, 2021. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the extraction (D7140) has been paid, however, the 
other dental services were received from an out-of-network provider and are not covered by your supplemental 
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. 
 
 The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for resin-based composite - one surface, anterior (D2330), add clasp to existing partial denture - per 
tooth (D5660), add tooth to existing partial denture (D5650), and resin-based composite - two surfaces, anterior 
(D2331) on February 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the removal of residual tooth roots (D7250) and 
mandibular partial denture - flexible base (D5226). 
 
You asked the Plan to pre-approve the removal of residual tooth roots (D7250) and mandibular partial denture - 
flexible base (D5226). You say that you would like to appeal the partial denture denial. You say that you were 
not told partial dentures were not covered. The Plan denied your request. The Plan says your benefit for the 
requested item or service 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 Plans coverage rules apply in this case. 
 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The 
mandibular partial denture (dental code D5226) is not covered by your Plans dental benefits. The record shows 
your benefit for the requested removal of residual tooth roots (D7250) was exhausted on date of service May 
19, 2022.  
 
Therefore, we decided that the Plan does not have to pre-approve the removal of residual tooth roots (D7250) 
and mandibular partial denture - flexible base (D5226).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids (V5298) purchased on 
February 11, 2022. 
 
You asked the Plan to issue reimbursement for these items. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says the items at issue are not payable 
as they were purchased from an out-of-network provider. 
 
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 when purchased from the Plans select hearing aid provider.  
 
We looked at the case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically, the hearing aids in this case were not purchased from 
the Plans select hearing aid provider. The Plan contract states that any hearing aids ordered through providers 
other than the Plans select hearing aid provider are not covered. Therefore, we decided that the Plan does not 
have to issue reimbursement for the hearing aids (V5298) purchased on February 11, 2022.
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 the services are medically necessary. The 
Plan denied your request. The Plan says coverage criteria has not been met. 
 
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 is not currently stable for transfer. The enrollee's needs can be met at the 
current acute care 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a standard wheelchair and oxygen equipment (E1392, 
K0001) provided on January 10, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the standard wheelchair and oxygen equipment. You say that the services should 
be covered as you disagree with the denial. The Plan denied your request. The Plan says the services items 
correctly as they are non-emergent and they can be provided in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 
  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. 
Therefore, we decided that the Plan does not have to pay for a standard wheelchair and oxygen equipment 
(E1392, K0001) provided on January 10, 2022 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Zilretta injections. 
 
You asked the Plan to pre-approve Zilretta injections. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the requested drug 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 Zilretta injections. Our reviewer says 
that the documentation does not support that the requested Zilretta injections are medically reasonable or 
necessary. Our physician reviewer found you have bilateral knee pain related to osteoarthritis. Based on the 
medical records provided and the Medicare-approved major drug compendia there is no documentation that the 
Zilretta at issue in this case meets Medicare criteria for medically reasonable and necessary. As stated in 
Drugdex/Micromedex: "The efficacy and safety of repeat administration of Zilretta have not been 
demonstrated." Therefore, you do not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Zilretta injections have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Zilretta injections.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 billed for date of service January 3, 
2022. 
 
You asked the Plan to pay for procedure code 99285. You say that code 99285 was supported in the medical 
record. The Plan denied your request. The Plan says the records do not support code 99285, so the code was 
downgraded to 99284.  The Plan says that there was no immediate danger to life or function and the provider 
did not specify the amount of time spent with the patient in the medical records. 
 
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 99285 is Emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive 
examination; and Medical decision making of high complexity. 
 
We asked our coder 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 procedure code 99285. Our reviewer says that procedure code 99285 is not supported. Our reviewer found the enrollee was a 37 year-old female with a history of 
seizure disorder and chronic headaches who presented to the emergency room with dysuria, urgency and 
frequency. She was treated with Cipor, Vancomycin, and Aztreonam. She was discharged home the same day. 
The review indicates that it was appropriate for the plan to downgrade this claim to code 99284. There was no 
no documentation of medical decision making of high complexity. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99285 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99285 billed for date of service January 3, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a custom fabricated oral appliance (E0486). 
 
You asked the Plan to pre-approve a custom fabricated oral appliance. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says that the requested item is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that oral devices are covered when A-D of the LCD above 
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 a custom fabricated oral appliance. Our 
reviewer says that the documentation supports that the requested item is medically reasonable and necessary. 
Our physician reviewer found you have Obstructive Sleep Apnea (OSA). A review of the documentation 
indicates that you could not tolerate a CPAP device. The results showed that a sleep test performed with an 
appliance was a more effective treatment than with a CPAP device. The documentation supports that an oral 
appliance would be more effective in treating your OSA. Therefore, you meet criteria for the requested 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 a custom fabricated oral appliance have been met. Therefore, we decided that 
the Plan has to pre-approve a custom fabricated oral appliance (E0486).   
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 pay for the consultation (D9310) and surgical extraction (D7210) 
provided on February 14, 2022. 
 
You asked the Plan to pay for the consultation and surgical extraction. You say that you were advised that the 
provider's office accepted your insurance. The Plan denied your request. The Plan says these services are not 
listed as covered benefits under your plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
consultation (D9310) and surgical extraction (D7210) provided on February 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve limited orthodontic treatment of the adolescent dentition 
(D8030). 
 
You asked the Plan to pre-approve the dental service. You say that you need this service. The Plan denied your 
request. The Plan says limited orthodontic treatment is not listed as a covered service. 
 
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 limited orthodontic treatment not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
limited orthodontic treatment of the adolescent dentition (D8030).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the ambulance services provided on 
February 22, 2022. 
 
You asked the Plan to reduce the copayment for the ambulance services. You say that you needed a ride to the 
hospital for severe internal bleeding. You say this copay is very unfair. The Plan denied your request. The Plan 
says you have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $290 
copayment per date of service for a ground ambulance.  
 
You have been asked to pay a $290 copayment for ground ambulance services. Ambulance services fall within 
the Ambulance Services benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to reduce the copayment for the 
ambulance services provided on February 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic manipulative treatment (CMT); extraspinal 
(98943) provided on March 25, 2022, and March 28, 2022 
 
You asked the Plan to pay for the chiropractic manipulative treatment. You say that you have non-Medicare 
coverage under your plan. The Plan denied your request. The Plan says chiropractic manipulative treatment of 
the extraspinal regions (head, upper and lower extremities, rib cage and abdomen) are not covered. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for chiropractic manipulative treatment (CMT); extraspinal (98943) provided on 
March 25, 2022, and March 28, 2022
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99202) provided on January 21, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit under 
your contractual policy or by Medicare. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit (99202) provided on January 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a temporary crown (D2799), rubber dam (D3910), and 
fitting and placing a post in a tooth (D3950). 
 
You asked the Plan to pre-approve the dental services. You say that you have periodontal disease and need this 
treatment. You say that you cannot afford to pay these services on your own. You also say that these services 
go with the ones that were approved. The Plan denied your request. The Plan says the requested dental services 
are not listed as covered dental services. 
 
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 temporary crown rubber 
dam, and fitting and placing a post in a tooth are not among those covered under this benefit. Therefore, we 
decided that the Plan does not have to pre-approve a temporary crown (D2799), rubber dam (D3910), and 
fitting and placing a post in a tooth (D3950).