Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve twenty (20) additional ostomy pouches (CPT code 
A5057). 
 
You asked the Plan to pre-approve additional ostomy pouches. You say that you are requesting coverage for 
ostomy pouches due to Ileostomy status. The Plan denied your request. The Plan says the clinical 
documentation provided supports the 40 pouches per 30 days; however, there is no justification provided for 
the need for the 20 pouches per 30 days that are being denied and thus, that part of the request cannot be 
considered reasonable or necessary again as outlined by the LCD. 
 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 additional ostomy pouches. Our 
physician reviewer found the LCD criteria supports the 40 pouches per 30 days, however, the extra 20 pouches 
per 30 days is not sufficiently supported in the provided documentation. There was no documentation stating 
the amount of pouches needed or reason why 60 pouches per 30 day period is needed for this patient. 
Therefore, criteria are not met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional ostomy pouches have not been met. Therefore, we decided that the 
Plan does not have to pre-approve twenty (20) additional ostomy pouches (CPT code A5057).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial mandibular overdenture (D5866) and a 
precision attachment (D6950). 
 
You asked the Plan to pre-approve an overdenture and attachment.. You say that you need new dentures. The 
Plan denied your request. The Plan says that a partial mandibular overdenture (D5866) and a precision 
attachment (D6950) are not covered by your routine 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 pre-approve a 
partial mandibular overdenture (D5866) and a precision attachment (D6950).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on May 
11, 2022. 
 
You asked the Plan to pay for the comprehensive oral evaluation. You say that this was not your 6-month 
exam, but was in preparation for the crown. The Plan denied your request. The Plan says your benefit for the 
requested service had already been exhausted for the time period. 
 
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 record 
shows your benefit for the requested service was exhausted for the time period on date of service March 4, 
2022. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) 
provided on May 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wheelchair accessory, tray (E0950). 
 
You asked the Plan to pre-approve wheelchair accessory. You say that you are requesting review of medical 
necessity of the equipment requested for the enrollee's medical needs. The Plan denied your request. The Plan 
says the requested item does not primarily serve a medical purpose. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a wheelchair accessory, tray (E0950).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on August 18, 2021 billed with 
codes 81206, 81275, 81276, and 81301. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as billed. 
 The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
August 18, 2021 billed with codes 81206, 81275, 81276, and 81301.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cleaning and inspection of a removable complete 
maxillary denture (9932) and the cleaning and inspection of a removable partial mandibular denture (D9935) 
provided on May 11, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says the requested items and services are not covered by your routine 
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 the 
cleaning and inspection of a removable complete maxillary denture (9932) and the cleaning and inspection of a 
removable partial mandibular denture (D9935) provided on May 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an abutment supported crown (D6059) and a 
prefabricated abutment (D6056) provided by an out-of-network provider. 
 
You asked the Plan to pre-approve an abutment supported crown and a prefabricated abutment. You say that 
this was covered previously. You say that you do not understand why this is being denied now. The Plan 
denied your request. The Plan says the requested services 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 pre-approve an 
abutment supported crown (D6059) and a prefabricated abutment (D6056) provided by an out-of-network 
provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive oral exam (D0150) to be provided by a 
periodontist. 
 
You asked the Plan to pre-approve dental services provided by a periodontist. You say that your were referred 
to a periodontist due to problems with your gums. The Plan denied your request. The Plan says services 
provided by a periodontist are not covered. 
 
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. In this case 
the requested dental services will be provided by a periodontist. Based on this information, we decided that the 
Plan's rules for coverage of the comprehensive oral exam have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a comprehensive oral exam (D0150) to be provided by a periodontist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for full mouth debridement (D4355) provided on June 14, 2022. 
 
You asked the Plan to pay for debridement. You say that this service should be covered. The Plan denied your 
request. The Plan says that full mouth debridement (D4355) is not covered by 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 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 full 
mouth debridement (D4355) provided on June 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for radiation therapy provided on April 19, 2022. 
 
You asked the Plan to waive the copayment for radiation therapy. You say that you were unaware that you 
would have a copayment for the services and cannot afford to pay them. The Plan denied your request. The 
Plan says the copayment applied is correct. 
 
  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 $60 
copayment for Medicare-covered therapeutic radiology services.  
 
You have been asked to pay a $60 copayment for radiation therapy. Radiation therapy falls within the 
Outpatient Diagnostic Test and Therapeutic Services and Supplies 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 waive the copayment for radiation therapy provided on April 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on April 28, 
2022, and a limited oral evaluation (D0140) and a periapical x-ray (D0220) provided on May 9, 2022. 
 
You asked the Plan to pay for the evaluations and an x-ray. You say that you were advised that your dental 
insurance would cover everything. The Plan denied your request. The Plan says that a limited oral evaluation 
(D0140) is not covered by your dental benefits.  The Plan also says that your benefit for a periapical x-ray 
(D0220) 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, a limited oral evaluation is not among 
those covered under this benefit. The record shows your benefit for a periapical x-ray has been exhausted on 
date of service April 28, 2022. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on April 28, 2022, and a limited oral evaluation (D0140) and a periapical x-ray 
(D0220) provided on May 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mandibular partial denture (D5214), a resin-based 
composite filling on tooth #22 (D2331), a resin-based composite filling on tooth #27 (D2335), and extractions 
of tooth #20, 21, 23, 24, 25, 26, 28, 29, and 30 (D7210). 
 
You asked the Plan to pre-approve the dental services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that the requested items and services are not covered by the enrollees 
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 pre-approve a 
mandibular partial denture (D5214), a resin-based composite filling on tooth #22 (D2331), a resin-based 
composite filling on tooth #27 (D2335), and extractions of tooth #20, 21, 23, 24, 25, 26, 28, 29, and 30 
(D7210).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a resin-based composite - four or more surfaces or 
involving incisal angle (anterior) (D2335). 
 
You asked the Plan to pre-approve a filling. You say that you need a filling. The Plan denied your request. The 
Plan says this service is not covered under your 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 pre-approve a 
resin-based composite - four or more surfaces or involving incisal angle (anterior) (D2335).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture (D5213). 
 
You asked the Plan to pre-approve the dental services. You say that you lost your partial. 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 record 
shows your benefit for the requested item or service was exhausted on date of service July 15, 2021. Therefore, 
we decided that the Plan does not have to pre-approve a maxillary partial denture (D5213).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve four precision attachments (D5862 x4), four 
prefabricated abutments (D6056 x4), and a mandibular implant/abutment supported removable denture for 
edentulous arch (D6111). 
 
You asked the Plan to pre-approve the precision attachments, prefabricated abutments, and mandibular 
implant/abutment supported removable denture. You say that you need the denture because you have not been 
able to eat solid foods. The Plan denied your request. The Plan says these services are not covered 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve four 
precision attachments (D5862 x4), four prefabricated abutments (D6056 x4), and a mandibular 
implant/abutment supported removable denture for edentulous arch (D6111).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an upper partial denture (D5225). 
 
You asked the Plan to pre-approve the dental services. You say that your current dentures were poorly made. 
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 record 
shows your benefit for the requested item or service was exhausted on date of service August 23, 2020. 
Therefore, we decided that the Plan does not have to pre-approve an upper partial denture (D5225).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical placement of implant body: endosteal implants 
(D6010). 
 
You asked the Plan to pre-approve endosteal implants. You say that this service is crucial to your health. The 
Plan denied your request. The Plan says this service is not covered under your 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 pre-approve 
surgical placement of implant body: endosteal implants (D6010).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a temporary partial denture (D5820). 
 
You asked the Plan to pre-approve the dental item. You say that a flipper replacement is all you can afford. 
You say that your body is rejecting the crown you got. You say that you do not want a bridge in case those 
crowns get rejected too. You also say that you want to be able to eat and smile again. The Plan denied your 
request. The Plan says that temporary procedures are not covered. 
 
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 partial denture 
is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-
approve a temporary partial denture (D5820).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the inhalation of nitrous oxide (D9230). 
 
You asked the Plan to pre-approve nitrous oxide. You say that you need this service for all future dental 
procedures. The Plan denied your request. The Plan says the inhalation of nitrous oxide (D9230) is not covered 
by 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
inhalation of nitrous oxide (D9230).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone grafts at time of implant placement (D6104 x2). 
 
You asked the Plan to pre-approve bone grafts at time of implant placement. You say that you want the Plan to 
cover this service. The Plan denied your request. The Plan says the service at issue 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 pre-approve bone 
grafts at time of implant placement (D6104 x2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pulp vitality tests (D0460). 
 
You asked the Plan to pre-approve pulp vitality tests. You say that you would like this service covered. The 
Plan denied your request. The Plan says this service is not covered under your 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 pre-approve pulp 
vitality tests (D0460).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex device insertion. 
 
You asked the Plan to pre-approve the Vertiflex device insertion. You say that the enrollee has suffered from 
this condition for 36 months and has failed 18 months of conservative approaches to treatment. You say that 
this treatment is considered safe and effective and should be approved. The Plan denied your request. The Plan 
says use of interspinous process or interlaminar stabilization/distraction spacers is considered investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Vertiflex device insertion. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that the Vertiflex device is experimental. 
 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Vertiflex device insertion have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the Vertiflex device insertion.