Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an intracept procedure. 
 
You asked the Plan to pre-approve an intracept procedure. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 an intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the record indicates that the enrollee would be excluded from these studies based 
upon his clinical situation. The provided records do not support the medical necessity and reasonableness, as 
defined by Medicare rules, of the requested service for the enrollee's specific condition. The elements of the 
coverage criteria are not satisfied. The requested service cannot be recommended. 
 
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 intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an intracept procedure.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Jemperli. 
 
You asked the Plan to pre-approve Jemperli. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
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 Jemperli. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the provided records do not indicate that 
the enrollee has tried and failed the plan's preferred step one alternative. The record does not indicate that the 
enrollee has a contraindication to or would have an adverse effect from the plan's preferred step one alternative. 
The elements of the coverage criteria are not satisfied. The requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Jemperli have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Jemperli.
Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay an additional amount for the destruction of skin lesions provided on 
December 6, 2021. We decided that the Plan does not have to waive the copayment for the destruction of skin 
lesions and office visit provided on January 28, 2021.  
 
You asked the Plan to pay an additional amount for the destruction of skin lesions and office visit provided on 
July 18, 2018, through January 28, 2022. You say that you would like reconsideration based on the records 
submitted. The Plan says that these claims have been processed correctly. 
 
We decided that the Plan has to pay an additional amount for the destruction of skin lesions provided on 
December 6, 2021.  
 
The Plan follows Medicare rules. Medicare rules say that a contract provider is an agent of the plan. Services 
and referrals given by a contract provider are considered approved by the plan unless notice is provided that the 
services will not be covered. The Plan follows these rules. 
 
The file shows that the destruction of skin lesions provided on December 6, 2019 were rendered by a contract 
provider. Under Medicare rules, this means that these services are considered approved by the Plan. Therefore, 
we decided that the Plan has to pay an additional amount for the destruction of skin lesions provided on 
December 6, 2021.  
 
We also decided that the Plan does not have to waive the copayment for the destruction of skin lesions 
and office visit provided on January 28, 2021. 
 
The Plan follows Medicare rules. Medicare rules say that 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 $40 copayment for specialist services. 
 
You have been asked to pay a $40 copayment for specialist services provided on January 28, 2022. The office 
visit falls within the Physician/Practitioner services, including doctor's office visits 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 pay an additional amount for the destruction of skin 
lesions and office visit provided on January 28, 2021. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two endosteal implants (D6010 x2), two surgical 
accesses to an implant body (D6011 x2), two custom fabricated abutments (D6057 x2), and two abutment 
supported porcelain fused to metal crowns (D6059 x2). 
 
You asked the Plan to pre-approve the endosteal implants, surgical accesses to an implant body, custom 
fabricated abutments, and abutment supported porcelain fused to metal crowns. The Plan denied your request. 
The Plan says these services 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, abutments that support partial 
removable prosthesis, fixed prosthesis, crowns and all other components are not among those covered under 
this benefit. The implant benefit covers only the dental implant to hold a complete denture. The provided 
documentation does not show that you are requesting these implant services in order to hold a complete 
denture. Therefore, we decided that the Plan does not have to pre-approve two endosteal implants (D6010 x2), 
two surgical accesses to an implant body (D6011 x2), two custom fabricated abutments (D6057 x2), and two 
abutment supported porcelain fused to metal crowns (D6059 x2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cone beam CT capture and interpretation (D0364), pulp 
vitality tests (D0460), surgical extraction (D7210), deep sedation/general anesthesia (D9222), and therapeutic 
parenteral drugs (D9612) provided on January 31, 2022, and February 22, 2022. 
 
You asked the Plan to pay for the dental services. You say that these services were provided to see the results 
of, and treat your damaged tooth. The Plan denied your request. The Plan says these services are not contract 
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. These services are not considered to be preventive. Therefore, we 
decided that the Plan does not have to pay for the cone beam CT capture and interpretation (D0364), pulp 
vitality tests (D0460), surgical extraction (D7210), deep sedation/general anesthesia (D9222), and therapeutic 
parenteral drugs (D9612) provided on January 31, 2022, and February 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gingival irrigation (D4921) for the upper left and upper 
right quadrants. 
 
You asked the Plan to pre-approve the dental services. You say that the enrollee needs these services. The Plan 
denied your request. The Plan says gingival irrigation is not listed as a covered dental 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 requested gingival irrigation are 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
gingival irrigation (D4921) for the upper left and upper right quadrants.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a fixed pontic on tooth #6 (D6245). 
 
You asked the Plan to pre-approve a pontic. You say that your bridge broke and you need to have it fixed. The 
Plan denied your request. The Plan says a fixed pontic (D6245) 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 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 a 
fixed pontic on tooth #6 (D6245).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a flexible protective outer surface cover (L5962), a flex-
walk system (L5981), an axial rotation unit (L5984) and a vertical shock reducing pylon feature (L5988) for a 
lower extremity prosthetic device. 
 
You asked the Plan to pre-approve a flexible protective outer surface cover, a flex-walk system, an axial 
rotation unit and a vertical shock reducing pylon feature. You say that the requested items are a medical 
necessity for you. The Plan denied your request. The Plan says medical necessity rules for coverage of the 
requested items have not been met. 
 
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 a flexible protective outer surface 
cover, a flex-walk system, an axial rotation unit and a vertical shock reducing pylon feature. Our reviewer says 
that the requested items are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the requested specialized lower limb prosthetic cover (L5962) exceeds your medical needs. 
The documentation does not support that you have special needs for protection against unusually harsh 
environmental situations where it is necessary to protect the lower limb prosthesis beyond the level of 
protection that is afforded by a standard prosthetic cover. 
 
The flex-walk system L5981 exceeds your medical needs and is not medically necessary. The treating medical 
physician documentation does not support that you are a K3 ambulator. 
 
Furthermore, the physician documentation does not indicate that you require the L5984 axial rotation unit and 
the L5988 shock reducing pylon feature which appear to exceed your functional and medical needs. 
 
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 flexible protective outer surface cover, a flex-walk system, an axial rotation 
unit and a vertical shock reducing pylon feature have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a flexible protective outer surface cover (L5962), a flex-walk system (L5981), an axial 
rotation unit (L5984) and a vertical shock reducing pylon feature (L5988) for a lower extremity prosthetic 
device.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on November 5, 2020 billed with 
codes 81407, 81408, 81432, and 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services billed are not separately payable. 
 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 
November 5, 2020 billed with codes 81407, 81408, 81432, and 81479.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy provided from January 3, 2022, to January 24, 2022.
You asked the Plan to pay for psychotherapy. The Plan denied your request. The Plan says services from non-participating providers are not covered unless preauthorized.
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 did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for psychotherapy provided from January 3, 2022, to January 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional payment for the limited oral evaluation - problem 
focused (D0140), intraoral - periapical first radiographic image (D0220), endodontic therapy, premolar tooth 
(excluding final restoration) (D3320), and pulp vitality tests (D0460) provided February 25, 2022. 
 
You asked the Plan to provide additional payment for the limited oral exam, periapical x-ray, root canal and 
pulp vitality tests. You say that the provider is in-network. The Plan denied your request. The Plan says the 
claims have processed correctly. The Plan also says they cannot find a record of contact with the Plan prior to 
services being rendered to check provider status. 
 
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 
limited oral exam and periapical x-ray with 30% coinsurance and root canals with 50% coinsurance 
when performed OON, after the $50 deductible is met. 
 
We looked at the file and Medicare rules. You have been asked to pay your $50 deductible plus 30% of the 
approved amount for the limited oral exam and periapical x-ray and 50% of the approved amount for the root 
canal. In this case the requested provider is OON. Additionally, you have been asked to pay the difference 
between the out-of-network provider's charges and the Plan's payment. 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 provide additional payment for the limited oral evaluation - problem focused (D0140), intraoral - periapical 
first radiographic image (D0220), endodontic therapy, premolar tooth (excluding final restoration) (D3320), 
and pulp vitality tests (D0460) provided February 25, 2022.  
 
Your complaint about potentially being given incorrect or confusing information about your benefits is not a 
valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the 
Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial lower denture (D5212). 
 
You asked the Plan to pre-approve the dental service. You say that you cannot get the partial without a down 
payment. You say that a down payment is beyond what you can afford. You also say that you cannot eat, chew 
or digest food well. The Plan denied your request. The Plan says your benefit for a lower partial denture 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 lower partial denture was exhausted on date of service September 18, 
2018. Therefore, we decided that the Plan does not have to pre-approve a partial lower denture (D5212).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transit system, caster color wheels, plastic coating, 
neoprene impact guards, a fold down push handle, and plastic side guards. 
 
You asked the Plan to pre-approve a transit system, caster color wheels, plastic coating, neoprene impact 
guards, a fold down push handle, and plastic side guards. You say that you need the wheelchair and 
accessories requested by your doctor because of your medical conditions and inability to walk. The Plan denied 
your request. The Plan says the items which remain in dispute are not medically necessary. 
 The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The items at issue in this appeal do not serve a purpose that is primarily medical in nature. Therefore, we 
decided that the Plan does not have to pre-approve a transit system, caster color wheels, plastic coating, 
neoprene impact guards, a fold down push handle, and plastic side guards.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the adjunctive pre-diagnostic testing (D0431) provided on 
October 14, 2021. 
 
You asked the Plan to pay for the dental service. You say that you have paid what you were supposed to pay. 
You say that your insurance company said you only had to pay $20 to $25 for your doctor visits. You also say 
that you would like to be done with all of this. The Plan denied your request. The Plan says the adjunctive pre-
diagnostic testing is not listed as a covered dental 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 adjunctive pre-diagnostic testing is 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
adjunctive pre-diagnostic testing (D0431) provided on October 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional periapical x-rays (D0230 x 5) and a 2D oral x-ray 
(D0350) provided on April 20, 2022. 
 
You asked the Plan to pay for the dental services. You say that you asked the office not to do anything that was 
not covered by the insurance. The Plan denied your request. The Plan says your benefit for periapical x-rays 
has already been exhausted. The Plan also says that 2D oral x-rays are not covered by your supplemental dental 
benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's 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 periapical x-rays was exhausted on date of service April 20, 2022. 2D oral x-rays are not 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for additional periapical x-
rays (D0230 x 5) and a 2D oral x-ray (D0350) provided on April 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and complete lower 
denture (D5120). 
 
You asked the Plan to pre-approve the dental items. You say that you need dentures so you can eat well. The 
Plan denied your request. The Plan says your benefit for the requested dentures have 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. 
 
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 May 16, 2019.  
 
Therefore, we decided that the Plan does not have to pre-approve a complete upper denture (D5110) and 
complete lower denture (D5120).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 16, 2021 billed with 
codes 81206, 81235, and 81321. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the services were not billed correctly. 
 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 
February 16, 2021 billed with codes 81206, 81235, and 81321.