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

We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on April 20, 2022.

You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related laboratory testing.

The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not separately payable. Laboratories should bill the facility directly for laboratory services as they are considered part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on April 20, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the cardioMems device implantation. 
 
You asked the Plan to pre-approve the cardioMems device. You say that you are enclosing the denial and 
supporting documentation for the procedure. Please review and approve. The Plan denied your request. The 
Plan says this device is considered investigational and not medically necessary. The requested services do not 
currently meet accepted standards of medical practice. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the cardioMems device have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the cardioMems device implantation.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home infusion therapy rendered on December 4, 2021, to 
December 31, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be 
covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The 
Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies. 
 
We looked at the file and Medicare and the Plan's rules. The file shows that home infusion therapy services 
were rendered. Based on this information, we decided that Medicare and the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion 
therapy rendered on December 4, 2021, to December 31, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scalings and root planings (D4341) for the 
upper right, upper left, lower right, and lower left quadrants. 
 
You asked the Plan to pre-approve the scalings and planings. You say that you need the deep cleanings. 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 dates of service November 19, 2020, 
December 28, 2020, January 28, 2021, and February 9, 2021. Therefore, we decided that the Plan does not have 
to pre-approve periodontal scalings and root planings (D4341) for the upper right, upper left, lower right, and 
lower left quadrants.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral exam (D0140) and the 
intraoral periapical additional x-ray (D0230) provided on May 20, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are appealing this denial. The Plan denied 
your request. The Plan says D0140 is not a covered service and your benefit for D0230 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 Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested item D0140 is not among 
those covered under this benefit. Additionally, the record shows your benefit for the intraoral periapical x-ray 
(D0230) was exhausted on date of service May 20, 2022. Therefore, we decided that the Plan does not have to 
pay for the problem focused limited oral exam (D0140) and the intraoral periapical additional x-ray (D0230) 
provided on May 20, 2022.
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. 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 March 21, 2022. 
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 gingival irrigation (D4921) and antimicrobial agents on 
tooth #4, 16, 17, 29, and 30 (D4381). 
 
You asked the Plan to pre-approve gingival irrigation and antimicrobial agents. You say that you disagree with 
the denial of dental services. The Plan denied your request. The Plan says gingival irrigation (D4921) and 
antimicrobial agents (D4381) are not covered by the enrollee's 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 
gingival irrigation (D4921) and antimicrobial agents on tooth #4, 16, 17, 29, and 30 (D4381).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2751) for teeth #5 and #6, provided by a 
participating provider. 
 
You asked the Plan to pre-approve a crown. You say that you need these services done. The Plan denied your 
request. The Plan says the medical criteria for D2751 have not 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 a crown when 
the services are medically necessary and reasonable.  
 
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 crown. Our reviewer says that D2751 
is not medically necessary for teeth #5 and #6. Our physician reviewer found tooth #5 clearly has no structure 
above the level of the bone, and #6 has inadequate structure above the level of the bone to allow for a good 
long-term prognosis. 
 
  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of a crown have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a crown (D2751) for teeth #5 and #6, provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for extraction, erupted tooth or exposed root (D7140) tooth #7 and #16, 
and extraction, erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of 
mucoperiosteal flap if indicated (D7210) for tooth #28. 
 
You asked the Plan to pay for dental services. You say that the enrollee's previous provider passed aways 
suddenly without completing the member's denture work. The Plan denied your request. The Plan says that 
since the teeth have already been extracted, they will maintain its reprocessed determination to not provide 
approval for the already extracted teeth. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. the Plan did not send medical records so we can consider whether it was 
necessary to perform the extractions given the history of the specific teeth. Therefore, we decided that the Plan 
has to pay for extraction, erupted tooth or exposed root (D7140) tooth #7 and #16, and extraction, erupted tooth 
requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated 
(D7210) for tooth #28.  
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional physical therapy visits. 
 
You asked the Plan to pre-approve 10 additional physical therapy visits. You say that you still have swelling 
and stiffness in your knee. The Plan denied your request. The Plan says these visits are not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 10 additional physical therapy visits. 
Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent 
deterioration of the enrollee's condition. Our physician reviewer found you have been instructed in a home 
exercise and your remaining conditions do not require ongoing formal therapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 10 additional physical therapy visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 10 additional physical therapy visits.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by the billed code is 
considered specimen validity testing which is not separately payable. Therefore, we decided that the Plan does 
not have to pay for validity testing billed with code 83789.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary and mandibular implant (D6110 and D6111) 
and semi-precision abutment (D6191 and D6192) provided by a participating provider. 
 
You asked the Plan to pre-approve a maxillary and mandibular implant and semi-precision abutment. You say 
that these services are medically necessary. The Plan denied your request. The Plan says the requested dental 
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 a 
maxillary and mandibular implant (D6110 and D6111) and semi-precision abutment (D6191 and D6192) 
provided by a participating provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for definitive urine drug testing provided on May 13, 2022. 
 
You asked the Plan to pay for definitive urine drug testing. You say that the service at issue was a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met 
because the service at issue was not medically necessary. 
 
The Plan follows Medicare rules. The rules say that definitive drug testing is indicated when the criteria listed 
in the Medicare rules section of this letter have been 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 pay for definitive urine drug testing. Our reviewer 
says that the service at issue was not medically reasonable and necessary in this case. Our physician reviewer 
found that the provided documentation did not include a prior and recent urine drug screening with abnormal or 
unexpected results to warrant follow-up definitive testing. Furthermore, multiple drug classes not relevant to 
the enrollee's clinical history were performed and were unnecessary. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of definitive urine drug testing have not been met. Therefore, we decided that the 
Plan does not have to pay for definitive urine drug testing provided on May 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4341) provided 
by an out-of-network provider. 
 
You asked the Plan to pre-approve periodontal scaling and root planing. You say that these services are 
medically necessary. The Plan denied your request. The Plan says the requested dental work 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 
periodontal scaling and root planing (D4341) provided by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gingivectomy on tooth #22, 23, 24, 25, 26, and 27 
(D4212). 
 
You asked the Plan to pre-approve gingivectomy. You say that this service is medically necessary. The Plan 
denied your request. The Plan says gingivectomy (D4212) 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 pre-approve 
gingivectomy on tooth #22, 23, 24, 25, 26, and 27 (D4212).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the cervical spine 
without contrast (72141). 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says you do not meet criteria for coverage of the requested 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve this service. Our reviewer says that this 
service is not medically necessary. Our physician reviewer found that you had two cervical spine epidural 
injections two years ago with relief. Your appeal letter as well as the notes from pain management indicate 
there is a contention that you have failed a recent physical therapy regimen and are taking oral non-steroidal 
anti-inflammatory drugs (NSAIDS) with continued symptoms. If there has been adequate and monitored 
physical therapy as alleged, you would qualify for the requested MRI of the cervical spine. However, the 
physical therapy records and post follow-up clinical evaluation are not included in the submitted records. If 
such records are produced, the request for the MRI of the cervical spine should be approved but not before the 
information is provided. 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve magnetic resonance imaging (MRI) of the cervical spine without contrast (72141).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete denture - maxillary (D5110), and complete 
denture - mandibular (D5120) provided on June 1, 2022. 
 
You asked the Plan to pay for a complete denture - maxillary (D5110), and complete denture - mandibular 
(D5120). You say that you are appealing the pay amount of $1004.00 for the services received with the out-of-
network dentist. The Plan denied your request. The Plan says the services were rendered by an out-of-network 
provider and the Plan paid the allowed amount, therefore any remaining balance for these services are your 
responsibility. 
 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. If the Plan covers services by 
an out-of-network dentist, you might be billed by that provider for any amount greater than what the Plan pays. 
 
The Plan paid up to their allowed amount of $1,304 for these covered dental services. You may be billed by the 
out-of-network dentist for any balance remaining above this amount. Therefore, we decided that the Plan does 
not have to pay for a complete denture - maxillary (D5110), and complete denture - mandibular (D5120) 
provided on June 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mass spectrometry and tandem mass spectrometry (83789) 
billed for date of service March 3, 2022. 
 
You asked the Plan to pay for mass spectrometry services. You say that these services were necessary and are 
supported as billed. The Plan denied your request. The Plan says this service is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of mass spectrometry services have not been met. Specifically, we find that the testing described by 
the billed code is considered specimen validity testing which is not separately payable. Therefore, we decided 
that the Plan does not have to pay for mass spectrometry and tandem mass spectrometry (83789) billed for date 
of service March 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a guided tissue regeneration (D4266) provided by an 
out-of-network provider. 
 
You asked the Plan to pre-approve a guided tissue regeneration. You say that these services are medically 
necessary. The Plan denied your request. The Plan says the requested dental service 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 a 
guided tissue regeneration (D4266) provided by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro Motion G orthotic device. 
 
You asked the Plan to pre-approve MyoPro Motion G. You say that this is an appropriate intervention and is 
medically necessary. The Plan denied your request. The Plan says this device is not medically necessary. 
 
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 MyoPro Motion G. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the MyoPro device is not known to be effective based on scientific evidence, 
professional standards, and expert opinion, in improving health outcomes in stroke patients. There is 
insufficient evidence in the literature that the MyoPro orthosis will improve the long-term outcomes for this 
enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MyoPro Motion G have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a MyoPro Motion G orthotic device.