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

 
We decided that the Plan does not have to pre-approve eleven custom fabricated abutments (D6057 x11). 
 
You asked the Plan to pre-approve the custom fabricated abutments. You say that dental implants were 
approved in 2021, and you experience pain at night with the screws in your mouth. The Plan denied your 
request. The Plan says this service is not covered under your 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 
eleven custom fabricated abutments (D6057 x11).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical extraction (D7210) provided on April 15, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the surgical extraction. You say that you went to an OON dentist because it was 
an emergency and there were no in-network dentists available. The Plan denied your request. The Plan says the 
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 the surgical extraction (D7210) provided on April 15, 2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve 2 levels of facet joint injections. We decided that the Plan does 
not have to pre-approve 1 level of facet joint injection.  
 
You asked the Plan to pre-approve 3 levels of facet joint injections. You say that the services are necessary. 
The Plan says that based on the documentation provided, coverage criteria have not been met. 
 
We decided that the Plan has to pre-approve 2 levels of facet joint injections.  
 
The Plan follows Medicare rules. Medicare rules say that one to two levels, either unilateral or bilateral, are 
allowed per session per spine region. 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 2 levels of facet joint injections. Our 
reviewer says that the services are medically necessary. Our physician reviewer found two levels of blocks are 
medically reasonable and necessary. A third level exceeds the utilization criteria of the LCD. A third level is 
not medically reasonable or necessary.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 2 levels of facet joint injections have been met. Therefore, we decided that the 
Plan has to pre-approve 2 levels of facet joint injections.  
 
We also decided that the Plan does not have to pre-approve 1 level of facet joint injection. 
 
The Plan follows Medicare rules. Medicare rules say that one to two levels, either unilateral or bilateral, are 
allowed per session per spine region. 
 
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 1 level of facet joint injection. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found two levels of blocks 
are medically reasonable and necessary. A third level exceeds the utilization criteria of the LCD. A third level 
is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 1 level of facet joint injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve 1 level of facet joint injection. 
 
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 a crown on tooth #8 (D2750). 
 
You asked the Plan to pre-approve the dental services. You say that you disagree with the denial of 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 January 22, 2019. 
Therefore, we decided that the Plan does not have to pre-approve a crown on tooth #8 (D2750).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for physician's services provided on March 16, 2022. 
 
You asked the Plan to pay for physician's services. You say that the member had a face to face with the NPP 
and the physician. The Plan denied your request. The Plan says that the documentation provided does not meet 
the incident to guidelines and is being billed by a different provider than the provider in the documentation. 
 
The Plan must follow Medicare rules. Medicare rules say that coverage of services and supplies incident to the 
professional services of a physician in private practice is limited to situations in which there is direct physician 
supervision of auxiliary personnel. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of physician's services have been met. Therefore, we decided that the Plan has to pay for physician's 
services provided on March 16, 2022.  
 
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 dental exam (D0140), the removal of tooth pulp (D3220), 
the nerve treatment on molar tooth (D3330), the ready-made post for a crown filling (D2954), the gum surgery 
(D4249), and the crown (D2752) provided by an out-of-network provider from September 23, 2020, to March 
25, 2021. 
 
You asked the Plan to pay for the dental services. You say that you had a dental emergency and would like to 
be reimbursed for the dental services. The Plan denied your request. The Plan says the 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 the dental exam (D0140), the removal of tooth 
pulp (D3220), the nerve treatment on molar tooth (D3330), the ready-made post for a crown filling (D2954), 
the gum surgery (D4249), and the crown (D2752) provided by an out-of-network provider from September 23, 
2020, to March 25, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam therapy for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that there is no published randomized evidence proton therapy 
improves outcomes or decreases toxicity for any stage of breast cancer. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Proton therapy is not 
necessary for routine use (i.e. not furnished in accordance with accepted standards or care per NCCN and 
ASTRO guidelines) in the post-mastectomy setting. Our physician reviewer found that the enrollee's condition 
does not meet criteria for coverage of these services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve proton beam therapy for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vabysmo for the enrollee. 
 
You asked the Plan to pre-approve Vabysmo. You say that this is medically necessary. The Plan denied your 
request. The Plan says that they do not see medical record documentation of therapeutic failure on, intolerance 
to, or contraindication to intravitreal bevacizumab (Avastin). 
 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 Vabysmo. Our reviewer says that 
Vabysmo is not medically reasonable and necessary. There is no indication that the patient has tried and failed 
intravitreal bevacizumab (Avastin). Based on the medical records provided and the Medicare-approved major 
drug compendia there is no indication that intravitreal bevacizumab (Avastin) would likely be less effective 
and/or likely have adverse effects for the patient. Our physician reviewer found that the enrollee's condition 
does not meet step therapy criteria for Vabysmo. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vabysmo have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Vabysmo for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional physical therapy sessions provided by an out-
of-network provider. 
 
You asked the Plan to pre-approve physical therapy. You say that you disagree with this denial. The Plan 
denied your request. The Plan says the enrollee does not meet the criteria outlined in the Medicare rules. 
 
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 physical therapy. 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 the provided records do not document any acute injury or changes in 
symptoms or function which would necessitate any further skilled therapy visits beyond what have already 
been approved. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of physical therapy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve additional physical therapy sessions provided by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you have provided medical records for 
reconsideration of the inpatient rehabilitation admission. The Plan denied your request. The Plan says the 
records do not show the enrollee needs to be seen by a rehabilitation doctor at least 3 times a week for 
evaluation of functional and medical goals and progress. The services needed can be provided safely in other 
settings, for example, a skilled nursing facility, home with home health services or home with outpatient 
therapy. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require the intensity of services provided at an IRF. 
Specifically, the enrollee is not shown to be able to tolerate fifteen hours per week of rehabilitative services and 
regular physical evaluation. The enrollee's care needs can be met at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the lab services provided on April 18, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says that this type of 
provider is not eligible to bill for these services. 
 
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 provider in question is an MD with a specialty in histology. First, the Plan 
says that this type of provider is not eligible to bill for assistant surgery service, but the services in question are 
not assistant surgery services. Second, the Plan says that this type of provider is not eligible to enroll in 
Medicare. However, an MD with a specialty in histology is eligible to enroll in Medicare and bill for Medicare 
services. The Plan has not provided documentation supporting its denial. Without supporting documentation, 
the Plan's denial cannot be substantiated. Therefore, we decided that the Plan has to pay for the lab services 
provided on April 18, 2022.  
 
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 provide additional payment for the limited oral evaluation - problem 
focused (D0140) and precision attachments (D6950) provided February 1, 2022. 
 
You asked the Plan to provide additional payment for the limited oral evaluation and precision attachments. 
You say that you disagree with the cost of these services. The Plan denied your request. The Plan says you 
have exhausted your dental benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the limited 
oral evaluation and precision attachments up to $500 every year. 
 
We looked at the file and Medicare rules. The Plan provided documentation showing that at the time the claim 
was processed you had $2 remaining in your dental allowance. This amount was applied to the claim. 
Therefore, we decided that the Plan does not have to provide additional payment for the limited oral evaluation 
- problem focused (D0140) and precision attachments (D6950) provided February 1, 2022.   
Your complaint about discrepancies in how your claim have been processed 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on November 17, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on November 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for a gym membership purchased April 25, 
2022. 
 
You asked the Plan to pay an additional amount for a gym membership. You say that you want the Plan to pay 
an additional amount. The Plan denied your request. The Plan says they reimbursed the eligible amount of 
$80.00 (May-December of 2022, 8 months x $10). The remaining amount of $40 was not eligible for 
reimbursement under the current year's benefit because this amount applied towards the months in 2023. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers gym benefits  
up to $150 per calendar year towards your cost for membership in a qualified health club or fitness facility 
during the calendar year. 
 
 
 
 
 
 
 The Plans rules for coverage of gym benefits have not been met because the remaining amount of $40.00 was 
not eligible for reimbursement under the current year's benefit. Therefore, we decided that the Plan does not 
have to pay an additional amount for a gym membership purchased April 25, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs IRF care. The Plan denied your 
request. The Plan says based on Medicare guidelines, the requested IRF services do not meet the requirements 
for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of the enrollees nursing, medical and rehabilitation needs does not require an IRF stay with an interdisciplinary approach to rehabilitation care. The enrollee does not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, at an intensive 
rehabilitation therapy program. The enrollee continues to have a need for skilled therapy with ongoing safety 
concerns and a potential for functional improvement however, the documentation doesnt support that criterion 
for admission to an IRF are met. There is no indication that the enrollee would require skilled rehabilitation in 
an IRF, participating in rehab services 15 hours a week, under the supervision of a physician with at least 3 
visits weekly to regain or maintain functional status. The enrollee can receive further services at a lower level 
of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the specimen validity testing provided on March 14, 2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this 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 the testing 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 the specimen validity testing provided on March 14, 2022.