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

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) and an extraction, erupted 
tooth or exposed root (D7140) on March 30, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says 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 a limited oral evaluation (D0140) was exhausted on date of service March 25, 2022. The 
service, an extraction, erupted tooth or exposed root (D7140) was received by an out-of-network provider and 
it was determined this service could have been received in-network. Therefore, we decided that the Plan does 
not have to pay for a limited oral evaluation (D0140) and an extraction, erupted tooth or exposed root (D7140) 
on March 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic radiographic image (D0330), limited oral 
evaluation-problem focused (D0140), the alveoplasty (D7321), and the unspecified oral surgery, by report 
(D7999) provided on March 23, 2022 and March 28, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says your benefit for the panoramic 
radiographic image and the limited oral evaluation has been exhausted. Additionally, the alveoplasty and the 
unspecified oral surgery provided are not covered under your contractual policy. 
 
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 panoramic radiographic image provided was exhausted on July 27, 2020 and the 
benefit for the limited oral evaluation was exhausted on March 7, 2022. Specifically, the Plan provides 
coverage for one panoramic radiographic image every five calendar years. You previously received this service 
on July 27, 2020, that was paid for by the Plan. The Plan provides coverage of one emergency diagnostic exam 
every year. You previously received a limited oral evaluation on March 7, 2022, that was paid for by the Plan. 
Therefore, you have exhausted the allowance benefit for these services. Additionally, an alveoplasty and an 
unspecified oral surgery are not listed as covered benefits under your contractual policy. Therefore, we decided 
that the Plan does not have to pay for the panoramic radiographic image (D0330), limited oral evaluation-
problem focused (D0140), the alveoplasty (D7321), and the unspecified oral surgery, by report (D7999) 
provided on March 23, 2022 and March 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic radiographic image (D0330) provided on  
May 10, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says your benefit for the service provided 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 service provided was exhausted on date of service June 17, 2019. Specifically, the 
Plan contract states that a full mouth or panoramic x-ray is covered once every five calendar years. You 
previously received this service on June 17, 2019, that was paid for by the Plan. Therefore, the allowable 
benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the panoramic 
radiographic image (D0330) provided on May 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an abutment (D6057) and a crown (D6065) for tooth #14 
provided on April 11, 2022. 
 
You asked the Plan to pay for the dental services. You say that you thought crowns were covered under your 
dental benefits. The Plan denied your request. The Plan says the denial for this service is correct, because 
crowns and any associated care for implant placement are not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an 
abutment (D6057) and a crown (D6065) for tooth #14 provided on April 11, 2022.
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. The Plan denied your request. The Plan says an IRF admission is 
not medically necessary, and services can be provided at a lower level of care. 
 
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's medical problems are stable and there are no complex nursing or 
rehabilitation needs. There is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable loop recorder. 
 
You asked the Plan to pre-approve an implantable loop recorder. You say that the medical records provided 
support the need for the requested device. The Plan denied your request. The Plan says the enrollee has not had 
syncope and does not meet the criteria for coverage of the requested item. 
 
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 implantable loop recorder. Our 
reviewer says that an implantable loop recorder is not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee had no history of atrial fibrillation, nor were any significant 
cardiac arrhythmias noted on electrocardiogram (ECG) monitoring. A recent randomized clinical trial found 
that continuous monitoring for atrial fibrillation with an implantable loop recorder (followed by treatment with 
oral anticoagulation if atrial fibrillation was detected) was not superior to usual care in reducing stroke or 
systemic embolism among patients at high risk of stroke but without a known prior history of atrial fibrillation. 
 
 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 implantable loop recorder have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an implantable loop recorder.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the requested procedure is safe and 
effective. You say that the enrollee clearly meets the Food and Drug Administration (FDA) indications for use. 
The Plan denied your request. The Plan says the requested procedure is considered experimental and 
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 Intracept procedure. Our reviewer 
says that the Intracept procedure is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Intracept procedure is experimental for treatment of back pain. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee needs SNF care. The Plan denied your 
request. The Plan says the enrollee's needs can be met at an alternate level of care such as outpatient therapy or 
home care service. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mandibular partial denture (D5226). 
 
You asked the Plan to pre-approve a mandibular partial denture. You say that you would like the Plan to 
reconsider their denial. The Plan denied your request. The Plan says dentures and partial dentures are not 
covered under the Plan's supplemental 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. 
 
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 (D5226).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ophthalmology visit to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve an OON ophthalmology visit. You say that you can't get a hold of the 
original providers you were approved to see, and you need to get eye care. The Plan denied your request. The 
Plan says ophthalmology care is available in-network.  You can be seen within 10 days with an in-network 
provider and the in-network provider is closer to your home than the requested out-of-network provider. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an ophthalmology visit to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on February 10, 2022. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says no modifiers 
are allowed with this code pair. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
 
In this case, we have confirmed that code 82465 is a column II code to column I code 80061 with a modifier 
indicator of 0. The column II code is therefore not payable. Based on the claim submitted, Medicare billing 
criteria have not been met. Therefore, we decided that the Plan does not have to pay for the lab services 
provided on February 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable loop recorder (ILR). 
 
You asked the Plan to pre-approve an ILR. You say that this device is medically necessary. The Plan denied 
your request. The Plan says you do not meet criteria for this device. 
 
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 ILR. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found while you have a history of stroke and atrial fibrillation, there is no documentation provided to 
suggest a history of unexplained syncope or any other apparent indication for an ILR. In summary, there is 
insufficient documentation to support the medical necessity for insertion of an ILR in your clinical 
management. 
 
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 ILR have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an implantable loop recorder (ILR).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve the acute inpatient hospital level of care for a planned total hip 
arthroplasty (THA). 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that you disagree with the denial. The 
Plan denied your request. The Plan says that the inpatient level of care is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation supports that the criteria for inpatient care are met. Our physician 
reviewer found the enrollee has rapidly progressive degeneration of left hip after a recent steroid injection of 
hip and findings concerning for septic arthritis. She is scheduled for incision and drainage and elective total hip 
replacement. The suspected presence of septic arthritis is a complication that makes it reasonable to anticipate 
that medically necessary care will span a time period of more than two midnights. The inpatient admission is 
medically 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 acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pre-approve the acute inpatient hospital level of care for a planned total hip arthroplasty (THA).  
 
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: Lab
Decision: Favorable

 
We decided that the Plan has to pay for decipher Prostate test, oncology (prostate), mRNA, microarray gene 
expression profiling of 22 content genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported 
as metastasis risk score (81542) provided Mary 3, 2022. 
 
You asked the Plan to pay for the decipher Prostate test. You say that the medical records provided will show 
proof of medical necessity. The Plan denied your request. The Plan says that the request does not meet criteria 
and the request is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 pay for the decipher Prostate test. Our reviewer says 
that the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found as the enrollee has low risk prostate cancer, the enrollee is eligible for observation decipher and 
the services should be approved per the LCD. 
 
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 decipher Prostate test have been met. Therefore, we decided that the Plan 
has to pay for decipher Prostate test, oncology (prostate), mRNA, microarray gene expression profiling of 22 
content genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as metastasis risk score 
(81542) provided Mary 3, 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: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve the Vertiflex interspinous spacer device 
 
You asked the Plan to pre-approve the Vertiflex interspinous spacer device. You say that this device is 
medically necessary for this patient. The Plan denied your request. The Plan says that this device is not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 the Vertiflex interspinous spacer 
device. Our reviewer says that the requested items/services are considered medically reasonable and necessary 
in this case. Our physician reviewer found the enrollee is an 82-year-old woman with diagnoses of ppinal 
stenosis in the lumbar region with neurogenic claudication and radiculopathy. The enrollee reports debilitating 
back pain for several years which disrupts her normal daily activities. Conservative treatment measures have 
been unsuccessful. A lumbar magnetic resonance imaging revealed significant stenosis at the L3-L4 and L4-L5 
levels. You believe that the minimally invasive implantation of a posterior interspinous process spacer device is 
the most appropriate treatment for this enrollee. Based on the current medical literature, interspinous spacer 
interventions for patients with symptomatic lumbar spinal stenosis have been shown to be safe and effective 
through 5 years of follow-up. The documentation supports that the proposed procedure is medically reasonable 
and necessary for the enrollee in this case. 
 
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 interspinous spacer device have been met. Therefore, we decided 
that the Plan has to pre-approve the Vertiflex interspinous spacer device  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Mass spectrometry and tandem mass spectrometry 
(83789) provided on February 11, 2022. 
 
You asked the Plan to pay for the Mass spectrometry and tandem mass spectrometry (83789). You say that you 
would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the 
services are not covered as billed. 
 
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 Mass spectrometry and tandem mass spectrometry (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 the Mass spectrometry and tandem mass 
spectrometry (83789) provided on February 11, 2022.