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

 
We decided that the Plan does not have to pre-approve an apicoectomy (D3425), bone graft (D3428), and a 
retrograde filling on tooth #14 (D3430). 
 
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 an apicoectomy (D3425), bone graft (D3428), and a 
retrograde filling (D3430) are not covered by your routine dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an 
apicoectomy (D3425), bone graft (D3428), and a retrograde filling on tooth #14 (D3430).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), bitewing x-rays (D0272), 
and prophylaxis (D1110). 
 
You asked the Plan to pay for the dental services. You say that you were never told the provider was out-of-
network. 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 a periodic oral evaluation (D0120), bitewing x-rays (D0272), and prophylaxis (D1110).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vertebral Axial Decompression (VAX-D). 
 
You asked the Plan to pre-approve the procedure. The Plan denied your request. The Plan says this is not a 
covered service. 
 
The Plan must follow Medicare rules. Medicare rules say that there is insufficient scientific data to support the 
benefits of this technique. Therefore, VAX-D is not covered by Medicare.  
 
We looked at the file and Medicare rules. Per NCD 160.16. the requested procedure is not covered by 
Medicare. Based on this information, we decided that Medicare rules for coverage of the procedure have not 
been met. Therefore, we decided that the Plan does not have to pre-approve Vertebral Axial Decompression 
(VAX-D).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial upper denture (D5211). 
 
You asked the Plan to pre-approve the dental item. You say that your current partial is hanging on by one tooth. 
You say that you have not used any of the benefits for 2022. You also say that you do not understand how you 
have exceeded the maximum allowed. The Plan denied your request. The Plan says your benefit for the partial 
upper 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 partial upper denture was exhausted on date of service July 29, 2021. Therefore, we 
decided that the Plan does not have to pre-approve a partial upper denture (D5211).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a frenulectomy (D7961). 
 
You asked the Plan to pre-approve a frenulectomy. You say that this service is medically necessary. The Plan 
denied your request. The Plan says a frenulectomy (D7961) is not covered by your routine dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
frenulectomy (D7961).
Appeal type: Other
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 December 22, 2021. 
 
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 
December 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Arthroplasty, glenohumeral joint; hemiarthroplasty 
(23470). 
 
You asked the Plan to pre-approve the shoulder arthroplasty. You say that this was previously approved but 
rescheduled due to COVID-19. Please reconsider the denial. The Plan denied your request. The Plan says 
procedure code 23470 is inclusive to the approved procedure code 23472 and cannot be separate. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. Medicare rules say that providers must report services correctly. Providers must 
report services with the appropriate CPT code. 
 
We looked at the file, and Medicare rules. In this case 23470 is inclusive to the approved procedure code 
23472. Based on this information, we decided that Medicare rules for coverage of the shoulder arthroplasty 
have not been met. Therefore, we decided that the Plan does not have to pre-approve Arthroplasty, 
glenohumeral joint; hemiarthroplasty (23470).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a filling for a crown with posts (D2950). 
 
You asked the Plan to pre-approve a filling for a crown with posts (D2950). You say that bite wings show 
adequate support of necessity for crown. The Plan denied your request. The Plan says this is not a covered code 
under this plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
filling for a crown with posts (D2950).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a removal of an impacted tooth (D7240). 
 
You asked the Plan to pre-approve the removal of an impacted tooth. You say that you need this service. The 
Plan denied your request. The Plan says this service is not covered under your benefit package. 
 
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 
removal of an impacted tooth (D7240).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a limited oral evaluation - problem focused (D0140) and 
intraoral - periapical first radiographic image (D0220). 
 
You asked the Plan to pre-approve the dental services. The Plan denied your request. The Plan says dental 
services from an out-of-network provider 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. 
 
You are requesting 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 pre-approve a limited 
oral evaluation - problem focused (D0140) and intraoral - periapical first radiographic image (D0220).
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 January 25, 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 January 
25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed. 
 
You asked the Plan to pre-approve the hospital bed. The Plan denied your request. The Plan says this is not a 
covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed (E0265, E0266, 
E0296, and E0297) is not covered.  
 
We looked at the file and Medicare rules. Per L33820, the requested total electric hospital bed is not a covered 
benefit. Based on this information, we decided that Medicare rules for coverage of the hospital bed have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital bed.
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 February 10, 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 
February 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an addition to lower limb prosthesis, multiaxial ankle 
with swing phase active dorsiflexion feature (L5968). 
 
You asked the Plan to pre-approve an addition to lower limb prosthesis. You say that you need this prosthetic 
in order to have full function of your foot. The Plan denied your request. The Plan says the requested prosthetic 
but does not meet Medicare criteria as reasonable and 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 an addition to lower limb prosthesis. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found an authorization for a College Park Odyssey K2 foot was approved by 
the Plan. The K3 code for partial L5968 is not medically necessary since you are a K2 level. 
 
 
  
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 addition to lower limb prosthesis have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an addition to lower limb prosthesis, multiaxial ankle with swing 
phase active dorsiflexion feature (L5968).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implant supported crown on tooth #3 (D6065). 
 
You asked the Plan to pre-approve a crown. You say that this service is medically necessary. The Plan denied 
your request. The Plan says implant supported crowns (D6065) are not covered by the enrollees routine dental 
benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an 
implant supported crown on tooth #3 (D6065).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve maxillary and mandibular dentures (D5110, D5120).
 
You asked the Plan to pre-approve the maxillary and mandibular dentures. You say that the services should be 
covered as you disagree with the denial. The Plan denied your request. The Plan says the services denied 
correctly as they do not fall within 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 
maxillary and mandibular dentures (D5110, D5120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custom abutments (D6057 x 5) and an abutment 
supported porcelain fused to metal crown for teeth# 18, 19, 24, 30, 3 (D6059 x 5). 
 
You asked the Plan to pre-approve these dental items. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says these items 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, the requested items are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve custom 
abutments (D6057 x 5) and an abutment supported porcelain fused to metal crown for teeth# 18, 19, 24, 30, 3 
(D6059 x 5).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2752) for tooth # 14 to be performed by an 
out-of-network provider. 
 
You asked the Plan to pre-approve the dental service. You say that you started a treatment with a provider. You 
say that the authorization was denied. You say that you did not want to continue the treatment. You also say 
that you went to a different provider that would not continue the treatment. The Plan denied your request. The 
Plan says that a dental service from an out-of-network provider is 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. 
 
You are requesting 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 pre-approve a crown 
(D2752) for tooth # 14 to be performed by an out-of-network provider.
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 January 19, 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 January 
19, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acute inpatient rehabilitation services provided to the 
enrollee from December 23, 2020, to December 29, 2020. 
 
You asked the Plan to pay for IRF care. You say that the claim should be reprocessed and paid. The Plan 
denied your request. The Plan says this admission does 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 pay for 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 enrollee did not require the intensity of services provided at an IRF. 
Specifically, the enrollee did not require fifteen hours per week of rehabilitative services and regular physician 
evaluation. The enrollees care needs could have been 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 pay for acute inpatient rehabilitation services provided to the enrollee from December 23, 2020, to 
December 29, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on November 5, 2021, billed 
with codes 87798 (12 units). 
 
You asked the Plan to pay for the genetic testing billed. You say that this drug testing is medically necessary. 
The Plan denied your request. The Plan says it was decided to pay all codes other than 87798 as it is not 
specified what tests this code is representing.  
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, 2021, billed with codes 87798 (12 units).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter. 
 
You asked the Plan to pre-approve a power scooter. You say that you need this in case your battery runs out. 
The Plan denied your request. The Plan says a duplicate item is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that equipment which the beneficiary owns or is a 
capped rental item may be replaced in cases of loss or irreparable damage.  
 
We looked at the file and Medicare rules. The Plan paid for a power scooter in January 2020. This scooter is not 5 years old and does not have irreparable damage. As such, the requested scooter is a duplicate item, and 
therefore is not covered. Based on this information, we decided that Medicare rules for coverage of a power 
scooter have not been met. Therefore, we decided that the Plan does not have to pre-approve a power scooter.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 8 additional one-way routine transportation trips. 
 
You asked the Plan to pre-approve the additional trips. The Plan denied your request. The Plan says the 
enrollee has used all 24 trips. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve 8 additional one-way routine transportation trips.