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

 
We decided that the Plan does not have to pay for gingival irrigation (D4921) provided on July 6, 2022. 
 
You asked the Plan to pay for gingival irrigation. You say that you only wanted a deep cleaning. The Plan 
denied your request. The Plan says D4921 has been correctly denied. 
 
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 gingival 
irrigation (D4921) provided on July 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the crowns (D4249) for tooth #12 and #14. 
 
You asked the Plan to pre-approve the dental services. You say that it is medically necessary for the enrollee to 
receive the crowns. The Plan denied your request. The Plan says the denial of authorization for these services is 
correct, because crowns 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 pre-approve the 
crowns (D4249) for tooth #12 and #14.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87634 billed for date of service August 4, 
2021. 
 You asked the Plan to pay for procedure code 87634. The Plan denied your request. The Plan says payment for 
code 87634 is bundled into payment for code 87631. 
 
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 87634 is a column II code to column I code 87631. This claim has 
not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing 
criteria have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 87634 
billed for date of service August 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99153 billed for services provided on May 
10, 2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the rules for 
payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99153 is not supported. There is an associated code that describes the professional 
component. Based on this information, we decided that Medicare rules for coverage of the billed services have 
not been met. Therefore, we decided that the Plan does not have to pay for procedure code 99153 billed for 
services provided on May 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a 2D oral facial image (D0350), and gingival irrigation 
(D4921) provided by a participating provider on July 18, 2022. 
 
You asked the Plan to pay for a 2D oral facial image and gingival irrigation. You say that you were told you 
needed the deep cleaning. You say that you thought this would be a normal cleaning. The Plan denied your 
request. The Plan says the rendered 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 pay for a 2D oral 
facial image (D0350), and gingival irrigation (D4921) provided by a participating provider on July 18, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the request is not medically necessary.

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 enrollee's medical problems are stable and there are no complex nursing or rehabilitation needs. While the medical record supports a need for physical or occupational therapy, 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 IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Granix.
You asked the Plan to pre-approve Granix. You say that Granix is medically necessary for the enrollee's
treatment of neutropenic disorder in a kidney transplant recipient. The Plan denied your request. The Plan says
the requested drug is not being prescribed for a medically accepted indication. The Plan says that Granix is not
considered a true biosimilar of filgrastim and is not supported by a compendia for the enrollee's condition.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDAapproved drugs if they are medically accepted as safe and effective or appropriate for the particular use.
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 Granix. Our reviewer says that the
criteria for coverage have not been met. Our physician reviewer found the requested use of Granix is not FDAapproved to treat a neutropenic disorder in a kidney transplant recipient. The use of Granix to treat a
neutropenic disorder in a kidney transplant recipient is not supported by one of the major drug compendia or by
clinical research that appears in a Medicare-approved medical journal. The use of Granix to treat a neutropenic
disorder in a kidney transplant recipient does not meet Medicare criteria for safe and effective and otherwise
reasonable and necessary 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 Granix have not been met. Therefore, we decided that the Plan does not have to
pre-approve Granix
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87634 billed for date of service September 1, 
2021. 
 
You asked the Plan to pay for procedure code 87634. You say that this claim should be paid as billed. The Plan 
denied your request. The Plan says payment for code 87634 is bundled into payment for code 87631.  
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 87634 
is a column II code to column I code 87631. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 87634 billed for date of service September 1, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the re-evaluation post-operative office visit (D0171), an 
extraction (D7210), and a bone replacement graft (D7953), provided by a participating provider on June 20, 
2022, to July 5, 2022. 
 
You asked the Plan to pay for the re-evaluation post-operative office visit, an extraction, and a bone 
replacement graft. You say that you were in pain, and you needed these services. The Plan denied your request. 
The Plan says the rendered 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 pay for the re-
evaluation post-operative office visit (D0171), an extraction (D7210), and a bone replacement graft (D7953), 
provided by a participating provider on June 20, 2022, to July 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital care provided on February 18, 2022 to February 25, 2022.

You asked the Plan to pay for the inpatient hospital care. You say that this was an emergency situation and you were admitted to the hospital. The Plan denied your request. The Plan says Medicare does not cover services rendered by any Veterans Affairs facility since Medicare does not cover any VA benefits, they are separate benefits and mutually exclusive.

The Plan must follow Medicare rules. Medicare rules say that payments may not be made to any Federal provider of services for any item or services that such provider is obligated by law, or contract with the United States, to render at public expense.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for inpatient hospital care provided on February 18, 2022 to February 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on August 11, 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 the requested item or service was exhausted on date of service August 11, 2022. 
Therefore, we decided that the Plan does not have to pay for the dental services on August 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composites - three surfaces, posterior 
(D2393) and intraoral - periapical first radiographic image (D0220) provided on May 24, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like these services covered. 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 resin-based composites - three surfaces, posterior (D2393) and intraoral - periapical first 
radiographic image (D0220) provided on May 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a resin-based composite (D2392), a periodic oral evaluation 
(D0120), and prophylaxis (D1110), provided by an out-of-network provider on April 7, 2022, to May 10, 2022. 
 
You asked the Plan to pay for a resin-based composite, a periodic oral evaluation, and prophylaxis. You say 
that this is the dentist you always go to. The Plan denied your request. The Plan says services must be provided 
by a participating provider. 
 
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 a resin-
based composite (D2392), a periodic oral evaluation (D0120), and prophylaxis (D1110), provided by an out-of-
network provider on April 7, 2022, to May 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve osseous surgery (D4260). 
 
You asked the Plan to pre-approve osseous surgery (D4260). You say that you had osseous surgery and 2021 
with the same codes and the services were covered. The Plan denied your request. The Plan says the 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, osseous surgery  four or more 
contiguous teeth or tooth bounded spaces per quadrant (D4260) are not among those covered under this benefit. 
Therefore, we decided that the Plan does not have to pre-approve osseous surgery (D4260).
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve prophylaxis - adult (D1110). 
 
You asked the Plan to pre-approve the dental services. You say that your dentist told you that you had to have a 
third cleaning because of build-up. The Plan denied your request. The Plan says that your benefit for the 
requested item or service has already been exhausted. 
 
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.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The Plan has 
not made reasonable and diligent efforts to gather and forward to us information regarding their decision to 
deny your request. There is no evidence showing your benefit for the requested item or service was previously 
exhausted. Therefore, we decided that the Plan has to pre-approve prophylaxis - adult (D1110).  
 
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 nitrous oxide (D9230). 
 
You asked the Plan to pre-approve nitrous oxide. You say that the enrollee needs this service. The Plan denied 
your request. The Plan says nitrous oxide is not listed as a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
nitrous oxide (D9230).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing identified with codes 81410 and 81411. 
 
You asked the Plan to pre-approve genetic testing. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the requested services are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that genetic testing identified with codes 81410 and 
81411 are not covered.  
 
We looked at the file and Medicare rules. The requested services are specifically not covered. Based on this 
information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we 
decided that the Plan does not have to pre-approve genetic testing identified with codes 81410 and 81411.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removal of torus mandibularis (21031 x 2). 
 
You asked the Plan to pre-approve the dental services. You say that the enrollee currently has a bridge that has 
a gap and needs an implant. You also say that the tori are enlarging which risk causing difficulty with speech, 
chewing and hygiene. The Plan denied your request. The Plan says the requested service is not covered by 
Medicare or the Plan. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement 
of the enrollees teeth or the structures directly supporting the enrollees teeth. These are dental services that 
are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve 
removal of torus mandibularis (21031 x 2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation and occlusal 
adjustment provided on August 2, 2021. 
 
You asked the Plan to pay for the dental services. You say that you did not know these services were not 
covered. The Plan denied your request. The Plan says these services are not covered by the Plan'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 pay for the 
problem focused limited oral evaluation and occlusal adjustment provided on August 2, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the acute inpatient hospital care for the elective left total 
shoulder replacement (CPT code(s) 23472, 23430, and 29823). 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the stay is necessary. The Plan 
denied your request. The Plan says the enrollee is medically stable and has been provided medical clearance to 
undergo this elective procedure. The Plan states the planned procedure listed under CPT code 23472, 23430, 
and 29823 are not listed on the Centers for Medicare & Medicaid Services (CMS) Inpatient Only List. The Plan 
states the procedure is currently approved as an ambulatory procedure and there is no documentation provided 
to support the expectation the enrollee will require a greater than 2 midnight stay. The Plan states if the enrollee 
experiences any peri- or post-operative complications, reconsideration for inpatient level of care can be 
performed on concurrent review with updated clinical information. 
 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 does not support that the criteria for inpatient payment are met in this 
case. Our physician reviewer found there is no documentation provided to support the expectation the enrollee 
will require a greater than 2 midnight stay. The review indicates that the inpatient hospital admission is not 
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 not been met. Therefore, we decided that the 
Plan does not have to pre-approve the acute inpatient hospital care for the elective left total shoulder 
replacement (CPT code(s) 23472, 23430, and 29823).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a prefabricated post and core (D2954) and a re-cemented 
crown (D2920) provided by an out-of-network provider on May 2, 2022. 
 
You asked the Plan to pay for a prefabricated post and core and a re-cemented crown. You say that these 
services are medically necessary. The Plan denied your request. The Plan says the rendered 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 pay for a 
prefabricated post and core (D2954) and a re-cemented crown (D2920) provided by an out-of-network provider 
on May 2, 2022.