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

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve an Intracept procedure. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the magnetic resonance imaging (MRI) shows foraminal stenosis and facet 
degenerative joint disease (DJD). The cause of the back pain is unclear. 
 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ondansetron. 
 
You asked the Plan to pre-approve the medication. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve ondansetron.   
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on December 13, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the 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 dental 
services on December 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive oral evaluation (D0150) and intraoral - 
comprehensive series of radiographic images (D0210) provided on December 16, 2022. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. 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 May 11, 2021. Therefore, 
we decided that the Plan does not have to pay for comprehensive oral evaluation (D0150) and intraoral - 
comprehensive series of radiographic images (D0210) provided on December 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve therapeutic CGM and supplies. 
 
You asked the Plan to pre-approve therapeutic CGM and supplies. You say that you would like the CGM and 
supplies approved. The Plan denied your request. The Plan says none of the covered testing supplies have been 
tried. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met.  
We looked at the file and Medicare rules. The Plan requested medical records from your provider but did not 
receive any, and without medical records we cannot determine whether you meet the criteria for the therapeutic 
CGM and supplies. Based on this information, we decided that there is insufficient information in the record to 
determine if Medicare rules for coverage of therapeutic CGM and supplies have been met. Therefore, we 
decided that the Plan does not have to pre-approve therapeutic CGM and supplies.
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 December 14, 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 
December 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for dental services provided on December 1, 2022. 
 
You asked the Plan to pay more for the dental services. You say that your extractions should all be covered. 
You say that you are on a limited income and cannot afford the billed amount. 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 the Plan paid $92 on July 21, 2022, and paid $908 on December 1, 2022 ($92+$908=$1,000). After the 
annual maximum is exhausted, any remaining charges are your responsibility. Therefore, this benefit has been 
exhausted as of December 1, 2022. Therefore, we decided that the Plan does not have to pay more for dental 
services provided on December 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on December 5, 2022. 
 
You asked the Plan to pay for the dental services. You say that this should be covered in full. The Plan denied 
your request. The Plan says your benefit for the requested item or service has been met during this visit. 
 
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 December 5, 2022. 
Therefore, we decided that the Plan does not have to pay for dental services provided on December 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prophylaxis (D1110) provided on January 9, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be paid. 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 10, 2022, and July 12, 2022. Therefore, we decided that the Plan does not have to pay for prophylaxis (D1110) provided on 
January 9, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for invalid procedure code (D2840), bone replacement graft  
retained natural tooth  first site in quadrant (D4263) and guided tissue regeneration - resorbable barrier, per 
site (D4266) provided on January 16, 2023. 
 
You asked the Plan to pay for dental services. You say that you do not agree with the denial, and you would 
like to be reimbursed the full amount. The Plan denied your request. The Plan says these services are not 
covered under your 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. Invalid procedure code 
(D2840), bone replacement graft  retained natural tooth  first site in quadrant (D4263) and guided tissue 
regeneration - resorbable barrier, per site (D4266) are not covered under the Plans dental benefits. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D2840, D4263 and 
D4266 are not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pay for invalid procedure code (D2840), bone replacement graft  retained natural tooth  first site in quadrant 
(D4263) and guided tissue regeneration - resorbable barrier, per site (D4266) provided on January 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an osseous surgery (D4261), and osseous tissue regeneration 
(D4265), provided by November 21, 2022. 
 
You asked the Plan to pay for the dental services. You say that this was not cosmetic. The Plan denied your 
request. The Plan says the dental services provided are not covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an 
osseous surgery (D4261), and osseous tissue regeneration (D4265), provided by November 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99223 provided on September 1, 2022. 
 
You asked the Plan to pay for procedure code 99223. You say that the medical records support the billing of 
code 99223 provided on September 1, 2022. The Plan denied your request. The Plan says the medical records 
do not support the billing of code 99223 provided on September 1, 2022. 
 
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, the CPT Code Manual definition of code 99223 is Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor or unit. 
 
We asked our coder 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 procedure code 99223. Our reviewer says that the medical 
records do not support the billing of code 99223 provided on September 1, 2022. Our reviewer found the 
review has determined that the medical records supported a comprehensive history and a comprehensive 
examination but not medical decision making of high complexity. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99223 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99223 provided on September 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and related 
supplies. 
 
You asked the Plan to pre-approve the CGM and related supplies. You say that you do not like needles or the 
fact you have to stick yourself so you would like the CGM approved. The Plan denied your request. The Plan 
says the Medicare criteria was not met. 
  The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of the CGM and 
related supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
continuous glucose monitor (CGM) and related supplies.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for resin-based composite - two surfaces, posterior (D2392) 
provided on January 9, 2023. 
 
You asked the Plan to pay for dental services. You say that you were not aware you only had preventative 
coverage. The Plan denied your request. The Plan says that you disenrolled from the optional supplemental 
plan effective August 1, 2021. Therefore, at the time of this service you did not have coverage. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for resin-based composite - two 
surfaces, posterior (D2392) provided on January 9, 2023.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for osseous, osteoperiosteal, or cartilage graft of the mandible or maxilla 
(D7950) provided by a periodontist on December 8, 2022. 
 
You asked the Plan to pay for the dental service. You say that it was recommended that you get the surgery 
done. The Plan denied your request. The Plan says that the denial of payment for these services is correct, 
because osseous surgery is 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. The Plan covers the dental 
service when the services are medically necessary and reasonable. 
 
We looked at the Plans coverage, the file, and Medicare rules. Based on this information, we decided that the 
Plan's rules for coverage of the dental service have been met. Therefore, we decided that the Plan has to pay for 
osseous, osteoperiosteal, or cartilage graft of the mandible or maxilla (D7950) provided by a periodontist on 
December 8, 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 issue reimbursement for the gym membership (S9970) purchased on 
January 1, 2022. 
 
You asked the Plan to issue reimbursement 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 this service is not payable as the 
proof of payment provided is invalid. 
 
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 Plans rules for coverage of gym benefits have not been met because the proof of payment provided is 
invalid. Specifically, the receipt submitted did not show that the membership has been paid. Proof of payment 
must include an itemized receipt with a credit card statement/cashed check and an itemized bill, or a statement 
from the provider indicating payment was made. Therefore, we decided that the Plan does not have to issue 
reimbursement for the gym membership (S9970) purchased on January 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodic oral evaluation - established patient (D0120) and 
periodontal maintenance (D4910) provided on November 28, 2022. 
 
You asked the Plan to pay for the dental services. You say that you feel these services should be covered. 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. This benefit includes the 
requested periodic oral evaluation - established patient and periodontal maintenance but each is limited to two 
per year. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows you received covered periodic oral evaluation - established patient on March 14, 2022, and on July 14, 
2022. You also received periodontal maintenance and prophylaxis  adult on March 14, 2022, and July 14, 
2022. Although these are two different services, they fall within the same category in your Evidence of 
Coverage and are subject to the same frequency limitations. Therefore, these benefits were exhausted as of 
November 28, 2022. Therefore, we decided that the Plan does not have to pay for periodic oral evaluation - 
established patient (D0120) and periodontal maintenance (D4910) provided on November 28, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy and speech therapy services provided on 
November 01, 2022, to November 30, 2022. 
 
You asked the Plan to pay for physical therapy and speech therapy services. You say that prior authorization is 
not required for these services. The Plan denied your request. The Plan says that unauthorized, out-of-network 
care is not covered. 
 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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for physical therapy and 
speech therapy services provided on November 01, 2022, to November 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation and pulp vitality tests (D0140, 
D0460) provided on September 30, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. The pulp vitality tests 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 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 September 29, 2022. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation and pulp vitality tests 
(D0140, D0460) provided on September 30, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care and occupational therapy services 
provided on November 18, 2022, to November 30, 2022. 
 
You asked the Plan to pay for nursing facility care and occupational therapy services. You say that 
authorization is not required for these services. The Plan denied your request. The Plan says that unauthorized, 
out-of-network care is not covered. 
 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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for nursing facility care and 
occupational therapy services provided on November 18, 2022, to November 30, 2022.