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

 
We decided that the Plan does not have to pay for two dimensional (2D) oral/facial photographic image 
obtained intra-orally or extra-orally (D0350) provided on June 8, 2023. 
 
You asked the Plan to pay for 2D oral/facial photographic image obtained intra-orally or extra-orally (D0350). 
You say that the provider who took the photographs was the consulting dentist. You also say you were referred 
to this provider for evaluation of a cracked tooth to determine the next steps. The Plan denied your request. The 
Plan says these are non-covered services. 
 
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 two 
dimensional (2D) oral/facial photographic image obtained intra-orally or extra-orally (D0350) provided on 
June 8, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve F2 (prothrombin, coagulation factor II) (eg, hereditary 
hypercoagulability) gene analysis (81240) and F5 (coagulation factor V) (eg, hereditary hypercoagulability) 
gene analysis (81241). 
 
You asked the Plan to pre-approve F2 gene analysis and F5 gene analysis. You say that the services are 
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 
has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that genetic testing is covered when specific criteria are 
met. 
 
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 F2 gene analysis and F5 gene analysis. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found [state the 
medical finding(s) upon which the physician based his/her conclusion] 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of F2 gene analysis and F5 gene analysis have not been met. Therefore, we 
decided that the Plan does not have to pre-approve F2 (prothrombin, coagulation factor II) (eg, hereditary 
hypercoagulability) gene analysis (81240) and F5 (coagulation factor V) (eg, hereditary hypercoagulability) 
gene analysis (81241).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composite-two surfaces, posterior for tooth 
number 28 (D2392) provided on July 13, 2023. 
 
You asked the Plan to pay for this dental item. 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 dental item 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 dental item provided was exhausted on date of service July 13, 2023. Specifically, 
the Plans contract states that four dental fillings (restorative services) are covered per calendar year.   
 
 
 
On this day, you received five dental fillings, of which four of these fillings were paid by the Plan. Therefore, 
you have exhausted the allowable benefit for the dental item at issue. Therefore, we decided that the Plan does 
not have to pay for the resin-based composite-two surfaces, posterior for tooth number 28 (D2392) provided on 
July 13, 2023.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes G0283, 97110, 97140, 97530, 97112 and 97164 billed 
for dates of service April 19, 2023, to April 29, 2023. 
 
You asked the Plan to pay for procedure codes G0283, 97110, 97140, 97530, 97112 and 97164. You say that 
these services were necessary and are supported as billed. The Plan denied your request. The Plan says that 
these codes are not supported in the records provided. 
 
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 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 codes G0283, 97110, 97140, 97530, 97112 and 
97164. Our reviewer says that these services are supported as billed. Our reviewer found each of these 
procedure codes is clearly documented in the provided records. These are seen in the handwritten notes and in 
the typed progress notes. 
 
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 codes G0283, 97110, 97140, 97530, 97112 and 97164 have been 
met. Therefore, we decided that the Plan has to pay for procedure codes G0283, 97110, 97140, 97530, 97112 
and 97164 billed for dates of service April 19, 2023, to April 29, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on May 11, 2023. 
 
You asked the Plan to pay for the dental services. You say that you feel like the Plan should pay for some of 
these charges. 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 dental services provided on May 11, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 20936 and 20930 billed for date of service 
September 2, 2022. 
 
You asked the Plan to pay for procedure codes 20936 and 20930. You say that you disagree with the denial. 
The Plan denied your request. The Plan says procedure codes 20936 and 20930 are considered bundled and not 
separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure codes 20936 and 20930 have a status indicator of B on the Physician Fee Schedule. 
This means that procedure codes 20936 and 20930 are not separately payable. Based on this information, we 
decided that Medicare rules for coverage of procedure codes 20936 and 20930 have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 20936 and 20930 billed for date of service 
September 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the re-cement or re-bond fixed partial denture (D6930) 
provided on March 30, 2023. 
 
You asked the Plan to pay for the re-cement or re-bond fixed partial denture. You say that you had a lot of pain 
and had problems taking food so this was needed to be resolved as soon as possible. The Plan denied your 
request. The Plan says code D6930 is not 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 pay for the re-
cement or re-bond fixed partial denture (D6930) provided on March 30, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health physical therapy to be provided by an OON 
provider.  
 
You asked the Plan to pre-approve home health physical therapy. You say that you do not agree with the denial 
of receiving home health physical therapy from an out-of-network provider.  The Plan denied your request. The 
Plan says the service can be provided by an in-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 
home health physical therapy to be provided by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve  percutaneous vertebral augmentation (PVA) for 
vertebral compression fracture (VCF). 
 
You asked the Plan to pre-approve percutaneous vertebral augmentation (PVA) for vertebral compression 
fracture (VCF). You say that it is medically necessary. The Plan denied your request. The Plan says the 
enrollee does not meet the requirements for approval. 
 
The Plan follows Medicare rules. Medicare rules say that PVA may be covered if certain criteria are met.  
 
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 percutaneous vertebral augmentation 
(PVA) for vertebral compression fracture (VCF). Our reviewer says that the service is not medically necessary. 
Our physician reviewer found there is no trial of a back brace. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of percutaneous vertebral augmentation (PVA) for vertebral compression fracture 
(VCF) have not been met. Therefore, we decided that the Plan does not have to pre-approve  percutaneous 
vertebral augmentation (PVA) for vertebral compression fracture (VCF).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the re-cement or re-bond crown (D2920) provided on June 
22, 2023. 
 
You asked the Plan to pay for the dental service. You say that this procedure was repeated on the same tooth 
because the original treatment did not fill the void in the crown with the correct material and the crown came 
loose. The second procedure used both substances to reattach the crown. The Plan denied your request. The 
Plan says your benefit for the re-cement or re-bond crown 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 re-cement or re-bond crown was exhausted on date of service November 2, 2022. 
Therefore, we decided that the Plan does not have to pay for the re-cement or re-bond crown (D2920) provided 
on June 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a consult, testing, and follow-up to be provided by an 
out-of-network (OON) provider.  
 
You asked the Plan to pre-approve a consult, testing, and follow-up. You say that you do not feel that the other 
in-network providers are able to treat you this provider is. The Plan denied your request. The Plan says there 
are other providers available who are in-network, who are within the Medicare allowable distance from your 
residence. 
 
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 
a consult, testing, and follow-up to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on May 10, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services provided on May 10, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing billed for date of service April 28, 2023. You asked the Plan to pay for the billed services. You say that the service was necessary to assist the enrollee's 
physician. The Plan denied your request. The Plan says one code must be submitted for the panel. 
 
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 the panel testing was not billed with a single code as required. 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 the panel testing billed for date of service April 28, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 continuous glucose monitor (CGM).  
You asked the Plan to pre-approve a CGM. You say that the enrollee would benefit from this CGM. The Plan 
denied your request. The Plan says the medical criteria for a CGM have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin. 
Based on this information, we decided that Medicare rules for coverage of a CGM have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 2 continuous glucose 
monitor (CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom fabricated abutment  includes placement 
(D6057), and abutment supported porcelain fused to metal crown (high noble metal) (D6059). 
 
You asked the Plan to pre-approve the dental services. You say that you had an extraction and the implant is 
necessary for you to have a crown placed. The Plan denied your request. The Plan says these implant services 
are not a covered expense 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. 
 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 
custom fabricated abutment  includes placement (D6057), and abutment supported porcelain fused to metal 
crown (high noble metal) (D6059).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for hearing aids (V5261) provided on January 25, 2023. 
 
You asked the Plan to reimburse for hearing aids (V5261). You say that you appreciate the consideration for 
partial reimbursement. The Plan denied your request. The Plan says the hearing benefit is not covered if the 
services are not registered in advance. The Plan also says that hearing aids ordered through providers other than 
the Plan Hearing are not covered. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when the hearing aids are obtained from an in-network provider.  
 
 
  We looked at the file and the Plan's rules. The Plan rules say that they pay up to a $500 allowance for hearing 
aids (combined for both ears) every 3 years. The Plan rules also say that hearing aids purchased outside of the 
Plan's hearing nationwide network are not covered. Based on this information, we decided that the Plan's rules 
for coverage of hearing aids (V5261) have not been met. Therefore, we decided that the Plan does not have to 
reimburse for hearing aids (V5261) provided on January 25, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from September 22, 2023, 
forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from September 22, 2023, forward. You say that 
the services at issue were medically necessary. The Plan denied your request. The Plan says the services at 
issue were not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric care from 
September 22, 2023, forward. Our reviewer says that the enrollee does not meet the criteria for treatment in an 
acute inpatient mental health treatment beyond the date in question of September 22, 2023, forward. Our 
physician reviewer found as of the last covered day, there is no indication in the available medical records that 
the enrollees psychiatric symptoms could not be managed on a less restrictive basis. As of the last covered day 
the enrollee did not express any active suicidal ideation or intent, or any intent to harm themselves or anyone 
else. The enrollee was not exhibiting any other significant symptoms. The enrollee had no acute psychiatric 
issues that would require continued inpatient care beyond the last covered day. The enrollee has chronic 
symptoms. The available medical records do not support that continued inpatient care will change these 
symptoms or the enrollees current condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care from September 22, 2023, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from September 22, 
2023, forward.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve an office visit. You say that you are requesting reconsideration for the 
service. The Plan denied your request. The Plan says the enrollee must receive their care from a network 
provider (for more information about this, see Section 2 of Chapter 3). In most cases, care the enrollee receives 
from an out-of-network provider (a provider who is not part of the plans network) will not be 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 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 office visit to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care provided from May 11, 2023, to 
May 30, 2023, by an OON provider.  
 
You asked the Plan to pay for the nursing facility care. You say that the services were medically necessary and 
provided in good faith. The Plan denied your request. The Plan says the services were not authorized. 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 Plan contract says the enrollees POS benefit only applies to 
nonMedicare covered dental services covered by the Plan. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the nursing facility care provided from May 11, 
2023, to May 30, 2023, by an OON provider.