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

 
We decided that the Plan does not have to pay for removal of residual tooth roots (D7250), inhalation of nitrous 
oxide/analgesia, anxiolysis (D9230) and infiltration of sustained release therapeutic drug, per quadrant (D9613) 
provided on June 1, 2023. 
 
You asked the Plan to pay for infiltration of sustained release therapeutic drug, per quadrant. You say that this 
should be covered. The Plan denied your request. The Plan says this 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 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 pay for 
infiltration of sustained release therapeutic drug, per quadrant (D9613) provided on June 1, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ED services provided on August 5, 2023. 
 
You asked the Plan to pay for the ED services. The Plan denied your request. The Plan says Medicare payment 
cannot be made to this type of provider. 
 
The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare and 
cannot receive payment for services.  
 
We looked at the file and Medicare rules. We find that the provider at issue is not affiliated with a hospital and 
cannot receive Medicare payment.  Therefore, we decided that the Plan does not have to pay for the ED 
services provided on August 5, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services (D0367 and D0350) on July 13, 2023. 
 
You asked the Plan to pay for the dental services (D0367 and D0350). You say that you would like to request 
reconsideration for payment. The Plan denied your request. The Plan says the services (D0367 and D0350) 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 (D0367 and D0350) on July 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a new patient evaluation to be provided by an out-of-
network provider. 
 
You asked the Plan to pre-approve the dental service. You say that there is no general dentist in your area and 
you do not want to see the same dentist as last time. The Plan denied your request. The Plan says dental 
services from an out-of-network provider are not covered by your supplemental benefits. Also, there are 
multiple in-network providers in your service area. 
 
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 new 
patient evaluation to be provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the acupuncture treatments (97810) 
provided from April 10, 2022, through May 22, 2023. 
 
You asked the Plan to issue reimbursement for these services. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services 
provided in this case are not payable as they were rendered by an ineligible provider.  
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
A review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to issue reimbursement for the acupuncture 
treatments (97810) provided from April 10, 2022, through May 22, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve knee arthroscopy. 
 
You asked the Plan to pre-approve knee arthroscopy. You say that the enrollee's quality of life and daily living 
is not well. The Plan denied your request. The Plan says that the knee arthroscopy is not reasonable or 
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 knee arthroscopy. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee had recent total knee replacement surgery. Additionally, the enrollee 
has loss of motion after the surgery. There is no 6-week trial of physical therapy documented. Manipulation of 
the knee under anesthesia is medically appropriate after physical therapy has been completed. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of knee arthroscopy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve knee arthroscopy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral-periapical additional radiographic image 
(D0230) provided on May 17, 2023. 
 
You asked the Plan to pay for this dental service. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says your benefit for the service provided 
has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the service provided was exhausted on date of service May 17, 2023.   
 
 
 
 
Specifically, the Plans contract states that one intraoral x-ray is covered per calendar year. On this day, you 
received two intraoral-periapical x-rays, of which one was paid for by the Plan. Therefore, you have exhausted 
the allowable benefit for this service. Therefore, we decided that the Plan does not have to pay for the intraoral-
periapical additional radiographic image (D0230) provided on May 17, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a light therapy device (E0691) provided on April 20, 2023. 
 
You asked the Plan to pay for the light therapy device. You say that this device was medically necessary. The 
Plan denied your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. The provided records make no mention of this device being needed or how it would be used. The record shows that the Plan made several attempts to obtain the necessary documentation without success. 
Therefore, we decided that the Plan does not have to pay for a light therapy device (E0691) provided on April 
20, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction, of an erupted tooth requiring removal of bone 
and/or sectioning of tooth (D7210) provided on May 22, 2023. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not covered under the 
supplemental dental 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 service provided is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the extraction, of 
an erupted tooth requiring removal of bone and/or sectioning of tooth (D7210) provided on May 22, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids (V5298) purchased on 
February 21, 2023. 
 
You asked the Plan to issue reimbursement for these items. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says the hearing aids are not payable 
as they were purchased from an out-of-network provider.  
 
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 purchased from the Plans select hearing aid provider.  
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically, the Plans contract states that hearing aids are covered 
only when purchased from the Plans select hearing aid provider. However, the hearing aids in this case were 
purchased from an out-of-network provider. Therefore, we decided that the Plan does not have to issue 
reimbursement for the hearing aids (V5298) purchased on February 21, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral-comprehensive series of radiographic images 
(D0210) provided on August 24, 2023. 
 
You asked the Plan to pay for this dental service. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says your benefit for the service provided 
has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the service provided was exhausted on date of service August 24, 2023.  
  
 
 
 
 
 
Specifically, the Plans contract states that one full mouth x-ray is covered every 36 months. On this day, you 
received two full mouth x-rays, of which one x-ray was paid for by the Plan. Therefore, you have exhausted the 
allowable benefit for this service. Therefore, we decided that the Plan does not have to pay for intraoral-
comprehensive series of radiographic images (D0210) provided on August 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for preventive health services provided on June 29, 2023, to July 
7, 2023. 
 
You asked the Plan to pay for preventive health services. You say that you are requesting reconsideration for 
the denied claim. The Plan denied your request. The Plan says that the Part D drug must be submitted to your 
Part D coverage. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide preventive health 
services. The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to preventive health 
services. Therefore, we decided that the Plan does not have to pay for preventive health services provided on 
June 29, 2023, to July 7, 2023.  
 
Benefits for preventive health services 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee qualifies for LTACH 
services and would greatly benefit from them. The Plan denied your request. The Plan says the enrollee's 
condition is not stable enough for transfer to an LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health Plan. The requested LTACH services are not 
medically necessary, reasonable, and appropriate for the diagnosis and condition of the 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral periapical radiographic image (D0707) provided 
on May 1, 2023. 
 
You asked the Plan to pay for the dental service. You say that you gave the supporting documentation so the 
Plan could pay for the dental services. The Plan denied your request. The Plan says the denial of payment for 
this service is correct, because the intraoral periapical radiographic image 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
intraoral periapical radiographic image (D0707) provided on May 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mental health services provided on June 15, 2023. 
 
You asked the Plan to pay for mental health services. You say that you are requesting reconsideration for the 
denied claim. The Plan denied your request. The Plan says that this provider was not certified or eligible to be 
paid for this procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that certain individuals and entities frequently 
attempt to enroll in Medicare but are not eligible to do so. If the Medicare contractor receives an enrollment 
application from the individual or entity, the contractor shall deny the application. Licensed Professional 
Counselor (LPC) is among the provider types that are not eligible to enroll in Medicare.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of mental health services have not been met. Therefore, we decided that the Plan does not have to pay 
for mental health services provided on June 15, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total knee replacement. 
 
You asked the Plan to pre-approve a total knee replacement. You say that the enrollee needs this surgery. The 
Plan denied your request. The Plan says the enrollee's body mass index is over 40. 
 
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 a total knee replacement. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no clear documentation of trial and failure of physical therapy and/or 
viscosupplementation injections. All conservative measured should typically be trialed prior to more invasive 
procedures are requested. Additionally, she is noted to have a body mass index is 40.02 kg/m2, without 
documentation of attempts at weight loss. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a total knee replacement have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a total knee replacement.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services billed with codes 87640, 87481, 
87798 x13, 87653, and 87500 for March 20, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly.  

The Plan must follow Medicare rules. The rules say that a test panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. The file shows that the test panel was not billed as a single unit of 
service. Based on this information, we decided that Medicare rules for coverage of these services have not been 
met. Therefore, we decided that the Plan does not have to pay for the laboratory services billed with codes 
87640, 87481, 87798 x13, 87653, and 87500 for March 20, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 93005 and 94640 billed for date of service June 13, 
2023. 
 
You asked the Plan to pay for codes 93005 and 94640. You say that these are payable codes. The Plan denied 
your request. The Plan says these codes are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that STV-packaged services are services for which separate 
payment is made only if there is no service with status indicator S, T, or V reported on the same claim. If a claim includes a service that is assigned status indicator S, T, or V reported on the same claim as the STV- 
packaged service, the payment for the STV-packaged service is packaged into the payment for the service(s) 
with status indicator S, T, V and no separate payment is made for the STV-packaged service. STV-packaged 
services are assigned status indicator Q1. In this case, the codes in dispute have a status indicator of QI, 
meaning that they are STV-packaged services.  These disputed codes were billed on the same claim with a code 
that has a status indicator of S, T, or V.  This means that the codes in dispute in this appeal are not separately 
payable. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 93005 have not been met. Therefore, we decided that the Plan does not have to pay for codes 
93005 and 94640 billed for date of service June 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture provided on August 10, 2023. 
 
You asked the Plan to pay for the acupuncture services. You say that acupuncture is a covered benefit, and the 
Plan has reimbursement you before. The Plan denied your request. The Plan says acupuncture is only covered 
to treat CLBP. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.   
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, services at issue were not used to treat CLBP. 
Therefore, we decided that the Plan does not have to pay for the acupuncture provided on August 10, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ED services provided on June 19, 2023. 
 
You asked the Plan to pay for the ED services. You say that you have provided the Medicare enrollment letter. 
The Plan denied your request. The Plan says Medicare payment cannot be made to this type of provider. 
 
The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare and 
cannot receive payment for services.  
 
We looked at the file and Medicare rules. We find that the provider at issue is not affiliated with a hospital and 
cannot receive Medicare payment. Therefore, we decided that the Plan does not have to pay for the ED services 
provided on June 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Zoster (shingles) vaccine (90750), polio vaccine (90713), 
haemophilus influenzae type B (Hib) vaccine (90647), and administrations (90471, 90472) provided on July 
11, 2023. 
 
You asked the Plan to pay for the shingles, polio and Hib vaccines and the administrations. You say that the 
provider had you get these vaccines at the facility due to the transplant. The Plan denied your request. The Plan 
says these are not covered under Medicare Part B. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the shingles, polio 
and Hib vaccines and the administrations. The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the shingles, polio and Hib vaccines and the administrations. Therefore, we decided that the Plan does not have to pay for the 
Zoster (shingles) vaccine (90750), polio vaccine (90713), haemophilus influenzae type B (Hib) vaccine 
(90647), and administrations (90471, 90472) provided on July 11, 2023.  
 
Benefits for the shingles, polio and Hib vaccines and the administrations may be available under Medicare Part 
D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal 
rights.