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

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), an intraoral - 
complete series of radiographic images (D0210), an adult prophylaxis (D1110), resin based composite of four 
or more surfaces (D2335), resin based composite of two anterior surfaces (D2331), resin based composite of 
two posterior surfaces (D2392), resin based composite of one posterior surface (D2391), and a resin based 
composite of three posterior surfaces (D2393) provided from February 14, 2023, to February 21, 2023. 
 You asked the Plan to pay for the dental services. You say that you called the Plan to verify enrollee coverage 
and were told that you were in-network. The Plan denied your request. The Plan says the dental services were 
received from an out-of-network provider and are not covered by your supplemental benefits.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a comprehensive oral evaluation (D0150), an intraoral - complete series of radiographic images 
(D0210), an adult prophylaxis (D1110), resin based composite of four or more surfaces (D2335), resin based 
composite of two anterior surfaces (D2331), resin based composite of two posterior surfaces (D2392), resin 
based composite of one posterior surface (D2391), and a resin based composite of three posterior surfaces 
(D2393) provided from February 14, 2023, to February 21, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on March 21, 2023. 
 
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 September 6, 2017. 
Therefore, we decided that the Plan does not have to pay for the dental services on March 21, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675). 
 
You asked the Plan to pay for a pneumatic compression device. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says a pneumatic compression 
device is not covered for the purpose of prevention of venous thromboembolism. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lower partial denture (D5214). 
 
You asked the Plan to pre-approve this dental item. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says your benefit for the requested item 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 was exhausted on date of service May 17, 2022.  
 
  
 
 
 
 
Specifically, the Plans contract states that partial dentures are covered once every three years. You previously 
received a lower partial denture on May 17, 2022, less than three years prior, which was paid for by the Plan. 
Therefore, you have exhausted the allowable benefit for the requested dental item in this case at this time. 
Therefore, we decided that the Plan does not have to pre-approve a lower partial denture (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve excision benign lesion (D7410). 
 
You asked the Plan to pre-approve excision benign lesion. You say that you have a lesion you need removed. 
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 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 
excision benign lesion (D7410).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) and the intraoral 
radiographic image (D0220) provided on May 2, 2023. 
 
You asked the Plan to pay for the dental services. You say that your dental office is requesting a cleaning every 
3 months plus x-rays. The Plan denied your request. The Plan says your benefit for the requested items or 
services 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 for a limited oral evaluation (D0140) and a intraoral radiographic image (D0220) on 
March 7, 2023, and March 9, 2023; therefore, your benefit for the requested items or services was exhausted on 
the date of service of March 9, 2023. Therefore, we decided that the Plan does not have to pay for a limited oral 
evaluation (D0140) and the intraoral radiographic image (D0220) provided on May 2, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
March 13, 2023. 
 
You asked the Plan to waive the copayment for an emergency room (ER) visit. You say that you feel that you 
are not liable for the copayment applied. The Plan denied your request. The Plan says this cost sharing was 
charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $120 
copayment for emergency care. 
 
You have been asked to pay a $120 copayment for an emergency room (ER) visit. This item/service falls 
within the emergency care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an 
emergency room (ER) visit provided on March 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ankle foot orthotics provided on April 20, 2023, by an out-
of-network (OON) provider.  
 
You asked the Plan to pay for ankle foot orthotics. You say that you are requesting reconsideration for the 
service provided. 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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
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 ankle foot orthotics provided on April 20, 2023, 
by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pre-approve 2 additional physical therapy visits. 
 
You asked the Plan to pre-approve the therapy services. You say that you have a spinal stenosis and a simulator 
in your back. You have problems with your back and legs and need the 2 additional physical therapy visits.  
The Plan denied your request. The Plan says that 2 additional physical therapy visits are not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy services. Our reviewer says 
that 2 additional physical therapy visits are medically necessary. Our physician reviewer found you have been 
receiving physical therapy since August 11, 2023. While it is gradual, you are making documented progress 
with your ability to transfer, stand and ambulate with the assistance of walker. Your strength and Oswestry 
score have improved from 56 to 68 when initially evaluated, and you are ambulating with less difficulty. The 
requested physical therapy is generally accepted as a specific and effective therapy for low back pain and 
lumbar spinal stenosis. Therefore, 2 additional physical therapy visits are appropriate given your medical 
condition and to transition to a home exercise program. 
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 therapy services have been met. Therefore, we decided that the Plan has to 
pre-approve 2 additional physical therapy visits.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on December 16, 2022. 
 
You asked the Plan to pay for the office visit. You say that you are requesting reconsideration of the denied 
claim. 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 the office visit provided 
on December 16, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each emergency room (ER) visit provided 
on May 12, 2023. 
 
You asked the Plan to waive the copayment for each emergency room (ER) visit. You say that you disagree 
with the copayment applied. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $125 
copayment for emergency care. 
 
You have been asked to pay a $125 copayment for each emergency room (ER) visit. This item/service falls 
within the emergency care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for each 
emergency room (ER) visit provided on May 12, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on April 21, 2023. 
 You asked the Plan to pay for the ambulance services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on April 4, 2023. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for the ambulance services 
provided on April 21, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incomplete endodontic therapy (D3332). 
 
You asked the Plan to pre-approve incomplete endodontic therapy (D3332). You say that you do not 
understand why it is being denied. You also say that you have no control that the dentist needs to do this, or it 
is incomplete. The Plan denied your request. The Plan says this 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, 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 
incomplete endodontic therapy (D3332).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a home ventilator system. 
 
You asked the Plan to pre-approve a home ventilator system. You say that you need the ventilator to breathe 
because you cannot get longer than an hour to an hour and a half of sleep. You say that the BiPAP machine is 
still not working for you, and you should qualify for a ventilator. The Plan denied your request. The Plan says 
that a home ventilator is not medically necessary for this patient because their needs can be met with an 
alternative device such as a BiPAP device with average volume-assured pressure support (AVAPS).  
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and necessary. 
 
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 home ventilator system. Our reviewer 
says that a home ventilator system is medically necessary. Our physician reviewer found that you were treated 
with CPAP and a BiPAP with a continued rise in carbon dioxide for 6 to 7 months. The ventilator is requested 
as pressure support ventilation (PSV), which is a mode of ventilation for pressure targeted volume support. 
Therefore, with the documented BiPAP failure the best practice would be a home ventilator. 
 
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 home ventilator system have been met. Therefore, we decided that the Plan 
has to pre-approve a home ventilator system.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve orthopedic footwear, men's shoes (L3219). 
 
You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says the requested items are not a covered benefit for the 
enrollees condition. 
 
Medicare rules state that supportive devices for the feet (such as orthopedic footwear) are only covered for 
patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. 
Medicare rules say that with the exception of these situations, orthopedic footwear billed using code L3219 will 
be denied as non-covered. Therefore, we decided that the Plan does not have to pre-approve orthopedic 
footwear, men's shoes (L3219).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve  the left and right minimally invasive lumbar (back) 
surgery. 
 
You asked the Plan to pre-approve the minimally invasive lumbar back surgery. You say that the enrollee has 
weakness and has tried and failed conservative measures have failed. The appellant says due to the degree of 
the weakness, the surgery is medically necessary.  The Plan denied your request. The Plan says the back 
surgery is not medically necessary. The Plan says there is no proof that the requested service would treat your 
diagnosis. 
 
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 the minimally invasive lumbar back 
surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has spinal stenosis. There is no current 
literature that shows that left and right minimally invasive surgery is a better option than conventional open 
surgery. The minimally invasive back surgery procedure remains experimental.  
 
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 minimally invasive lumbar back surgery have not been met. Therefore, we 
decided that the Plan does not have to pre-approve  the left and right minimally invasive lumbar (back) surgery.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 27335 rendered on February 16, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services billed. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found that the 
procedure details a titrated synovectomy was performed in the suprapatellar pouch extending modestly medial 
and lateral. Similarly, a titrated synovectomy was performed around the patella, patellar tendon, and quadriceps 
tendon to visualize the patella and minimize the potential scarring and crepitus. A spacer block was utilized and 
the knee was found to be very well balanced in both flexion and extension, not requiring any release. A titrated posterior synovectomy was performed in the medial and lateral compartments as well as into the notch. 
However, synovectomies were performed to optimize fit and tracking of implants. Therefore, the 
documentation does not support CPT 27335: arthrotomy with synovectomy, knee, anterior AND posterior 
including popliteal area as a separate and distinct procedure from CPT 27447: arthroplasty, knee, condyle and 
plateau; medial AND lateral compartments with or without patella resurfacing (total knee arthroplasty). 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 27335 rendered on February 16, 2022.