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

 
We decided that the Plan does not have to pay for periodontal maintenance (D4910) provided on March 28, 
2023. 
 
You asked the Plan to pay for D4910. You say that this service should be covered. The Plan denied your 
request. The Plan says the rendered dental service is not a coverer 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 
periodontal maintenance (D4910) provided on March 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on July 28, 2022. 
 
You asked the Plan to pay for office visit. You say that you are requesting reconsideration for 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 office visit provided on 
July 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for complete maxillary dentures (D5110) provided on February 
6, 2023. 
 
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 the services denied correctly as they were 
rendered by a provider who does not participate with Medicare. 
 
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. 
 
 
  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 pay for complete maxillary dentures (D5110) 
provided on February 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anti-reflective coating (V2750), progressive lenses (V2781), 
photochromatic tint (V2744), and frames (V2020) provided on April 06, 2023. 
 
You asked the Plan to pay for anti-reflective coating (V2750), progressive lenses (V2781), photochromatic tint 
(V2744), and frames (V2020). You say that you are appealing with supporting records. 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 anti-reflective coating 
(V2750), progressive lenses (V2781), photochromatic tint (V2744), and frames (V2020) provided on April 06, 
2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the Guardant360 CDx testing (0242U) provided on March 3, 2023. 
 
You asked the Plan to pay for the Guardant360 CDx testing (0242U). You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says that the records do not support 
the services billed. 
 
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 0242U is Targeted genomic sequence analysis panel, solid organ neoplasm, cell-free circulating DNA 
analysis of 55-74 genes, interrogation for sequence variants, gene copy number amplifications, and gene 
rearrangements. 
 
We find that CPT code 0242U is supported in the medical record. Specifically, the records document a signed 
order for, and results of a Guardant360 CDx test panel. Based on this information, we decided that Medicare 
rules for coverage of the Guardant360 CDx testing (0242U) have been met. Therefore, we decided that the Plan 
has to pay for the Guardant360 CDx testing (0242U) provided on March 3, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the laboratory services provided on May 
05, 2023. 
 
You asked the Plan to waive the copayment for the laboratory services. You say that this service should be 
fully covered. 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 $40 
copayment for in-network outpatient hospital services. 
 
You have been asked to pay a $40 copayment for the laboratory services. This item/service falls within the in-
network outpatient hospital services 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. However, since the allowed amount is less than the standard copayment, you 
only owe $26.96. Therefore, we decided that the Plan does not have to waive the copayment for the laboratory 
services provided on May 05, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110). 
 
You asked the Plan to pre-approve the dental service. You say that your previous upper denture does not 
properly fit for your daily needs. 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 for a complete upper denture (D5110) on March 20, 2020; therefore, your benefit for the 
requested item or service was exhausted on the date of service of March 20, 2020. Therefore, we decided that 
the Plan does not have to pre-approve a complete upper denture (D5110).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a labial veneer (D2962) tooth #8. 
 
You asked the Plan to pre-approve the dental service. You say that you needed a crown or a veneer to prevent 
further damage to your tooth and it is a necessary procedure. The Plan denied your request. The Plan says the 
denial of authorization for this service is correct, because the labial veneer 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. 
 
  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 pre-approve a 
labial veneer (D2962) tooth #8.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Saphnelo. 
 You asked the Plan to pre-approve Saphnelo. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet the Part B Step Therapy requirements for 
Saphnelo. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Saphnelo. Our reviewer says that the 
medication is not medically necessary. Our physician reviewer found the case file does not contain 
documentation of trial and failure of Benlysta. The clinical documentation does not support that Benlysta 
would likely be less effective or would likely have adverse effects for the enrollee in this case. Therefore, the 
request for Saphnelo cannot be approved at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Saphnelo have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Saphnelo.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous injection of allogeneic cellular and/or 
tissue-based product, intervertebral disc, unilateral or bilateral injection, with fluoroscopic guidance, lumbar; 
first level (0627T). 
 
You asked the Plan to pre-approve percutaneous injection of allogeneic cellular and/or tissue-based product, 
intervertebral disc, unilateral or bilateral injection, with fluoroscopic guidance, lumbar; first level. You say that 
this is medically necessary. The Plan denied your request. The Plan says the requested injection of allograft 
into the intervertebral disc for the treatment of degenerative disc disease is considered experimental and 
investigational. 
 
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 percutaneous injection of allogeneic 
cellular and/or tissue-based product, intervertebral disc, unilateral or bilateral injection, with fluoroscopic 
guidance, lumbar; first level. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found published studies do not demonstrate any 
long-term health outcome advantage with the use of VIA Disc as an alternative to standard treatments. 
 
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 injection of allogeneic cellular and/or tissue-based product, 
intervertebral disc, unilateral or bilateral injection, with fluoroscopic guidance, lumbar; first level have not been 
met. Therefore, we decided that the Plan does not have to pre-approve percutaneous injection of allogeneic 
cellular and/or tissue-based product, intervertebral disc, unilateral or bilateral injection, with fluoroscopic 
guidance, lumbar; first level (0627T).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are medically necessary. The 
Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care and does not 
require transfer to a 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 the enrollee appears to be improving with current treatment and requires only short-
term additional acute care services that can safely be provided at the current facility until more stable and 
appropriate for transfer to a lower level of care soon. The enrollee does not require services at the LTACH 
facility that are not already available at the current facility.  
 
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 long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and the intraoral 
complete series of radiographic images (D0210) provided on June 9, 2023. 
 
You asked the Plan to pay for the dental services. You say that the dental services should be covered because 
this was the first cleaning you received this year. 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 comprehensive oral evaluation (D0150) and the intraoral complete series of 
radiographic images (D0210) on December 14, 2022; therefore, your benefit for the requested items or services 
was exhausted on the date of service of December 14, 2022. Therefore, we decided that the Plan does not have 
to pay for a comprehensive oral evaluation (D0150) and the intraoral complete series of radiographic images 
(D0210) provided on June 9, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex device (22869, 22870). 
 
You asked the Plan to pre-approve the Vertiflex device. You say that this is medically necessary. The Plan 
denied your request. The Plan says given the diagnosis of lumbar spinal stenosis, this device is contraindicated 
for the enrollee. Under Medicare, the service is not medically 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 the Vertiflex device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Vertiflex device is experimental. More research is needed. 
 
   
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 Vertiflex device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Vertiflex device (22869, 22870).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a crown (D2740) provided on June 7, 2023. 
 
You asked the Plan to pay more for the dental service. You say that crowns are covered at 100% and you had 
plenty of benefits to cover the crown. The Plan denied your request. The Plan says your annual dental 
maximum benefit for the year 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 $328 for dental services on February 28, 2023. On March 7, 2023, the Plan paid $1,835 for 
dental services. On May 12, 2023, the Plan paid $34 for dental services. On June 7, 2023, the Plan paid $303 
for dental services. For the year of 2023 the Plan paid $2,500 ($328 paid + $1,835 paid + $34 paid + $303 paid) 
for dental services; therefore, your annual dental maximum benefit for the year of 2023 was exhausted on the 
date of service of June 7, 2023. Therefore, we decided that the Plan does not have to pay more for a crown 
(D2740) provided on June 7, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140), a comprehensive oral 
evaluation (D0150), the intraoral complete series of radiographic images (D0210), the intraoral radiographic 
image (D0220 and D0230), a crown (D2740) for tooth #18, the core buildup (D290) for tooth #18, the 
endodontic therapy (D3330) for tooth #18, gingivectomy (D4212) for tooth #18, and the periodontal scaling 
and root planing (D4341) provided by an out-of-network provider on March 22, 2023, March 27, 2023, April 5, 
2023, April 12, 2023, April 13, 2023, and April 20, 2023. 
 
You asked the Plan to pay for the dental services. You say that you called the Plan to get pre-approval to have 
dental work done out-of-network and they assured you that is would be covered. The Plan denied your request. 
The Plan says the dental services were received from an out-of-network provider and are not covered by your 
supplemental benefits. The core buildup and gingivectomy are not covered by the Plan. Also, it was verified 
you were advised you only had in-network benefits and the provider requested was out-of-network. 
 
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 limited oral evaluation, a comprehensive oral 
evaluation, the intraoral complete series of radiographic images, the intraoral radiographic image, a crown, the 
endodontic therapy, and the periodontal scaling and root planing are not covered under this benefit when 
received from an out-of-network provider. The core buildup and gingivectomy are not covered under the Plans 
dental benefit. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140), a 
comprehensive oral evaluation (D0150), the intraoral complete series of radiographic images (D0210), the 
intraoral radiographic image (D0220 and D0230), a crown (D2740) for tooth #18, the core buildup (D290) for 
tooth #18, the endodontic therapy (D3330) for tooth #18, gingivectomy (D4212) for tooth #18, and the 
periodontal scaling and root planing (D4341) provided by an out-of-network provider on March 22, 2023, 
March 27, 2023, April 5, 2023, April 12, 2023, April 13, 2023, and April 20, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an abutment supported to crown (D6058) for tooth #2 
provided on May 3, 2023. 
 
You asked the Plan to pay for the dental service. You say that you were told that your coverage included 
implants at a 50% coverage rate. The Plan denied your request. The Plan says the denial of authorization for 
this service is correct, because implants and all related services are not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an 
abutment supported to crown (D6058) for tooth #2 provided on May 3, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.  
 
You asked the Plan to pre-approve the PET scan. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 PET scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found you were not noted to have either AD or 
FTD, let alone both. It cannot be independently adjudged that the requested service would otherwise be 
reasonable and necessary as defined by the NCD as criteria for coverage have not been met. 
 
 
  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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan.