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

 
We decided that the Plan has paid the full $1,000 dental benefit for services provided on February 7, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you do not agree with the out-of-pocket 
amount that you owe. 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 February 7, 2023. 
Therefore, we decided that the Plan has paid the full $1,000 dental benefit for service provided on February 7, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for topical application of fluoride varnish (D1206) provided on 
February 23, 2023. 
 
You asked the Plan to pay for dental services. You say that fluoride should be included within preventive 
measures regardless as to your age. The Plan denied your request. The Plan says this service is not covered 
under your Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. Topical application of fluoride 
varnish (D1206) is not covered under the Plans dental benefits. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D1206 is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for topical 
application of fluoride varnish (D1206) provided on February 23, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the medial branches 
(64635, 64636). 
 
You asked the Plan to pre-approve RFA of the medial branches. 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 the thermal radiofrequency destruction of cervical, 
thoracic, or lumbar paravertebral facet joint (medial branch) nerves are considered medically reasonable and 
necessary for patients who meet certain criteria. 
 
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 RFA of the medial branches. Our reviewer says that the services are not medically necessary. Our physician reviewer found the LCD requires 2 sets of diagnostic medial branch blocks (MBBs), each of which produces 80% pain relief. There is no documentation of the results of the first set and there is no documentation of a second set of MBBs. Therefore, at this time, the request is deemed not medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of RFA of the medial branches have not been met. Therefore, we decided that the 
Plan does not have to pre-approve radiofrequency ablation (RFA) of the medial branches (64635, 64636).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a computed tomographic (CT) colonography screening (74263). 
 
You asked the Plan to pre-approve a CT colonography screening. You say that the enrollee is unable to 
complete a standard colonoscopy procedure, and a CT colonography is needed as the enrollee has polyps. The 
Plan denied your request. The Plan says that a screening CT colonography is not covered by Medicare and is 
therefore not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a CT colonography is indicated in those patients in 
whom a diagnostic optical colonoscopy of the entire colon is incomplete. 
 
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 CT colonography screening. Our 
reviewer says that the enrollee meets the coverage criteria for a CT colonography screening. Our physician 
reviewer found the enrollee meets the Medicare definition of high risk for colon cancer, but their January 2023, 
attempt at colonoscopy was incomplete due to sedation intolerance and technical difficulty.  A follow-up study 
is needed to complete their colon survey. Our reviewer found that LCD 33562 approves a diagnostic CT 
colonography for the enrollee's scenario. If additional polyps are identified, follow-up colonoscopy with 
polypectomy in-hospital may be required.  
 
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 CT colonography screening have been met. Therefore, we decided that the 
Plan has to pre-approve a computed tomographic (CT) colonography screening (74263).  
 
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 fillings (D2331, D2330) provided on December 13, 
2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your $725 dental benefit maximum allowance 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 9, 2022. 
Therefore, we decided that the Plan does not have to pay for dental fillings (D2331, D2330) provided on 
December 13, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for PT visits provided from December 23, 
2022, to February 3, 2023. 
 
You asked the Plan to reduce the copayment for PT visits. You say that you were expecting a $10 copayment 
and are unable to afford the cost share 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 $40 
copayment for each Medicare-covered physical therapy visit.  
 
 You have been asked to pay a $400 copayment for PT visits ($40 per visit x 10 visits = $400). This 
item/service falls within the outpatient rehabilitation 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. Therefore, we decided that the Plan does not have 
to reduce the copayment for PT visits provided from December 23, 2022, to February 3, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a dental extraction (D7210) provided on December 1, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the dental services were received from an out-of-
network/opt-out 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 dental extraction (D7210) provided on December 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bitewing x-ray, periapical x-ray, and oral exam (D0140, 
D0220, D0270) provided on June 23, 2022 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your $1,500 dental benefit maximum allowance 
for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service January 25, 2022. 
Therefore, we decided that the Plan does not have to pay for a bitewing x-ray, periapical x-ray, and oral exam 
(D0140, D0220, D0270) provided on June 23, 2022
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on August 08, 2022. 
 
You asked the Plan to pay for laboratory services. You say that these services are medically necessary. 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 laboratory services 
provided on August 08, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core buildup, including any pins when required (D2950), 
pontic - porcelain fused to predominantly base metal (D6241), and retainer crown - porcelain fused to 
predominantly base metal (D6751) provided on October 25, 2022. 
 
You asked the Plan to pay for the dental services represented by codes D2950, D6241 and D6751. You say that 
you were given invoices for the amounts you agreed to pay and you paid them. You also say that the provider  
told you they made a mistake and you feel you should not be held responsible for it. The Plan denied your 
request. The Plan says procedure codes D6751, D6241 and D2950 are not listed in the supplemental dental 
benefit, therefore, they are not covered. 
 
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 core 
buildup, including any pins when required (D2950), pontic - porcelain fused to predominantly base metal 
(D6241), and retainer crown - porcelain fused to predominantly base metal (D6751) provided on October 25, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a computed tomography (CT) scan 
performed at an outpatient hospital provided on February 07, 2023. 
 
You asked the Plan to reduce the copayment for a computed tomography (CT) scan performed at an outpatient 
hospital. You say that you feel the copayment is incorrect because you did not go to an outpatient hospital 
facility but went to an imaging center located near the hospital. 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 $165 
copayment for outpatient diagnostic test. 
 
You have been asked to pay a $165 copayment for a computed tomography (CT) scan performed at an outpatient hospital. This item/service falls within the outpatient diagnostic test 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 reduce the copayment for a computed tomography (CT) scan performed at an outpatient 
hospital provided on February 07, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on November 16, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says Medicare does not separately 
pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
November 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture services provided on December 6, 2022, and 
December 14, 2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the acupuncture services. You say that there is no in-network provider close to 
you. The Plan denied your request. The Plan says you must receive your care from a 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 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 
items/services 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 acupuncture services provided on December 6, 
2022, and December 14, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 3 sensor. 
 
You asked the Plan to pre-approve a Freestyle Libre 3 sensor. You say that the enrollee would benefit from the 
Freestyle Libre 3 sensor. The Plan denied your request. The Plan says the Freestyle Libre 3 sensor cannot be 
covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that a non-adjunctive continuous glucose monitor 
(CGM) must be billed with code E2103. The rules also say that only devices reviewed by the PDAC and 
assigned code E2103 may be billed using this code.  We looked at the file and Medicare rules. The request at issue is for the Freestyle Libre 3 non-adjunctive CGM. 
However, this device has not been reviewed by the PDAC and has not been assigned code E2103. As such, this 
non-adjunctive CGM device is not eligible for coverage at this time. Therefore, we decided that the Plan does 
not have to pre-approve a Freestyle Libre 3 sensor.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve knee replacement to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve knee replacement. You say that you would like to continue care with this 
doctor. The Plan denied your request. The Plan says the enrollee must use network providers to get their 
medical care and services. If the enrollee goes elsewhere without proper authorization the enrollee will have to 
pay in full. The only exceptions are emergencies, urgently needed services when the network is not available 
(that is, in situations when it is unreasonable or not possible to obtain services in-network), out-of-area dialysis 
services, and cases in which the Plan authorizes use of out-of-network providers. 
 
 
 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 
knee replacement to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Partially Favorable

We decided that the Plan has to pay for 29879. We decided that the Plan does not have to pay for 29875.

You asked the Plan to pay for surgical knee arthroscopy (procedure code 29875 and 29879) rendered on December 9, 2022. You say that this should be paid for. The Plan says that the records do not support the services billed.

We decided that the Plan has to pay for 29879.

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 CPT 29879 is "Arthroscopy, knee, surgical; abrasion arthroplasty (includes chondroplasty where necessary) or multiple drilling or microfracture."

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 for CPT 29879. Our reviewer says that the records do support CPT 29879 in this case. The procedure details have an addendum that notes she underwent an abrasion chondroplasty of all 3 compartments. This does reasonably corroborate that an abrasion arthroplasty had been performed.

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 been met. Therefore, we decided that the Plan has to pay for 29879.

We also decided that the Plan does not have to pay for 29875.

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 CPT 29875 is "Arthroscopy, knee, surgical; synovectomy, limited (eg, plica or shelf resection) (separate procedure)."

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 for CPT 29875. Our reviewer says that the records do not support CPT 29875 was a separate and distinct procedure from CPT 29880. The procedure details cite the medial compartment meniscus tear was shaved using the shaver. The knee was flushed, injected, and closed. There is no detailed indication that a separate synovectomy was performed.

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 29875.

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 pre-approve the removal of torus mandibularis (D7473). 
 
You asked the Plan to pre-approve the dental service. You say that you are appealing the denied dental services 
because you need it for your health. The Plan denied your request. The Plan says the denial of authorization for 
these services is correct, because the removal of torus mandibularis 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 pre-approve the 
removal of torus mandibularis (D7473).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture (D5211) and mandibular 
partial denture (D5212). 
 
You asked the Plan to pre-approve the dental services. You say that you lost your dentures in a car accident. 
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 dates of service February 26, 2019, and 
May 20, 2020. Therefore, we decided that the Plan does not have to pre-approve a maxillary partial denture 
(D5211) and mandibular partial denture (D5212).