Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the Flexsteel Clive power lift recliner with power 
headrest and lumbar purchased on May 29, 2023. 
 
You asked the Plan to reimburse you for the power lift recliner. You say that this is medically necessary. The 
Plan denied your request. The Plan says there was no documentation provided to support the medical necessity 
of this item. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the power lift recliner have been met. Specifically, there were no medical records supplied to support the medical necessity of this device. The file 
shows that the Plan requested medical records, but none were received. Therefore, we decided that the Plan 
does not have to reimburse you for the Flexsteel Clive power lift recliner with power headrest and lumbar 
purchased on May 29, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the prostate cancer screening (G0103) provided on 
August 14, 2023. 
 You asked the Plan to pre-approve the prostate cancer screening. You say that this must be a mistake because 
you already received this screening in January by the same provider on January 19, 2023. The Plan denied your 
request. The Plan says the benefit maximum for this time period or occurrence has been reached. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, the prostate cancer screening, is being requested solely for screening purposes, 
and is covered by the Plan once every 12 months. The record shows that you received a prostate cancer 
screening (G0103) on January 19, 2023, and this benefit has been exhausted. Therefore, we decided that the 
Plan does not have to pre-approve the prostate cancer screening (G0103) provided on August 14, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral first x-ray (D0220), intraoral each additional x-ray 
(D0230), limited oral evaluation (D0140), and comprehensive oral evaluation (D0150) provided from July 18, 
2023, to August 9, 2023. 
 
You asked the Plan to pay for the dental services. You say that the dentist assured you the insurance would 
cover the services.  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 intraoral first x-ray (D0220), intraoral each additional x-ray (D0230), and limited oral 
evaluation (D0140) was exhausted on date of service June 14, 2023. The record also shows your benefit for 
comprehensive oral evaluation (D0150) was exhausted on date of service July 15, 2021. Therefore, we decided 
that the Plan does not have to pay for intraoral first x-ray (D0220), intraoral each additional x-ray (D0230), 
limited oral evaluation (D0140), and comprehensive oral evaluation (D0150) provided from July 18, 2023, to 
August 9, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214) provided on August 15, 2023, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for the physician service. You say that this was medically necessary. The Plan 
denied your request. The Plan says prior authorization was not obtained. 
 
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 in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. 
We found no exception that would require the Plan to pay for the service. Therefore, we decided that the Plan 
does not have to pay for the office visit (99214) provided on August 15, 2023, by an out-of-network (OON) 
provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings (A6549 x 2). 
 
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 by Medicare 
or the Plan.  
  
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although these items may be appropriate, they do not fall into a covered benefit category and cannot be paid 
for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings (A6549 x 2).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0500 rendered on January 23, 2023. 
 
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 Healthcare Common Procedure Coding System (HCPCS) code G0500 (1 Unit) remains not 
supported. 
 
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 G0500 is "Moderate sedation services provided by the 
same physician or other qualified health care professional performing a gastrointestinal endoscopic service that 
sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the 
patient's level of consciousness and physiological status; initial 15 minutes of intra-service time; patient age 5 
years or older (additional time may be reported with 99153, as appropriate)." 
 We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the submitted medical records in 
this case do not indicate the intra-service time for moderate sedation services, which means the billed service 
cannot be verified. The documentation submitted did not indicate the presence of an independent trained 
observer during the procedure for the billed services.  In addition, there were no anesthesiology records 
documenting intra-operative monitoring of this patient (including blood pressure, heart rate, respiratory rate, 
electrocardiogram, oxygen saturation) or medications administered.  The review has determined that the use of 
CPT G0500 is not supported by the records provided. 
 
We looked at this coder'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 G0500 rendered on January 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for miscellaneous supplies and equipment provided on August 
15, 2023. 
 
You asked the Plan to pay for miscellaneous supplies and equipment. You say that you are requesting 
reconsideration for the denied claim. The Plan denied your request. The Plan says the provider has opted out of 
Medicare from January 1, 2018, to January 1, 2024. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
miscellaneous supplies and equipment provided on August 15, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on May 25, 2023. 
 
You asked the Plan to pay for psychotherapy. You say that the services were 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 psychotherapy provided 
on May 25, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing provided on August 24, 2023. 
 
You asked the Plan to pay for the drug testing. You say that this testing was 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 the drug testing 
provided on August 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the pontic - porcelain fused to high noble metal tooth #'s 
12 and 13 (D6240), tooth # 11 core buildup, including any pins when required (D2950), and retainer crown - 
porcelain fused to high noble metal tooth #'s 11 and 14 (D6750). 
 
You asked the Plan to pre-approve the dental services. You say that the services should be approved. The Plan 
denied your request. The Plan says these services remain denied until a panoramic or full mouth series of x-
rays is received so the claims review process can be completed. 
 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 Plan covers the dental 
services when the services are medically necessary and reasonable. 
 
The records do not show that x-rays have been provided to the Plan. Therefore, we decided that the Plan does 
not have to pre-approve the pontic - porcelain fused to high noble metal tooth #'s 12 and 13 (D6240), tooth # 11 
core buildup, including any pins when required (D2950), and retainer crown - porcelain fused to high noble 
metal tooth #'s 11 and 14 (D6750).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve second stage endosteal implant (D6010). 
 
You asked the Plan to pre-approve D6010. You say that you need this dental work. The Plan denied your 
request. The Plan says the requested dental service 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 
second stage endosteal implant (D6010).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infectious agent detection by nucleic acid (DNA or RNA); 
candida species, amplified probe technique (87481), vancomycin resistance (eg, enterococcus species van A, 
van B), amplified probe technique 87500), staphylococcus aureus, amplified probe technique (87640), 
streptococcus, group A, quantification (87652), and infectious agent detection by nucleic acid (DNA or RNA), 
not otherwise specified; amplified probe technique, each organism (87798 x13, 87798-91x8) provided on 
August 23, 2023. 
 
You asked the Plan to pay for the lab services. You say that the claim was billed correctly The Plan denied 
your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the lab services. Our reviewer says that the services are not 
supported. Our reviewer found the documentation submitted was reviewed and does not meet criteria. 
Laboratory report describes multiple tests performed by same methodology. In this case, a more appropriate 
code to report is CPT 87999.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for infectious agent detection by nucleic acid (DNA or RNA); candida species, amplified probe 
technique (87481), vancomycin resistance (eg, enterococcus species van A, van B), amplified probe technique 
87500), staphylococcus aureus, amplified probe technique (87640), streptococcus, group A, quantification 
(87652), and infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; amplified 
probe technique, each organism (87798 x13, 87798-91x8) provided on August 23, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed (E0265). 
 
You asked the Plan to pre-approve the total electric hospital bed. You say that this service was medically 
necessary. The Plan denied your request. The Plan says this is not a covered item. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed (E0265).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete upper denture (D5110) and the lower partial 
denture (D5214) provided on July 10, 2023. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to cover the $1,800 that 
you are being charged by the provider. 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 complete upper denture (D5110) and the lower partial denture (D5214) was 
exhausted on date of service June 3, 2022. Therefore, we decided that the Plan does not have to pay for the complete upper denture (D5110) and the lower partial denture (D5214) provided on July 10, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visits and treatment to be provided by an  
out-of-network provider. 
 
You asked the Plan to pre-approve office visits and treatment to be provided by an out-of-network provider. 
You say that you started counseling in 2010 to help with childhood trauma that has been the cause of other 
issues such as posttraumatic stress disorder (PTSD), anxiety, depression, and dissociation. You say that you 
moved in 2017 to be near family and you had to stop treatment and your symptoms have increased to the point 
it is impacting your daily life, your marriage relationship, and other relationships. The Plan denied your 
request. The Plan says based on the contract you and the Plan have with Medicare, your mental health benefit is 
to be provided only to Medicare contracted, 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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve office 
visits and treatment to be provided by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve straps for a continuous positive air pressure (CPAP) 
machine (A7035)) every 3 months instead of every 6 months. 
 
You asked the Plan to pre-approve the additional CPAP straps. You say that the additional straps are medically 
necessary. The Plan denied your request. The Plan says the request exceeds the benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that CPAP straps (A7035) are covered 1 per every 6 
months. 
 
We looked at the file and Medicare rules. The benefit provides coverage for 1 head strap every 6 months. 
Based on this information, we decided that Medicare rules for coverage of the additional CPAP straps have not 
been met. Therefore, we decided that the Plan does not have to pre-approve straps for a continuous positive air 
pressure (CPAP) machine (A7035)) every 3 months instead of every 6 months.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crown - porcelain fused to high noble metal (D2750), 
prefabricated post and core in addition to crown (D2954), and prefabricated post and core in addition to crown 
(D3310) for tooth number 10. 
 
You asked the Plan to pre-approve crown - porcelain fused to high noble metal, prefabricated post and core in 
addition to crown, and prefabricated post and core in addition to crown for tooth number 10. You say that tooth 
number 10 is decayed with fracture and is in pain. The provider also says that the enrollee will need these 
services to restore the tooth for proper function.  The Plan denied your request. The Plan says the services do 
not meet the criteria for coverage 
 
  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 Plan covers crown - 
porcelain fused to high noble metal, prefabricated post and core in addition to crown, and prefabricated post 
and core in addition to crown for tooth number 10 when the services are medically necessary and reasonable.  
 
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 crown - porcelain fused to high noble 
metal, prefabricated post and core in addition to crown, and prefabricated post and core in addition to crown for 
tooth number 10. Our reviewer says that the criteria for the requested services have not been met. Our 
physician reviewer found the documentation provided was inadequate. Our physician reviewer also found that 
the radiographs were not of diagnostic quality and could not determine the restorability of the tooth. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of crown - porcelain fused to high noble metal, prefabricated post and core in 
addition to crown, and prefabricated post and core in addition to crown for tooth number 10 have not been met. 
Therefore, we decided that the Plan does not have to pre-approve crown - porcelain fused to high noble metal 
(D2750), prefabricated post and core in addition to crown (D2954), and prefabricated post and core in addition 
to crown (D3310) for tooth number 10.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a percutaneous laminotomy/laminectomy. 
 
You asked the Plan to pre-approve the procedure. You say that your last injection did not provide much relief 
and your provider is recommending this procedure if the next injection does not provide relief. The Plan denied 
your request. The Plan says the service may be considered medically necessary only for Medicare enrollees 
currently enrolled in a clinical trial. Furthermore, this is considered experimental/investigational due to lack of 
clinical evidence to support improved health outcomes. 
 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 procedure. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the posterior image-guided lumbar decompression procedure is considered 
experimental/investigational and is not medically necessary for the treatment of chronic low back pain. 
 
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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a percutaneous laminotomy/laminectomy.