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

 
We decided that the Plan does not have to pre-approve a vitrectomy (eye surgery) positioning chair/pillow 
(E1399, A9270). 
 
You asked the Plan to pre-approve positioning chair/pillow. You say that you need a vitrectomy chair at home 
immediately post retinal surgery. You will be required to use the chair up to a week post-surgery. The Plan 
denied your request. The Plan says this item is not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
 
 While a positioning chair/pillow may be appropriate in this case, neither the Plan nor Medicare offers coverage 
of this item. Therefore, we decided that the Plan does not have to pre-approve a vitrectomy (eye surgery) 
positioning chair/pillow (E1399, A9270).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), a panoramic radiographic 
image (D0330), a cleaning (D1110), and the application of fluoride (D1206) provided by an out-of-network 
provider on June 26, 2023. 
 
You asked the Plan to pay for the dental services. You say that the facility told you that you would be covered 
under your plan when you had the services done. 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 periodic oral evaluation (D0120), a panoramic radiographic image (D0330), a cleaning (D1110), 
and the application of fluoride (D1206) provided by an out-of-network provider on June 26, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve immediate mandibular partial denture - resin base 
(including retentive/clasping materials, rests and teeth) (D5222), and bone replacement graft for ridge 
preservation - per site (D7953). 
 
You asked the Plan to pre-approve the dental services. The Plan denied your request. The Plan says these 
services are not covered under the enrollee's 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 services are not among 
those covered under this benefit.  Therefore, we decided that the Plan does not have to pre-approve immediate mandibular partial denture - resin 
base (including retentive/clasping materials, rests and teeth) (D5222), and bone replacement graft for ridge 
preservation - per site (D7953).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (E0676) and segmental 
appliances (E0673, E0656). 
 
You asked the Plan to pay for the pneumatic compression device and segmental appliances . You say that the 
items were medically necessary. The Plan denied your request. The Plan says a PCD is not covered for 
preventative services. 
 
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 the pneumatic compression device (E0676) and segmental appliances (E0673, E0656).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic parenteral drug, single administration (D9610), 
endodontic therapy, molar tooth (excluding final restoration) (D3330), intraorifice barrier (D3911), and pulp 
vitality tests (D0460) provided on July 25, 2023. 
 
You asked the Plan to pay for the dental services. You say that you should have not been billed for code 
D3330, this mistake is on the dental practice.  You also say that you should have been billed for the D3331 only. The Plan denied your request. The Plan says 
your benefit for the endodontic therapy, molar tooth D331 has already been exhausted. The Plan says the dental 
services represented by codes D9610, D3911 and D0460 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 services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for therapeutic 
parenteral drug, single administration (D9610), intraorifice barrier (D3911), and pulp vitality tests (D0460) 
provided on July 25, 2023. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the endodontic therapy, molar tooth D3330 was exhausted on date of service July 25, 
2023 with code D3331. Therefore, we decided that the Plan does not have to pay for the endodontic therapy, 
molar tooth (excluding final restoration) (D3330) provided on July 25, 2023.
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 enrollee needs this level of care. The 
Plan denied your request. The Plan says the enrollee's needs can be safely managed at the current facility until 
they are more stable for transfer to another level of care 
 
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 is receiving appropriate care in their current acute care setting. The 
documentation does not support that LTACH services are medically appropriate 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0676) and a pad for 
a water circulating heat unit (E0249). 
 
You asked the Plan to pre-approve a pneumatic compression device and a pad for a water circulating heat unit. 
You say that you need the requested items for surgery. The Plan denied your request. The Plan says a 
compression device and heat circulating pad are not covered benefit with your plan. 
 
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 
because a water circulating heating pad system is not medically necessary, a pad (E0249, A9999) will be 
denied as not reasonable and necessary. 
 
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, these items are 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. A pad for a water circulating unit is not covered due to 
a water circulating system not being covered. Therefore, we decided that the Plan does not have to pre-approve 
a pneumatic compression device (E0676) and a pad for a water circulating heat unit (E0249).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that it is reasonable and necessary for the 
enrollee to receive an LTACH level of care and medical management for their condition. The Plan denied your 
request. The Plan says the enrollee does not meet all the requirements for admission to an LTAC.  
 
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 that the enrollee does not require services that are not available at the current acute 
care hospital. The requested LTACH services are not medically necessary, reasonable, or appropriate to be 
done as an inpatient. These services can be performed safely at a SNF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel provided on 
January 24, 2023. 
 
You asked the Plan to pay for the urine PCR panel. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components regardless of the fact that the test reports multiple individual pathogens and/or targets.  
 
We looked at the file and Medicare rules. Review of the file shows that the services at issue was a panel that 
was billed as individual pathogens/targets. This means these codes are not payable as billed. Based on this 
information, we decided that Medicare rules for coverage of the urine PCR panel have not been met. Therefore, 
we decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel provided on 
January 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the bone replacement graft (D7953) for tooth #7 
provided on February 21, 2023. 
 
You asked the Plan to pay more for the dental service. You say that you are asking for reimbursement and the 
provider is charging incorrectly. The Plan denied your request. The Plan says your 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 Plan's 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 $296 for dental services on March 7, 2023, which was processed prior to the claim for 
February 21, 2023. On February 21, 2023, the Plan paid $704 for dental services. For the year of 2023 the Plan 
paid $1,000 ($296 paid + $704 paid) for dental services; therefore, your dental maximum benefit for the year of 
2023 was exhausted on the date of service of February 21, 2023. Therefore, we decided that the Plan does not 
have to pay more for the bone replacement graft (D7953) for tooth #7 provided on February 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve osteogenesis stimulators. 
 
You asked the Plan to pre-approve osteogenesis stimulators. You say that it is medically necessary. The Plan 
denied your request. The Plan says Medicare require a 90-day trail of conservation therapy before the 
placement of a bone stimulator. 
 
The Plan follows Medicare rules. Medicare rules say that nonunion of a fracture documented by a minimum of 
two sets of radiographs obtained prior to starting treatment with the osteogenesis stimulator, separated by a 
minimum of 90 days. 
 
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 osteogenesis stimulators. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found that it is not enough time has 
passed for nonunion. Two sets of radiographs are required to begin the treatment with the osteogenesis 
stimulator by a minimum of 90 days. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of osteogenesis stimulators have not been met. Therefore, we decided that the Plan 
does not have to pre-approve osteogenesis stimulators.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure codes 96365, 96366, 96521, and 99214 provided on July 13, 2023.

You asked the Plan to pay for OIVIT services. You say that the enrollee was seen for problems with diabetes. The Plan denied your request. The Plan says the codes are not supported.

The file shows that OIVIT services were billed with codes 96365 and 96366. The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered under Medicare when furnished pursuant to an OIVIT regimen. Based on this information, we decided that the Medicare rules for coverage have not been met.

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 99214 is office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. We find that code 99214 is not supported in the medical record. The records show that the enrollee was seen for a follow up visit and infusion services. The records do not show a moder level of decision making was provided.

The definition of code 96521 is refilling and maintenance of portable pump. We find that CPT code 96521 is not supported in the medical record. The records show that an order was placed, but the records do not document the service actually being provided on the date of service at issue. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 96365, 96366, 96521, and 99214 provided on July 13, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a fluid circulating cold pad with pump (E0218) provided on 
March 29, 2023, through April 18, 2023. 
 
You asked the Plan to pay for a fluid circulating cold pad with pump. You say that the item was medically 
necessary. The Plan denied your request. The Plan says the item was not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a fluid circulating cold pad with pump (E0218) 
will be denied as not reasonable and necessary 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a fluid circulating cold pad with pump have not been met. Therefore, we decided that the Plan does 
not have to pay for a fluid circulating cold pad with pump (E0218) provided on March 29, 2023, through April 
18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on July 
13, 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 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 Plan's 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 March 22, 2023 and 
March 23, 2023. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation 
(D0150) provided on July 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a pontic, retainer crown, and extraction (D6740, 
D7140, D6245) for teeth #23, #25 and #27 provided on April 25, 2023. 
 
You asked the Plan to pay more 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 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 Plan's 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 April 25, 2023. 
Therefore, we decided that the Plan does not have to pay more for a pontic, retainer crown, and extraction 
(D6740, D7140, D6245) for teeth #23, #25 and #27 provided on April 25, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services billed with codes 87581, 87641, 
87651, 87653, 87798, and U0005 for January 9, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says there is no valid physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 
We looked at the file and Medicare rules. The file does not contain documentation of a valid physician order 
for the codes at issue. Therefore, we decided that the Plan does not have to pay for the laboratory services 
billed with codes 87581, 87641, 87651, 87653, 87798, and U0005 for January 9, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy (99199) provided on March 16, 2023, 
through April 15, 2023. 
 
You asked the Plan to pay for the psychotherapy. You say that the services were medically necessary. The Plan 
denied your request. The Plan says this service was received through a provider not eligible 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 the psychotherapy (99199) provided on 
March 16, 2023, through April 15, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for polycarbonate lenses (V2784), blue light lenses (V2745), and 
progressive lenses (V2781) provided on June 17, 2023. 
 
You asked the Plan to pay for polycarbonate lenses (V2784), blue light lenses (V2745), and progressive lenses 
(V2781). You say that this provider is in the network. The Plan denied your request. The Plan says The Plan 
says that services from provider out-of-network are not covered. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when services are obtained from an in-network Plan vision provider. 
 
We looked at the file and the Plan's rules. The Plan rules say that non-Medicare-covered routine eye 
examinations and eyewear must be obtained from a provider in the Plan's vision vendor network. Services 
obtained from vendors outside this network are not covered. Based on this information, we decided that the 
Plan's rules for coverage of polycarbonate lenses (V2784), blue light lenses (V2745), and progressive lenses 
(V2781) have not been met. Therefore, we decided that the Plan does not have to pay for polycarbonate lenses 
(V2784), blue light lenses (V2745), and progressive lenses (V2781) provided on June 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve pontics (D6245) and retainer crowns (D6740) for teeth
#2, #3, #4, #5, and #6 for the enrollee.

You asked the Plan to pre-approve these services. You say that you are appealing the denied dental bridge. The
Plan denied your request. The Plan says that records do not indicate the enrollee has physical or neurological
condition that precludes the use of a removable prosthesis.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for pontics and
retainer crowns. Our Medical Director states that the clinical documentation does not support that the enrollee
in this case has a physical or neurological disorder that precludes the placement of a removable device. Our
Medical Director found that the enrollee's condition does not meet criteria for coverage of these services.

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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve pontics (D6245) and retainer crowns (D6740) for teeth #2, #3, #4, #5, and #6 for the
enrollee.