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

 
We decided that the Plan does not have to pay more for the amalgam - two surfaces, primary or permanent, 
posterior tooth #28 (D2150) provided on August 9, 2023. 
 
You asked the Plan to pay more for the amalgam - two surfaces. You say that you are disputing the cost share 
amount of the service provided. The Plan denied your request. The Plan says the benefit was paid at the least 
costly method of treatment, and you are responsible for the remaining balance. 
 
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. 
 
 This benefit includes coverage for fillings once every 24 months per surface, per tooth. White fillings on 
posterior teeth will be processed as a silver filling and the patient is responsible for up to the contracted fee. 
You pay 20% coinsurance for Class 2 Basic services. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage that covers the amalgam - two surfaces, 
primary or permanent, posterior, the Plan processes it as a silver filling and you are responsible for up to the 
contracted fee. The record shows that you received an amalgam - two surfaces, primary or permanent on tooth 
#28 which is a posterior tooth. You are responsible for a 20% coinsurance, plus the difference between the 
allowed amounts. Therefore, we decided that the Plan does not have to pay more for the amalgam - two 
surfaces, primary or permanent, posterior tooth #28 (D2150) provided on August 9, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the amalgam (D2150) for tooth #20 provided on 
August 24, 2023. 
 
You asked the Plan to pay more for the dental service. You say that you do not understand why the Plan denied 
the service because you are covered for fillings. The Plan denied your request. The Plan says you are 
responsible for the difference in allowed amount and the proper cost share was applied. 
 
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 total allowed amount for the resin-based composite white filling (D2392) for tooth #20 was $231.43 and 
the total allowed amount for the amalgam (D2150) for tooth #20 was $179.83 leaving a difference of $51.60 
($231.43 allowed - $179.83 allowed). The total coinsurance amount was $89.92 ($179.83 allowed x 50% 
coinsurance). The total enrollee responsibility was $141.52 ($51.60 difference + $89.92 coinsurance). 
 
You have been asked to pay the difference between the allowed amount of the less expensive alternate 
procedure along with the coinsurance. 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 pay more for the amalgam (D2150) 
for tooth #20 provided on August 24, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided on December 29, 2021. 
 
You asked the Plan to pay for self-administered drugs. You say that you would like reconsideration for this 
claim. The Plan denied your request. The Plan says that self-administered drugs do not fall under Medicare Part 
B coverage. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
provided on December 29, 2021.  
 
Benefits for self-administered drugs may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740) for tooth #14. 
 
You asked the Plan to pre-approve the dental service. You say that you need the tooth fixed so you can get 
Invisalign. The Plan denied your request. The Plan says the denial of authorization for the crown is correct, 
because the x-rays do not show the damage needed for a crown to fix the tooth. 
 
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 
service 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 the dental service. Our reviewer says 
that the crown (D2740) for tooth #14 is not medically reasonable or necessary. Our physician reviewer found 
that tooth #14 has an existing composite filling with possible decay underneath the filling or there is a potential 
void in the filling, or it can be a medicant that underneath the filling when the decay is close to the nerve area 
of a tooth. From the x-rays, there are not visible fractures noted in tooth #14. There was also no clinical 
documentation as why a crown is recommended for tooth #14. There were also no intraoral photos included of 
the tooth that would show the condition of the tooth. A crown is placed on a tooth when a filling material 
cannot restore the tooth back into function due to more than half of its natural tooth structure being 
compromised by either decay, or fracture of the tooth. A more conservative treatment may be needed to address 
tooth #14. 
 
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 the dental service have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a crown (D2740) for tooth #14.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Januvia. 
 
You asked the Plan to pre-approve Januvia. The Plan denied your request. The Plan says that self-administered 
drugs do not fall under the Medicare Part B coverage. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Januvia.  
 
Benefits for Januvia may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 standard power wheelchair with single power 
option (K0856) and additional items and accessories (codes E2361, E1002, E1012, E2311, and E2607). 
 
You asked the Plan to pre-approve a Group 3 standard power wheelchair and additional items and accessories. 
The Plan denied your request. The Plan says the enrollee does not have medical need for power tilt option 
included with a K0856 Group 3 power wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair (PWC) with single 
power option (such as code K0856) is covered if the criteria listed in the Medicare rules section of this letter 
are met. Medicare rules also say that if the PWC base is not covered, then related accessories will be denied. 
 
 
  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 Group 3 standard power wheelchair 
and additional items and accessories. Our reviewer says that the Group 3 power wheelchair with power tilt and 
power elevating foot platform is not medically necessary. Our physician reviewer found the enrollee is 
functionally non-ambulatory and cannot use a cane or walker for mobility. They cannot functionally propel a 
manual wheelchair due to upper extremity weakness. The enrollee requires a power wheelchair for mobility 
and accomplishing their daily activities. However, the clinical documentation is insufficient why a lower-level 
power wheelchair would not meet the patients needs versus a Group 3 power wheelchair. Our reviewer found 
that there is inadequate clinical documentation regarding why they require power tilt and cannot adequately 
perform pressure relief. The enrollee is noted to have significant neck and low back pain. However, there is no 
history of skin breakdown. Our physician reviewer also found that the clinical documentation indicates that the 
enrollee has 5 out of 5 motor strength in the upper extremities and intact sensation. A group 3 power 
wheelchair base is typically indicated in patients with significant paralysis due to conditions such as a spinal 
cord injury and complex seating requirements. 
 
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 Group 3 standard power wheelchair and additional items and accessories have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 3 standard power 
wheelchair with single power option (K0856) and additional items and accessories (codes E2361, E1002, 
E1012, E2311, and E2607).
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pre-approve 12 additional PT visits. 
 
You asked the Plan to pre-approve the therapy services. You say that you will greatly benefit from the 
additional 12 PT sessions. The Plan denied your request. The Plan says that you do not meet the criteria for 
continued coverage of PT. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the therapy services. Our reviewer says 
that skilled services are necessary to restore or maintain function or to prevent deterioration of your  condition. 
Our physician reviewer found the requested PT is generally accepted as a specific and effective therapy for 
knee pain and impaired range of motion after knee arthroplasty or surgery. The additional PT is necessary to 
improve your level of mobility, range of motion and strength, and transition to a home exercise program. 
Therefore, the 12 visits of additional PT are medically 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 the therapy services have been met. Therefore, we decided that the Plan has to 
pre-approve 12 additional PT visits.  
 
 
 
 
 
 
 
 If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy services to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve physical therapy with an out-of-network provider. You say that you want 
the Plan to approve the services with this provider. The Plan denied your request. The Plan says no medical 
need is shown as to why the enrollee cannot get this service from a provider in-network. 
 
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 
physical therapy services to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
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. 
 
You asked the Plan to pre-approve percutaneous injection of allogeneic cellular and/or tissue-based product, 
intervertebral disc, unilateral or bilateral injection. You say that this is medically necessary. The Plan denied 
your request. The Plan says the procedure is still being studied to determine efficacy in the treatment of back 
pain due to disc disease. There is not enough peer-reviewed literature on whether the procedure is as good or 
better than other treatments for back pain due to degenerative disc disease. 
 
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. Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found the requested injection of 
allograft (in this case, VIA Disc NP) into the intervertebral disc for the treatment of degenerative disc disease, 
is considered experimental and investigational. VIA Disc is considered investigational and not medically 
necessary for the treatment of degenerative disc disease. The review has determined that the items/services at 
issue in this case are not medically reasonable or 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 percutaneous injection of allogeneic cellular and/or tissue-based product, 
intervertebral disc, unilateral or bilateral injection 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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department visit provided on October 7, 2022. 
 
You asked the Plan to pay for the emergency department visit. You say that the claim should be reprocessed. 
The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the emergency department visit provided on October 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 very heavy-duty power wheelchair, multiple 
power option (K0863) and additional items and accessories (codes E1007, E2342, E1028, E0955, E1010, 
K0037 x2, E2609, E2617, E0953 x2, E1028 x2, E1028, E2377, E2313, E2311, E2208, E2363 x2, and K0108). 
 
You asked the Plan to pre-approve a Group 3 very heavy-duty power wheelchair and additional items and 
accessories. You say that you would like the documentation provided to be reconsidered for the wheelchair and 
accessories that are medically necessary to meet the enrollee's needs. The Plan denied your request. The Plan 
says the enrollee does not have medical need for multiple power options included with a Group 3 power 
wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair (PWC) with multiple 
power options (such as code K0863) is covered if the criteria listed in the Medicare rules section of this letter 
are met. Medicare rules also say that if the PWC base is not covered, then related accessories will be denied. 
 
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 Group 3 very heavy-duty power 
wheelchair and additional items and accessories. Our reviewer says that the criteria for coverage have not been 
met. Our physician reviewer found the enrollee has obesity and neuropathy. The enrollee is able to transfer 
with contact guard assist after an acute stay. Our reviewer found that at baseline the enrollee is able to walk and 
transfer modified independently. Our physician reviewer also found that the enrollee does not have high risk 
for skin breakdown, use a catheter intermittently, have spasticity or require an alternative means of managing 
power drive. 
 
 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 Group 3 very heavy duty power wheelchair and additional items and 
accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 3 
very heavy-duty power wheelchair, multiple power option (K0863) and additional items and accessories (codes 
E1007, E2342, E1028, E0955, E1010, K0037 x2, E2609, E2617, E0953 x2, E1028 x2, E1028, E2377, E2313, 
E2311, E2208, E2363 x2, and K0108).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a video head impulse test (vHIT) (92700), vestibular 
evoked myogenic potential (VEMP) (92519), and computerized dynamic posturography (92548). 
 
You asked the Plan to pre-approve a vHIT, VEMP, and computerized dynamic posturography. You say that 
you were advised you had vertigo, and no one can get to the bottom of the issue. You also say that they would 
like to perform this test to finally understand why you continue to feel the way you do. The Plan denied your 
request. The Plan says the request for computerized dynamic posturography, vHIT, and VEMP are considered 
investigational and not covered by the Plan. 
 
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 a vHIT, VEMP, and computerized 
dynamic posturography. Our reviewer says that the requested services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found the provided medical records and review of the 
current peer-reviewed medical literature do not document that use of video head impulse test (vHIT) (92700), 
vestibular evoked myogenic potential (VEMP) (92519), and computerized dynamic posturography (92548) has 
been shown in controlled studies in a Centers for Medicare & Medicaid Services (CMS) approved journal to 
result in sustained long term health benefits in patients with vertigo 
 
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 vHIT, VEMP, and computerized dynamic posturography have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a video head impulse test (vHIT) (92700), 
vestibular evoked myogenic potential (VEMP) (92519), and computerized dynamic posturography (92548).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital inpatient or observation discharge day management 
provided on March 23, 2023. 
 
You asked the Plan to pay for hospital inpatient or observation discharge day management. You say that the 
enrollee was in the hospital from March 7, 2023, to, March 23, 2023, and the charge is not covered by hospice 
services at it did not start until after the enrollee was discharged. The Plan denied your request. The Plan says 
Original Medicare is responsible for payment. 
 
  Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for hospital inpatient or observation discharge day management 
provided on March 23, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for complete maxillary dentures (D5110) provided on February 
21, 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 benefit for the requested item or service has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service September 21, 2021. 
Therefore, we decided that the Plan does not have to pay for complete maxillary dentures (D5110) provided on 
February 21, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs on July 4, 2023. 
 
You asked the Plan to pay for the medication. The Plan denied your request. The Plan says the medication is 
not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs on 
July 4, 2023.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.