Persius/hicric huggingface dataset:
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pre-approve duplex scan of extracranial arteries, complete bilateral study. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the notes do not show any covered symptoms. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 scan. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that due to elevated risk factors for stroke and a prior abnormal carotid ultrasound three years ago, the 
request for a surveillance carotid ultrasound is 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 the scan have been met. Therefore, we decided that the Plan has to pre-approve 
duplex scan of extracranial arteries, complete bilateral study.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing (81415). 
 
You asked the Plan to pre-approve the genetic testing. You say that this service is medically necessary. The 
Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that whole exome sequencing (81415) is unlikely to 
impact therapeutic decision making and therefore is considered not medically necessary and is non-covered. 
 
We looked at the file and Medicare rules. This test is non-covered. Based on this information, we decided that 
Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does 
not have to pre-approve genetic testing (81415).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve deep gum and root cleaning, all four quadrants (D4341). 
 
You asked the Plan to pre-approve deep gum and root cleaning upper left and right quadrants. You say that this 
is medically necessary. The Plan denied your request. The Plan says your tooth must have noticeable bone loss 
or show on an x-ray that there is a hard substance built up on the root of the tooth. Your x-rays do not show that 
you have these issues. 
 
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. The Plan covers deep gum and 
root cleaning upper left and right quadrants 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 deep gum and root cleaning upper left 
and right quadrants. Our reviewer says that the service is not medically necessary. Our physician reviewer 
found due to the poor quality of x-rays included, we cannot determine whether D4341 for all four quadrants are 
medically reasonable. Based on the information in the appeal, D4341 is not medically necessary for the upper 
right and upper left quadrants. 
 
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 deep gum and root cleaning upper left and right quadrants have not been met. 
Therefore, we decided that the Plan does not have to pre-approve deep gum and root cleaning, all four 
quadrants (D4341).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the surgical placement of implant body: endosteal 
implant (D6010) provided on August 15, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you were advised by the dental practice to 
have the few teeth you had left extracted and get dentures. You also say that you had to go to another provider 
to start the process again because the other provider never called you. The Plan denied your request. The Plan 
says your benefit for the requested 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 dental services has been exhausted.  The Plan has provided evidence of having make payments totaling $2,500 towards the cost of dental services 
provided in 2023. This included a partial payment of $864 towards the surgical placement of implant body in 
dispute. Once this partial payment was made, the yearly benefit maximum was exhausted. Therefore, we 
decided that the Plan does not have to pay more for the surgical placement of implant body: endosteal implant 
(D6010) provided on August 15, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a power wheelchair provided on July 17, 
2023. 
 
You asked the Plan to waive the coinsurance for a power wheelchair. You say that you thought the plan would 
cover this. You cannot afford these payments. 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 20% 
coinsurance for durable medical equipment (DME) and related supplies. 
 
You have been asked to pay 20% coinsurance for a power wheelchair. This item/service falls within the 
durable medical equipment (DME) and related supplies 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. The total you owe is $91.55 ($457.78 x 20% = $91.55). 
Therefore, we decided that the Plan does not have to waive the coinsurance for a power wheelchair provided on 
July 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81162 billed for date of service December 7, 
2022.  
 
You asked the Plan to pay for procedure code 81162. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code 81162 is bundled into payment for code 81541. 
 
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, we have confirmed that code 81162 is a column two code to column one code 81541 with a modifier indicator of 0. The column two code is 
therefore not payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 81162 billed for date of service December 7, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intensive care services provided on November 01, 2022, 
to November 03, 2022. 
 
You asked the Plan to pay for the intensive care services. 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 the intensive care 
services provided on November 01, 2022, to November 03, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for retainer crowns (D6245 x2) provided on June 13, 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 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 June 13, 2023. Therefore, 
we decided that the Plan does not have to pay more for retainer crowns (D6245 x2) provided on June 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for resin based composite (D2331) provided on July 27, 
2023. 
 
You asked the Plan to pay more for the dental services. You say that you received a check for one of the 
invoices but nothing for this claim. You do want to know why one got paid and ignore the other one with no 
explanation. The Plan denied your request. The Plan says you are responsible for any charged amount above 
the Plans cost-sharing amount when your services are received from an out-of-network provider.  
 
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. 
 
 You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 resin based composite (D2331) provided on 
July 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral  comprehensive series of radiographic images 
(D0210), panoramic radiographic image (D0330), extraction, erupted tooth or exposed root (elevation and/or 
forceps removal) (D7140), bone replacement graft for ridge preservation - per site (D7953), and cone beam CT 
capture and interpretation with field of view of one full dental arch  maxilla, with or without cranium (D0366) 
provided on March 1, 2022, to October 19, 2022. You asked the Plan to pay for the dental services. You say that you have filed several claims because the 
surgical help is continuing. You also say that you cannot understand why the claims were denied because of the 
time when the surgeries and bone grafts take time to heal.  The Plan denied your request. The Plan says there is 
no coverage for D0364 cone beam computed tomography capture. The Plan says the claims wer untimely, and 
the submissions did not meet the exception criteria guidelines outlined in 42 CFR Section 424.4. 
 
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 cone beam CT capture and 
interpretation with field of view of one full dental arch  maxilla, with or without cranium is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for cone beam CT capture 
and interpretation with field of view of one full dental arch  maxilla, with or without cranium (D0366) 
provided on October 19, 2022.  
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the intraoral  comprehensive series of radiographic images, panoramic 
radiographic image, extraction, erupted tooth or exposed root (elevation and/or forceps removal), bone 
replacement graft for ridge preservation - per site was not filed until August 14, 2023, and August 15, 2023. 
This means that more than one calendar year from the date of service had passed before the claims were filed. 
Therefore, we decided that the Plan does not have to pay for intraoral  comprehensive series of radiographic 
images (D0210), panoramic radiographic image (D0330), extraction, erupted tooth or exposed root (elevation 
and/or forceps removal) (D7140), bone replacement graft for ridge preservation - per site (D7953) provided on 
March 1, 2022, and June 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a shower chair (E0245).  
 
You asked the Plan to pay for a shower chair. You say that the items should be covered as you disagree with 
the denial. The Plan denied your request. The Plan says this item is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair 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 pay for a shower chair (E0245).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bitewing - single radiographic image (D0270) provided 
on August 11, 2023. 
 
You asked the Plan to pay for the bitewing - single radiographic image. You say that this was an emergency x-
ray as you cracked the filling and it was necessary to see if the crack went all the way through. The Plan denied 
your request. The Plan says your benefit for the requested 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 bitewing - single radiographic image was exhausted on dates of service 
May 17, 2023, and September 27, 2023 exhausting this benefit for the rest of the 2023 plan year. The plan 
confirmed with the dental team that there was a plan discrepancy that occurred when the claim for August 11, 
2023 was being processed but has been corrected. Therefore, we decided that the Plan does not have to pay for 
the bitewing - single radiographic image (D0270) provided on August 11, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the VivAer procedure.  
 
You asked the Plan to pre-approve the VivAer procedure. You say that you have determined this is the most 
appropriate treatment option to address and resolve the enrollee's condition. The Plan denied your request. The 
Plan says the request is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the VivAer procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. 
 
 
 Our physician reviewer found the enrollee has hypertrophy of the nasal turbinate. There is insufficient literature 
to support the safety and efficacy of the requested service for the enrollee's specific condition. The record 
provided does not establish the medical necessity and reasonableness of the requested service. The elements of 
the coverage criteria are not satisfied and the requested service is not recommended. 
 
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 VivAer procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the VivAer procedure.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home maker service (S5131). 
 
You asked the Plan to pre-approve the home health services. You say that the services should be covered as 
you disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they 
are excluded from Medicare. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
 
  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health services have not been met. Specifically, we find that the services at issue in this 
case are considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve home 
maker service (S5131).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for panoramic x-rays (D0330), limited oral evaluation (D0140) 
and drugs or medicaments (D9630) provided on September 7, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says your benefit for the panoramic x-rays 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 panoramic x-rays was exhausted on date of service October 28, 2022. Limited oral 
evaluation and drugs or medicaments are not covered services Therefore, we decided that the Plan does not have to pay for panoramic x-rays (D0330), limited oral evaluation (D0140) and drugs or medicaments (D9630) 
provided on September 7, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for endosteal implants and the inhalation of nitrous 
oxide/analgesia (D6010 x2, D9230) provided on June 19, 2023.  
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental 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. 
 
 
  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 endosteal 
implants and the inhalation of nitrous oxide/analgesia (D6010 x2, D9230) provided on June 19, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup (D2950) and root amputation (D3450) 
provided on September 6, 2023. 
 
You asked the Plan to pay for the dental services. You say that due to the urgency of the situation and 
unexpected pain you had to see the out-of-network provider. 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 the core buildup (D2950) and root amputation (D3450) provided on September 6, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for a continuous glucose monitor, and supplies (A4239, E2103) provided 
on July 12, 2023. 
 
You asked the Plan to pay for the CGM. You say that the items should be covered as you disagree with the 
denial. The Plan denied your request. The Plan says that the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does contain a valid physician order and proof of delivery. Review of the file does not reveal any 
reason that the required documentation is invalid. Therefore, we decided that the Plan has to pay for a 
continuous glucose monitor, and supplies (A4239, E2103) provided on July 12, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics (L3020). 
 
You asked the Plan to pre-approve the foot orthotics. You say that you previously had your cadaver tendons 
reattached due to a tear. You also say that the L3020 shoe inserts were ordered by your physician and you are 
on a fixed income and cannot afford to pay for the shoe inserts yourself. The Plan denied your request. The 
Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics (L3020).