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

 
We decided that the Plan does not have to pay for the colonoscopy (45385) provided on August 7, 2023. 
 
You asked the Plan to pay for the colonoscopy. You say that the service was medically necessary. 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. Your 
contract with the Plan says that there is a $400 deductible which applies to outpatient surgery.  
 
The item or service you asked the Plan to pay for falls within the outpatient surgery benefit category. The Plan 
has followed Medicare rules by clearly disclosing in the contract that there is a $400 deductible which applies 
to outpatient surgery. This cost sharing is a contractual obligation that had not been met at the time the 
colonoscopy was received on August 7, 2023. Therefore, we decided that the Plan does not have to pay for the 
colonoscopy (45385) provided on August 7, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown (D2740) provided on March 8, 2023. 
 
You asked the Plan to pay for the crown. You say that you believe this service should be covered under the 
non-Medicare dental services provided by your Plan as a comprehensive dental service for restorative services. 
The Plan denied your request. The Plan says while you have a supplemental dental benefit, procedure code 
D2740 is not listed as a covered benefit under your supplemental dental 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the crown 
(D2740) provided on March 8, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health skilled nursing (G0299 x4). 
 You asked the Plan to pre-approve home health services. You say that this is medically necessary. The Plan 
denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the enrollee is 
noted to be medically stable. The enrollee does not require wound care, catheterization, tube feeding, or 
administration of intravenous or complex medications. The enrollee has been educated regarding their 
medications and they have not recently been hospitalized. The enrollee is modified independent with mobility 
and may require some degree of assistance and supervision with daily activities. They have access to help from 
their family with regards to routine foot care, activities of daily living, and medication management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health skilled nursing (G0299 x4).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection(s), anesthetic agent(s) and/or steroid; genicular 
nerve branches, including imaging guidance, when performed (64454). 
 
You asked the Plan to pre-approve injection(s), anesthetic agent(s) and/or steroid; genicular nerve branches, 
including imaging guidance. You say that this is medically necessary. The Plan denied your request. The Plan 
says this is not medically necessary because based on the medical literature this procedure is not considered 
standard of care for management of the enrollee's chronic knee pain. 
 
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 injection(s), anesthetic agent(s) and/or 
steroid; genicular nerve branches, including imaging guidance. Our reviewer says that the requested 
items/services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found genicular nerve blocks and genicular nerve radiofrequency ablations are considered investigational and 
not medically necessary for the treatment of chronic knee 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 injection(s), anesthetic agent(s) and/or steroid; genicular nerve branches, 
including imaging guidance have not been met. Therefore, we decided that the Plan does not have to pre-
approve injection(s), anesthetic agent(s) and/or steroid; genicular nerve branches, including imaging guidance, 
when performed (64454).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composite (D2331) provided on September 
25, 2023. 
 
 
You asked the Plan to pay for the resin-based composite (D2331). You say that the service was not cosmetic. 
You say the back of your front tooth needed to be repaired in order to prevent chipping or further breaking. The 
Plan denied your request. The Plan says the 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 resin-based composite (D2331) is 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
resin-based composite (D2331) provided on September 25, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the periodic oral evaluation (D0120) and prophylaxis 
(D1110) provided on August 16, 2023, by an out-of-network (OON) provider. 
 
You asked the Plan to pay more for the dental services. You say that you only got this Plan for the dental 
insurance, but none of the Plan's in-network dental providers are any good. You also say that this means you 
have to go OON, and it is appalling how little is paid for the OON services. 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 OON 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 the periodic oral evaluation (D0120) and 
prophylaxis (D1110) provided on August 16, 2023, by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that the enrollee needs an SNF admission for further 
therapy and safe discharge planning. The Plan denied your request. The Plan says the enrollee does not meet 
the requirements for an SNF admission. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not require the level of observation and treatment provided in 
terms of physician oversight and skilled nursing care. The enrollee does not require daily skilled nursing 
services. The enrollee has not had a significant change in her baseline level of function and mobility and 
continues to be dependent or require maximum assistance with mobility and daily activities. The enrollee does 
not require the intensity of skilled therapy services provided in the SNF setting. Therefore, the SNF care is not 
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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 50547 billed for date of service July 13, 
2023. 
 
You asked the Plan to pay for the billed code. You say that modifiers were billed on the claim. The Plan denied 
your request. The Plan says an appropriate modifier was not billed. 
 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 50547 is laparoscopy, surgical; donor nephrectomy 
(including cold preservation), from living donor. We find that CPT code 50547 is not supported. The claim was 
not billed with a modifier to specify which kidney was worked on. Based on this information, we decided that 
Medicare rules for coverage of the billed code have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 50547 billed for date of service July 13, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient admission from July 23, 2023, through July 26, 
2023. 
 
You asked the Plan to pay for inpatient admission from July 23, 2023, through July 26, 2023. You say that the 
services were medically necessary. The Plan denied your request. The Plan says the services needed to be pre-
approved once the enrollee was stable for transfer. 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
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 pay for inpatient admission from July 23, 2023, 
through July 26, 2023. Our reviewer says that there was no documentation provided indicating medical 
necessity for post-stabilization care services at the non-Plan facility from July 23, 2023, through July 26, 2023. 
Our physician reviewer found the review indicates that the enrollee was hemodynamically stable and 
appropriate for ambulance transport with monitoring to a Plan facility after the emergency room evaluation on 
July 23, 2023. The review has determined that the treating physician did not document (in the physician notes, 
on a form, or in an order) that the patient was not stable for transfer on any dates of service. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient admission from July 23, 2023, through July 26, 2023, have not been 
met. Therefore, we decided that the Plan does not have to pay for inpatient admission from July 23, 2023, 
through July 26, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips (A0120). 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that the enrollee needs 
transportation for medical appointments. The Plan denied your request. The Plan says the enrollee has utilized 
the maximum number of transportation trips allowed per year. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the enrollee exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips (A0120).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve epidural steroid injections.  
You asked the Plan to pre-approve epidural steroid injections. You say that this is medically necessary. The 
Plan denied your request. The Plan says this does not meet the criteria for approval. 
 
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 epidural steroid injections. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the request does not 
meet the criteria of three months of 50% pain relief post-epidural steroid injection. Therefore, the request is 
deemed not medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of epidural steroid injections have not been met. Therefore, we decided that the 
Plan does not have to pre-approve epidural steroid injections.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an unspecified maxillofacial prosthesis (D5999). 
 
You asked the Plan to pre-approve an unspecified maxillofacial prosthesis. You say that you were not aware of 
the $3,500 credit, and believe you should be entitled to be covered for all the dental procedures you need. The 
Plan denied your request. The Plan says this service is not covered under your benefit package. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an 
unspecified maxillofacial prosthesis (D5999).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the endodontic therapy (D3310) for tooth #10 and to 
pay for the limited oral evaluation (D0140) and the cone beam (D0364) provided on August 28, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you were referred to the out-of-network 
provider and the dental services were medically necessary. The Plan denied your request. The Plan says your 
annual 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 $88 for dental services on May 16, 2023. On August 14, 2023, the Plan paid $253 for 
dental services. On September 13, 2023, which was processed prior to the claim for August 28, 2023, the Plan 
paid $173 for dental services. On October 25, 2023, which was processed prior to the claim for August 28, 
2023, the Plan paid $654 for dental services. On August 28, 2023, the Plan paid $832 for dental services. For 
the year of 2023 the Plan paid $2,000 ($88 paid + $253 paid + $173 paid + $654 paid + $832 paid) for dental 
services; therefore, your annual dental maximum benefit for the year of 2023 was exhausted on the date of 
service of August 28, 2023. Therefore, we decided that the Plan does not have to pay more for the endodontic 
therapy (D3310) for tooth #10 and to pay for the limited oral evaluation (D0140) and the cone beam (D0364) 
provided on August 28, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Proteor Kinterra foot (L5968, L5981). 
 
You asked the Plan to pre-approve a Proteor Kinterra foot. You say that the item is necessary. The Plan denied 
your request. The Plan says the enrollee currently has a Ottobock Taleo foot which is still under its 36-month 
warranty. Medicare does not cover replacement of items that are still under manufacturer's warranty. 
 
The Plan must follow Medicare rules. Medicare rules say that payments for repair and maintenance may not 
include payment for parts and labor covered under a manufacturers or suppliers warranty. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a Proteor Kinterra foot have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a Proteor Kinterra foot (L5968, L5981).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bag hook set (K0108). 
 
You asked the Plan to pre-approve a bag hook set. The Plan denied your request. The Plan says this does not 
serve a medical purpose. The Plan also says that this cannot be covered as these are not reasonable and 
necessary per Medicare criteria.  

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a bag hook set (K0108).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for guided tissue regeneration, natural teeth (D4266) for tooth #7 
provided on June 21, 2023. 
 
You asked the Plan to pay for guided tissue regeneration, natural teeth (D4266) for tooth #7. You say that it 
was recommended to extract the tooth and place bone graft material within the socket to preserve the bone 
ridge for a future implant placement within four to six months. The Plan denied your request. The Plan says 
this procedure will not be covered in this case as code D4266 is to be used with natural teeth only. 
 
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 service is only covered 
on natural teeth. D4266 would not be the appropriate code for this service since tooth #7 was extracted. 
Therefore, we decided that the Plan does not have to pay for guided tissue regeneration, natural teeth (D4266) 
for tooth #7 provided on June 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the lumbar sympathetic nerve block. 
 
You asked the Plan to pre-approve the lumbar sympathetic nerve block. The Plan denied your request. The Plan 
says the lumbar sympathetic nerve block 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 lumbar sympathetic nerve block. 
Our reviewer says that the lumbar sympathetic nerve block is not medically necessary. Our physician reviewer 
found that the enrollee is considered to have a peripheral neuropathy due to systemic disease or caused by other 
conditions. Also, the enrollee has neuropathic pain in both lower extremities which the provider believes may 
be related to his chronic vascular disease. However, the use of peripheral nerve blocks with or without the use 
of electrostimulation, and the use of electrostimulation alone for neuropathies or peripheral neuropathies 
caused by underlying systemic diseases is insufficient to warrant coverage. Furthermore, these procedures are 
considered investigational and are not eligible for coverage for the treatment of neuropathies or peripheral 
neuropathies caused by underlying systemic diseases. Therefore, the service at issue is not medically 
reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the lumbar sympathetic nerve block have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the lumbar sympathetic nerve block.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from September 
28, 2022, through September 29, 2022.  
You asked the Plan to pay for acute inpatient hospital care. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the enrollee did not meet criteria for inpatient admission. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 pay for acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the record did not show that at the time of inpatient admission it was reasonable for 
the admitting physician to expect that the patient's necessary hospital care (including earlier emergency 
department and/or observation care) would span two midnights with supporting documentation of the patients 
history and comorbidities, signs and symptoms, current medical needs, and risk of an adverse event. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided from September 28, 2022, through 
September 29, 2022.