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

We decided that the Plan does not have to pre-approve Leqvio.

You asked the Plan to pre-approve Leqvio. You say that you disagree with the Plan's denial. The Plan denied your request. The Plan says the requested drug is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Leqvio. Our reviewer says that the documentation does not support that the requested drug is medically reasonable or necessary. Our physician reviewer found the enrollee has a diagnosis of mixed hyperlipidemia. The record provided is insufficient to determine whether the requested drug is being prescribed in accordance with Medicare rules. The Food and Drug Administration has not stated that the requested drug is indicated for the enrollee's condition as reported. The Medicare approved drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation as reported. Therefore, the enrollee does not meet criteria for the requested drug.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Leqvio have not been met. Therefore, we decided that the Plan does not have to pre-approve Leqvio.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bone graft at time of implant placement (D6104) for tooth 
#9 and #10provided on February 8, 2023. 
 
You asked the Plan to pay for D6104. You say that this dental work is medically necessary. The Plan denied 
your request. The Plan says the rendered dental service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a bone 
graft at time of implant placement (D6104) for tooth #9 and #10provided on February 8, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive oral evaluation - new or established patient 
(D0150), intraoral - complete series of radiographic images (D0210) and topical application of fluoride varnish 
(D1206) provided on December 15, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were told these services would be covered 
by your insurance. 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. This benefit includes the 
requested D0150 and D0210, but each is limited to one procedure every three plan years and D1206 but is 
limited to two procedures per plan year. Also, the requested item or service is limited to an annual maximum of 
$500  after the annual maximum is exhausted, any remaining charges are your responsibility. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The Plan paid 
$39 on date of service February 9, 2022, $404 on date of service February 12, 2022, and $57 on date of service 
August 9, 2022 ($39 + $404 + $57 = $500). The record shows your annual maximum benefit was exhausted on 
date of service August 9, 2022. Therefore, we decided that the Plan does not have to pay for topical application 
of fluoride varnish (D1206) provided on December 15, 2022. 
 
We looked at the file, the Plans rules, and Medicares rules. You previously received covered D0150 on date 
of service August 16, 2021, and covered D0210 on date of service August 9, 2022. Therefore, these benefits 
were exhausted as of December 15, 2022. Therefore, we decided that the Plan does not have to pay for 
comprehensive oral evaluation - new or established patient (D0150) and intraoral - complete series of 
radiographic images (D0210) provided on December 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for repair of maxillofacial soft and/or hard tissue defect (D7955) 
provided on October 7, 2022. 
 
You asked the Plan to pay for the dental services. You say that the service D7955 should be covered as dental. 
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 repair of maxillofacial soft and/or hard tissue defect (D7955) provided on October 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on March 1, 
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 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 October 11, 2022. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on 
March 1, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on December 4, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that 911 was 
called and there were other emergencies at the same time. They came but did not have an emergency medical 
technician (EMT) available, and another responded with an EMT. The Plan denied your request. The Plan says 
these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on December 4, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on December 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on July 20, 2022. 
 
You asked the Plan to pay for the dental services. You say that this should be a covered service. 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 Plan paid 
$229 for services on May 5, 2022, $23 for services on June 30, 2022, $259 for services on August 1, 2022, and 
$2,239 for services on August 26, 2022, which is the annual maximum of $2,750. The record show your benefit 
for the requested item or service was exhausted on date of service August 26, 2022. Therefore, we decided that 
the Plan does not have to pay for dental services provided on July 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom fabricated abutment (D6057), an abutment 
supported crown (D6058), a guided tissue regeneration (D4266), a bone replacement graft (D7953), a cone 
beam CT capture (D0383), and a surgical implant (D6190). 
 
You asked the Plan to pre-approve the dental services. You say that you need this dental work. 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 D6057 and D6058 was exhausted on date of service February 10, 2022, and November 
22, 2022. Therefore, we decided that the Plan does not have to pre-approve a custom fabricated abutment 
(D6057), an abutment supported crown (D6058), a guided tissue regeneration (D4266), a bone replacement 
graft (D7953), a cone beam CT capture (D0383), and a surgical implant (D6190).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for crown re-cementing (D2920) provided on December 2, 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 January 12, 2022. 
Therefore, we decided that the Plan does not have to pay for crown re-cementing (D2920) provided on 
December 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a risk assessment and documentation, periodic oral 
evaluation, bitewing x-rays, cleaning, intraoral x-rays, and the topical application of fluoride (D0120, D0274, 
D0603, D1110, D0220, D0230, D1208) provided on January 3, 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 dental services were received from an out-of-
network provider and are not covered by your supplemental benefits. Coverage for the risk assessment 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. 
 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 risk assessment and documentation, periodic oral evaluation, bitewing x-rays, cleaning, intraoral x-
rays, and the topical application of fluoride (D0120, D0274, D0603, D1110, D0220, D0230, D1208) provided 
on January 3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95908 billed for date of service June 23, 
2022. 
 
You asked the Plan to pay for procedure code 95908. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment for code 95908 is bundled into 
payment for code 95870. 
 
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 95908 
is a column II code to column I code 95870 with a modifier indicator of 0. The column II 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 95908 billed for date of service June 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes G0480 and 83789 rendered on December 5, 
2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) code 83789-59 and Healthcare Common Procedure 
Coding System (HCPCS) code G0480 remain not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. Medicare rules also say that Medicare rules say that a physician order must be 
present for labs to be covered. Medicare rules also say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of G0480 have been met. The provider 
did not submit a physician order/lab requisition stating exactly what tests were to be performed. Additionally, 
we find that the testing described by the billed code 83789 is considered specimen validity testing which is not 
separately payable. Therefore, we decided that the Plan does not have to pay for procedure codes G0480 and 
83789 rendered on December 5, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Orthovisc. 
 
You asked the Plan to pre-approve Orthovisc. You say that the requested Orthovisc is medically necessary. The 
Plan denied your request. The Plan says the enrollee must try and fail Euflexxa first. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Orthovisc. Our reviewer says that the 
Plan's step therapy criteria have not been met. Our physician reviewer found the case file does not contain 
documentation of trial and failure of Euflexxa. The documentation does not support that Euflexxa would likely 
be less effective, and/or would likely have adverse effects for the enrollee in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Orthovisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Orthovisc.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the supply allowance for a continuous glucose monitor 
(CGM). 
 
You asked the Plan to pre-approve the supply allowance for the CGM. You say that you were prescribed a 
CGM, and you need the Plan to pay for the supplies for it. The Plan denied your request. The Plan says the 
Medicare criteria was not met. 
  The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of the supply 
allowance for the CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve 
the supply allowance for a continuous glucose monitor (CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for limited oral evaluation  problem focused (D0140) provided 
on September 27, 2022. 
 
You asked the Plan to pay for dental services. You say that you were not aware this service could only be done 
by an oral surgeon. The Plan denied your request. The Plan says this service is only covered under your Plan if 
performed by an oral surgeon. 
 
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 limited 
oral evaluation  problem focused (D0140) but only when performed by an oral surgeon only. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D0140 is not among 
those covered under this benefit because it was not performed by an oral surgeon. Therefore, we decided that 
the Plan does not have to pay for limited oral evaluation  problem focused (D0140) provided on September 
27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for implant maintenance procedures and implant repalacement 
services (D6080, D6091) provided on December 6, 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 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 implant 
maintenance procedures and implant repalacement services (D6080, D6091) provided on December 6, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the audiology diagnostic testing provided 
on January 12, 2023. 
 
You asked the Plan to reduce the copayment for the audiology diagnostic testing. You say that you should only 
be charged a $35 copayment. 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 a $85 
copayment for in-network outpatient diagnostic tests and services provided in an outpatient hospital. 
 
You have been asked to pay a $85 copayment for the audiology diagnostic testing. This item/service falls within the in-network outpatient diagnostic tests and services provided in an outpatient hospital 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. Therefore, we 
decided that the Plan does not have to reduce the copayment for the audiology diagnostic testing provided on 
January 12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional implant body services (D6011) provided on 
January 3, 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 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 January 3, 2023. 
Therefore, we decided that the Plan does not have to pay for additional implant body services (D6011) 
provided on January 3, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the gym membership (A9270) provided 
from October 21, 2022, through December 31, 2022. 
 
You asked the Plan to issue reimbursement for this service. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says the gym membership provided is 
not a covered benefit under the wellness allowance policy.  
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.  
 
The Plans rules for coverage of gym benefits have not been met because the gym membership provided is not 
a covered benefit. Specifically, the wellness allowance benefit does not provide coverage for a sports club 
membership. Therefore, we decided that the Plan does not have to issue reimbursement for the gym 
membership (A9270) provided from October 21, 2022, through December 31, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on September 17, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that your son 
was there this day and by trying to save you some money, he drove you to the hospital. The Plan denied your 
request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on September 17, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on September 17, 2022.