Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cardiac catheterization and coronary angiography. 
 
You asked the Plan to pre-approve cardiac catheterization and coronary angiography. You say that it is 
medically necessary. The Plan denied your request. The Plan says they need results of the prior approved study 
that show the need for repeat imaging. 
 
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 cardiac catheterization and coronary 
angiography. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found there is no record of the result of the previously requested 
study or rationale for repeating the study. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of cardiac catheterization and coronary angiography have not been met. Therefore, 
we decided that the Plan does not have to pre-approve cardiac catheterization and coronary angiography.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the refraction provided on August 22, 2023. 
 
You asked the Plan to pay for the refraction. You say that you have pre-glaucoma and need vision exams every 
6 months. You also say that the refraction should be included in the exam. The Plan denied your request. The 
Plan says this request exceeds your benefit limit. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers up to 1 routine eye exam including contact lens fitting every calendar year. 
 
We looked at the file and the Plan's rules. Specifically, a refraction is covered once annually, and the benefit 
was paid previously in the plan year on date of service February 20, 2023. Based on this information, we 
decided that the Plan's rules for coverage of the refraction have not been met. Therefore, we decided that the 
Plan does not have to pay for the refraction provided on August 22, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve kyphoplasty. 
 
You asked the Plan to pre-approve kyphoplasty. You say that you are requesting reconsideration for the denied 
claim. The Plan denied your request. The Plan says the enrollee does not meet all of the requirements for 
approval. 
 
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 kyphoplasty. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the detailed documentation is not evident regarding diagnostic imaging study corroborating a 
compression fracture at L1. Moreover, there is magnetic resonance imaging (MRI) corroboration other 
plausible causes of 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 kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve kyphoplasty.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic radiographic image (D0330) and a limited oral 
evaluation (D0140) provided on May 3, 2023. 
 
You asked the Plan to pay for the dental services. You say that you live on a fixed income and this is not for 
cosmetic purposes. You say you cannot pay this added expense. 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 panoramic radiographic image was exhausted on date of service January 29, 2021 
and your benefit for the limited oral evaluation was exhausted on date of service May 2, 2023. Therefore, we 
decided that the Plan does not have to pay for a panoramic radiographic image (D0330) and a limited oral 
evaluation (D0140) provided on May 3, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics (codes L3216 and L2232).  
 
You asked the Plan to pre-approve foot orthotics. You say that you suffer from ankle fusion which causes you 
to be unable to walk and you are currently having severe pain in your knee. 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. Medicare rules 
also say that L coded additions to AFOs and KAFOs (such as code L2232) will be denied as not reasonable and 
necessary if either the base orthosis is not reasonable and necessary, or the specific addition is not reasonable 
and necessary.  
 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 (codes L3216 and 
L2232).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laparoscopy, surgical, colpopexy and revision (including 
removal) of prosthetic vaginal graft, laparoscopic approach provided on June 20, 2023. 
 
You asked the Plan to pay for laparoscopy, surgical, colpopexy and revision (including removal) of prosthetic 
vaginal graft, laparoscopic approach. You say that the services were medically necessary. The Plan denied your 
request. The Plan says this provider specialty does not have the capacity to bill directly for the services 
rendered.  The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for laparoscopy, surgical, colpopexy and 
revision (including removal) of prosthetic vaginal graft, laparoscopic approach provided on June 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment of varicose veins of the lower extremity. 
 
You asked the Plan to pre-approve treatment of varicose veins of the lower extremity. You say that you are 
requesting reconsideration for the denied claim. The Plan denied your request. The Plan says it is not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that the treatments for symptomatic varicose tributaries 
are either compressive sclerotherapy or microphlebectomy. The treatments of the tributary veins will be 
considered medically necessary if saphenous reflux is not present or already successfully eliminated, the veins 
are greater than 4 mm in diameter and if the enrollee remains symptomatic after a six-week trial of 
conservative 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 treatment of varicose veins of the lower 
extremity. Our reviewer says that the service is not medically necessary. Our physician reviewer found that 
tributary treatment such as sclerotherapy to be considered medically necessary per coverage criteria, there 
needs to be persistent significant symptoms following successful treatment of truncal (saphenous) reflux with 
these symptoms existing more than six weeks after the reflux was treated and despite conservative efforts.  Additionally, the veins to be treated need to be at least 4 mm in diameter. As the enrollee has not yet undergone 
saphenous vein reflux treatment, the above criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of treatment of varicose veins of the lower extremity have not been met. 
Therefore, we decided that the Plan does not have to pre-approve treatment of varicose veins of the lower 
extremity.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for root amputation (D3450) provided on April 28, 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 root 
amputation (D3450) provided on April 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on March 16, 2023.  
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the Plan 
was not the primary insurer at the time of services. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. The Plan has met its obligation with regards to coordination of benefits. As the secondary insurer, the Plan 
cannot be held responsible for the physician's services until the primary insurer has denied the claim for these 
services. Therefore, we decided that the Plan does not have to pay for physician's services provided on  
March 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intracept intraosseous nerve ablation system. 
 
You asked the Plan to pre-approve intracept intraosseous nerve ablation system. You say that you are 
requesting reconsideration for the denied claim. The Plan denied your request. The Plan says it is 
investigative/experimental and 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 intracept intraosseous nerve ablation 
system. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found there is no magnetic-resonance imaging (MRI) showing 
only modic changes without facet degenerative joint disease (DJD) or stenosis. The cause of pain is not clear. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of intracept intraosseous nerve ablation system have not been met. Therefore, we 
decided that the Plan does not have to pre-approve intracept intraosseous nerve ablation system.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for resin-based composite-three surfaces posterior 
(D2393), a porcelain or ceramic crown (D2740), and core buildup (D2950) provided on September 7, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you were told this would be covered under 
your $1,500 annual coverage allowed. You also say you were not informed of in-network versus out-of-
network difference. 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-three surfaces 
posterior (D2393), a porcelain or ceramic crown (D2740), and core buildup (D2950) provided on September 7, 
2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
May 22, 2023.  
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules 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 Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service May 22, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lower complete denture (D5120) provided on August 11, 
2023. 
 
You asked the Plan to pay for this dental item. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says your benefit for the dental item provided 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 item provided was exhausted on date of service September 30, 2022.  
  
 
Specifically, the Plans contract states the one lower complete denture or associated dental item is covered 
every 60 months. You previously received an immediate lower denture on September 30, 2022, less than 60 
months prior, which was paid for by the Plan. This is an associated dental item to a lower complete denture. 
Therefore, you have exhausted the allowable benefit for the dental item at issue in this case. Therefore, we 
decided that the Plan does not have to pay for the lower complete denture (D5120) provided on August 11, 
2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from May 30, 2023, to 
June 30, 2023. 
 
You asked the Plan to pay for the home health services as billed. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as 
billed. 
 The Plan follows Medicare rules. The rules state that home health services under a plan of care are paid based 
on a 30-day period of care. The rules say that when periods of care are created from a notice of admission, the 
common working file (CWF) calculates a period end date that does not exceed the start date plus 29 days. 
 
We looked at the file and Medicare rules. In this case, the file shows that the claim submitted includes a 32-day 
period of care. Therefore, we decided that the Plan does not have to pay for the home health services provided 
from May 30, 2023, to June 30, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the scaling in presence of generalized moderate or severe 
gingival inflammation (D4346) provided on June 29, 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 the 
scaling in presence of generalized moderate or severe gingival inflammation (D4346) provided on June 29, 
2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from August 27, 2023, 
through August 29, 2023. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says that the acute inpatient hospital care provided 
was not medically necessary.  
 
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 these services. Our reviewer says that the 
documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer 
found that you had a transient ischemic attack versus a cerebral vascular accident (CVA). You were transferred 
from an outpatient hospital for a higher level of care on August 27, 2023. You were seen by Neurology, and no 
intervention was planned. You had known asymptomatic bradycardia. You were then discharged on August 29, 
2023 when considered medically stable. The review has determined that the record showed that at the time of 
the inpatient admission it was reasonable for the admitting physician to expect that your necessary hospital care 
(including earlier emergency department (ED) and/or observation care) would span two midnights with 
supporting documentation of your 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 these services have been met. Therefore, we decided that the Plan has to pay for 
the acute inpatient hospital care provided from August 27, 2023, through August 29, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral-comprehensive series of radiographic images 
(D0210) provided on September 5, 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 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 November 2, 2022. 
Therefore, we decided that the Plan does not have to pay for intraoral-comprehensive series of radiographic images (D0210) provided on September 5, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance (D4910) provided on August 9, 
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 4, 2023, and 
April 5, 2023. Therefore, we decided that the Plan does not have to pay for periodontal maintenance (D4910) 
provided on August 9, 2023.