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

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on 
August 26, 2022. 
 
You asked the Plan to pay for the dental service. You say that you had to switch dentist and you felt a new 
exam was medically necessary. 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 the Plan paid for a comprehensive oral evaluation (D0150) on February 10, 2022; therefore, your benefit 
for the requested item or service was exhausted on the date of service of February 10, 2022. Therefore, we 
decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on August 
26, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 15 hours of psychological testing. 
 
You asked the Plan to pre-approve 7 additional hours of psychological testing. You say that the enrollee has a 
complex medical history that may point to multiple etiologies, warranting a full evaluation for adequate 
specificity.  The Plan denied your request. The Plan says additional testing 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 7 additional hours of psychological 
testing. Our reviewer says that the request for 7 additional hours of psychological testing is not considered 
medically reasonable and necessary in this case. Our physician reviewer found the guidelines indicate that 
additional testing beyond 8 hours must be supported in the records. The reviewer also found that the provided 
documentation does not sufficiently support that 7 additional hours of neuropsychological testing are medically 
reasonable and necessary 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 7 additional hours of psychological testing have not been met. Therefore, we 
decided that the Plan does not have to pre-approve 15 hours of psychological testing.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implantation of an Optimizer Smart device. 
 
You asked the Plan to pre-approve implantation of an Optimizer Smart device. You say that the services are 
necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, 
coverage criteria have not been met. 
 
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 implantation of an Optimizer Smart 
device. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found while the clinical studies led to FDA approval in 2019, 
cardiac contractility modulation (CCM) remains the subject of multiple studies examining long-term efficacy, 
as well as randomized, controlled, double-blinded trials to quantify clinical efficacy. Until such statistically rigorous studies are completed, it is premature to presume clinical outcomes and benefit. At the current time, 
the CCM system is not considered to be medically necessary in this enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of implantation of an Optimizer Smart device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve implantation of an Optimizer Smart device.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve L1 kyphoplasty surgery. 
 
You asked the Plan to pre-approve kyphoplasty. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says there is fracture retropulsion/canal compromise and the enrollee's 
current pain is not primarily due to VCF. 
 
The Plan follows Medicare rules. Medicare rules state that kyphoplasty surgery may be covered under certain 
clinical circumstances. 
 
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 
enrollee does not meet criteria for kyphoplasty. Our physician reviewer found imaging shows fracture 
retropulsion which is a contraindication to kyphoplasty. 
 
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 L1 kyphoplasty surgery.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrodes provided on March 27, 2023. 
 
You asked the Plan to pay for the electrodes. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the item rendered is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that electrodes are not valid for claim submission. 
 
We looked at the file and Medicare rules. The items at issue are electrodes. These items are not separately 
payable as billed. Based on this information, we decided that Medicare rules for coverage of the electrodes 
have not been met. Therefore, we decided that the Plan does not have to pay for the electrodes provided on 
March 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care visit provided on June 30, 2023, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for nursing facility care visit. You say that you were unaware a prior authorization 
was required. The Plan denied your request. The Plan says an authorization was not obtained prior to services 
rendered. 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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for nursing facility care visit provided on June 30, 
2023, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical placement of implant body (D6010), a semi-
precision abutment (D6191), and a semi-precision attachment (D6192) for tooth #4, #6, #10, and #12 provided 
by an out-of-network provider on March 4, 2022. 
 
You asked the Plan to pay for the dental services. You say that the dental work was started on March 4, 2023, 
but it as not completed until August 26, 2022. The Plan denied your request. The Plan says more than 1 
calendar year from the date of service had passed before the claim was filed. Also, you do not have out-of-
network benefits. 
 
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 dental services was not filed until April 7, 2023. Specifically, the 
statement of services rendered, and the explanation of benefits show the date of service being March 4, 2022. 
This means that more than one calendar year from the date of service had passed before a claim was filed. 
Therefore, we decided that the Plan does not have to pay for the surgical placement of implant body (D6010), a 
semi-precision abutment (D6191), and a semi-precision attachment (D6192) for tooth #4, #6, #10, and #12 
provided by an out-of-network provider on March 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial lower denture (D5214). 
 
You asked the Plan to pre-approve the dental service. You say that it is medically necessary for you to get a 
new partial denture because the previous one is unwearable. 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 the Plan paid for a partial lower denture (D5214) on September 17, 2020; therefore, your benefit for the 
requested item or service was exhausted on the date of service of September 17, 2020. Therefore, we decided 
that the Plan does not have to pre-approve a partial lower denture (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal scaling and root planing - four or more teeth 
per quadrant (D4341) provided on June 2, 2023. 
 
You asked the Plan to pay for the periodontal scaling and root planing The Plan denied your request. The Plan 
says your benefit for the periodontal scaling and root planing 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 periodontal scaling and root planing was exhausted on date of service September 14, 
2021. Therefore, we decided that the Plan does not have to pay for the periodontal scaling and root planing - 
four or more teeth per quadrant (D4341) provided on June 2, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on March 9, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services were necessary and are supported in 
the medical record. The Plan denied your request. The Plan says you billed with an incorrect place of service 
on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on March 9, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided from May 25, 2023, 
through June 4, 2023. 
 
You asked the Plan to pay for these items. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says the self-administered drugs provided are not covered 
as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs provided in this case are not among the types which are 
covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered 
drugs provided from May 25, 2023, through June 4, 2023.  
 
Benefits for these items may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 44950 billed for date of service April 6, 
2023.   

You asked the Plan to pay for procedure code 44950. You say that this code is allowable and payable. The Plan 
denied your request. The Plan says payment for code 44950 is bundled into payment for code 44143. 
 
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 44950 
is a column II code to column I code 44143 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 44950 billed for date of service April 6, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes A4221 and A4223 provided from February 
25, 2023, to March 3, 2023. 
 
You asked the Plan to pay for procedure codes A4221 and A4223. 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. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure codes A4221 and A4223 have a Status Indicator of X on the Physician Fee Schedule. This means that procedure codes A4221 and A4223 are excluded from Medicare coverage. Based on this 
information, we decided that Medicare rules for coverage of procedure codes A4221 and A4223 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes A4221 and A4223 provided 
from February 25, 2023, to March 3, 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), and intraoral  comprehensive series of radiographic images (D0210) provided on May 3, 2023. We 
also decided that the Plan does not have to pay more for the prophylaxis - adult (D1110) provided on May 3, 
2023.  
You asked the Plan to pay for the dental services. You say that you are asking for additional reimbursement for 
the routine cleaning because your EOC states coverage of 100%. You also say that you are requesting coverage 
on the denied services because your policy is new as of January 1, 2023. The Plan denied your request. The 
Plan says your benefit for the comprehensive oral evaluation and intraoral  comprehensive series of 
radiographic images has already been exhausted. The Plan also 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 the prophylaxis - adult (D1110) provided on 
May 3, 2023. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the comprehensive oral evaluation  and intraoral  comprehensive series of radiographic 
images was exhausted on date of service August 10, 2022. Therefore, we decided that the Plan does not have to 
pay for the comprehensive oral evaluation - new or established patient (D0150), and intraoral  comprehensive 
series of radiographic images (D0210) provided on May 3, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the residence visit for an evaluation provided on April 28, 
2023, by an out-of-network (OON) provider.  
  You asked the Plan to pay for the evaluation. You say that the enrollee should not need a referral or 
authorization. The Plan denied your request. The Plan says the rendering provider is an OON provider and 
there was no referral from an in-network provider or approved authorization. Also, the service rendered was 
not urgent or emergent. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the residence visit for an evaluation provided on 
April 28, 2023, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee has spine upcoming surgery  and needs 
physical therapy. The Plan denied your request. The Plan says the enrollee's records do not show the need for 
an intensive team for care. The Plan says that the services needed may be provided safely in a lower level of 
care.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section.  
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy (PT) services provided on March 29, 
2023. 
 
You asked the Plan to pay for the physical therapy (PT) services. You say that records have been provided to 
show medical necessity. 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 physical therapy 
(PT) services provided on March 29, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services (D9612 and D9999)  
 
You asked the Plan to pay for the dental services (D9612 and D9999). You say that you would like to request 
reconsideration for payment. 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 dental services (D9612 and D9999)
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endosteal implants (D6010) for teeth #11 and #13. 
 
You asked the Plan to pre-approve the dental services. You say that these implants are necessary. 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 with the approval of D6010 for teeth #4 and 
#6. Therefore, we decided that the Plan does not have to pre-approve endosteal implants (D6010) for teeth #11 
and #13.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to preapprove additional one-way trips. 
 
You asked the Plan to preapprove additional one-way trips. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says this benefit has been exhausted. 
 
  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 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to preapprove additional one-way trips.