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

We decided that the Plan does not have to pay for the surgery services provided on September 9, 2021. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the codes are not 
supported by the medical records. 
 
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 35665 is bypass graft, with other than vein; iliofemoral. 
The CPT Code Manual definition of code 37242 is Vascular embolization or occlusion, inclusive of all 
radiological supervision and interpretation, intraprocedural road mapping, and imaging guidance necessary to 
complete the intervention; arterial, other than hemorrhage or tumor. 

We asked our coder 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 the billed services. Our reviewer found that CPT code 35665 
is not supported by the medical record. The operative report does not describe an iliofemoral bypass graft. The 
operative report describes, left external iliac artery, profunda and superficial femoral artery was clamped, and 
sheath and wire removed. The femoral artery dissected and sewn end-to-end proximally and distally.  
CPT code 37242 is not supported in the medical record. The operative report does not describe an embolization 
or occlusion. Per the operative report, the VCF was exchanged for a vertebral catheter and the left hypogastric 
artery was embolized with excellent result. The operative report does not have sufficient documentation to 
support this procedure was performed. Therefore, the billed codes cannot be verified.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan does 
not have to pay for the surgery services provided on September 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the cone beam computed tomography (CT) image capture 
with limited field of view (D0380) provided on October 21, 2021. 
 
You asked the Plan to pay for the cone beam CT image capture. You say that you would like to know if either 
the referring provider or treating provider should have inquired about your benefits prior to the service being 
rendered. You also say that it was your understanding that the referral process and resulting procedures were all 
inclusive as part of your dental insurance coverage. The Plan denied your request. The Plan says this service is 
not a covered benefit under your dental plan. 
 
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 pay for the cone 
beam computed tomography (CT) image capture with limited field of view (D0380) provided on October 21, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220) and panoramic x-
ray (D0330) provided on October 12, 2021. 
 
You asked the Plan to pay for the first intraoral periapical x-ray and panoramic x-ray. You say that you are on a 
fixed income and if the Plan could cover this dental bill it would be a great help. The Plan denied your request. 
The Plan says these services are not covered. 
 
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 first 
intraoral periapical x-ray (D0220) and panoramic x-ray (D0330) provided on October 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on October 
19, 2021. 
 
You asked the Plan to pay for the periodontal maintenance. You say that the dentist office contacted the Plan 
and was advised that localized delivery of antimicrobial agents (D4381) was covered at 100%. The Plan denied 
your request. The Plan says your benefit plan has a limit for how often this procedure is covered. The Plan also 
says that you have hit your maximum amount for the year for this service. 

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, periodontal maintenance (D4910) is 
limited to two per calendar year. The record shows that you received a periodontal maintenance (D4910) on 
February 17, 2021, and on June 15, 2021 and your periodontal maintenance (D4910) benefit has been 
exhausted. Therefore, we decided that the Plan does not have to pay for the periodontal maintenance (D4910) 
provided on October 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) 
provided on November 30, 2021. 
 
You asked the Plan to pay for the problem focused limited oral evaluation. You say that you would like the 
Plan's denial of this claim to be reversed. The Plan denied your request. The Plan says this service is not a 
covered expense under your dental plan. The Plan also says that you did not contact the Plan prior to the date of 
service to verify benefits. 
 
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 pay for the 
problem focused limited oral evaluation (D0140) provided on November 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a comprehensive periodontal evaluation (D0180), 
localized delivery of microbial agents (D4381 x 4), and gingival irrigation (D4921 x 4). 
 
You asked the Plan to pre-approve the comprehensive periodontal evaluation and gingival irrigation. You say 
that you are in constant pain. You say that you are on a small, fixed income. You also say that you need these 
services. The Plan denied your request. The Plan says comprehensive periodontal evaluation is not listed as a 
covered service. The Plan says that gingival irrigation is not listed as a covered service either. 
 
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 comprehensive 
periodontal evaluation and gingival irrigation are not among those covered under this benefit. Therefore, we 
decided that the Plan does not have to pre-approve a comprehensive periodontal evaluation (D0180), localized 
delivery of microbial agents (D4381 x 4), and gingival irrigation (D4921 x 4).
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory services (87486, 87496, 87498 87541, 87581, 
87640, 87798) provided on July 31, 2020. 

 You asked the Plan to pay for laboratory services. You say that this should be covered. The Plan denied your 
request. The Plan says this was not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that 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 laboratory 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 laboratory services (87486, 87496, 87498 87541, 87581, 87640, 87798) 
provided on July 31, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve dental services to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve dental services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says there are in-network dentist available for these services. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
dental services to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a crown (D2751) for tooth # 21, and core build up 
(D2950) for teeth # 20, 21, and 29. 
 
You asked the Plan to pre-approve the dental services. You say that you need these services. The Plan denied 
your request. The Plan says the frequency limit for crowns has been reached. The Plan also says that core build 
up is not a covered service. 
 
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 and crowns are listed as covered, there 
is a limit of 2 crowns per arch per calendar year.  The record shows that the Plan approved crowns for teeth # 20 and 29, thus reaching the frequency limit.  
 
Additionally, the requested core build up are not among those covered under this benefit. Therefore, we 
decided that the Plan does not have to pre-approve a crown (D2751) for tooth # 21, and core build up (D2950) 
for teeth # 20, 21, and 29.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve services provided by an out of network provider at the 
in network rate. 
 
You asked the Plan to pre-approve in network rate for service you receive out of network. You say that you do 
not want to be balance billed. You say that there are no in network dentists within 50 miles of your address. 
You say that the closest in network provider is over 1 hour away. You also say that you should not be penalized 
because you do not live in a metropolitan area. The Plan denied your request. The Plan says the provider in this 
case is out of network. The Plan says that out of network providers may bill you for any amount greater than 
what the Plan pays. 
 
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 and the services are covered, the Plan 
confirmed that the dental services are paid the same regardless of the provider's network status.  However, out of network providers may bill you for any amount greater than what the plan pays. Therefore, we 
decided that the Plan does not have to pre-approve services provided by an out of network provider at the in 
network rate.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endosteal implants (D6010 x 12). 
 
You asked the Plan to pre-approve the dental services. You say that you need these services. The Plan denied 
your request. The Plan says endosteal implants are not covered. 
 
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 endosteal implants are 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
endosteal implants (D6010 x 12).
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for needle electromyography (95885), nerve conduction studies 
(95911) and electroencephalogram (EEG) during nonintracranial surgery (95955) provided on November 4, 
2021. 
 
You asked the Plan to pay for the needle electromyography, nerve conduction studies and 
electroencephalogram. You say that these services are supported as billed. The Plan denied your request. The 
Plan says these services are not supported as 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, CPT codes 95885 (needle 
electromyography each extremity, with related paraspinal areas, when performed with nerve conduction, 
amplitude and latency/velocity study, limited); 95911 (nerve conduction studies 9-10 studies); and 95955 (EEG 
during nonintracranial surgery) were reported. 

We asked our coder 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 the needle electromyography, nerve conduction studies and 
electroencephalogram. Our reviewer says that these services are not supported as billed. Our reviewer found 
that CPT codes 95885 and 95911 are not supported as the procedure report documents pedicle screw 
stimulation, which are not nerve conduction studies. In order to report these procedure codes, nerve conduction 
studies would be performed. Therefore, these procedures cannot be verified. CPT code 95955 is considered in 
the CPT Manual as a "Special EEG Tests". Any additional EEG testing is inclusive to the intraoperative 
neuromonitoring procedure code and would not be reported separately.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the needle electromyography, nerve conduction studies and 
electroencephalogram have not been met. Therefore, we decided that the Plan does not have to pay for needle 
electromyography (95885), nerve conduction studies (95911) and electroencephalogram (EEG) during 
nonintracranial surgery (95955) provided on November 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the limited oral evaluation (D0140), the first intraoral 
periapical x-ray (D0220), the additional intraoral periapical x-ray (D0230), and the adjunctive pre-diagnostic 
test (D0431) provided by a network provider on November 19, 2021. 
 
You asked the Plan to pay for the limited oral evaluation (D0140), the first intraoral periapical x-ray (D0220), 
the additional intraoral periapical x-ray (D0230), and the adjunctive pre-diagnostic test (D0431). You say that 
this was an emergency and due to the pandemic, these services should be considered preventive and should be 
covered.  The Plan denied your request. The Plan says the services are not covered benefits. 
   
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 pay for the 
limited oral evaluation (D0140), the first intraoral periapical x-ray (D0220), the additional intraoral periapical 
x-ray (D0230), and the adjunctive pre-diagnostic test (D0431) provided by a network provider on November 
19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740) for teeth #14 & #18 to be provided by 
a participating provider. 
 
You asked the Plan to pre-approve a crown. You say that you would like the Plan to approve this. The Plan 
denied your request. The Plan says the requested dental services are not covered 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 pre-approve a 
crown (D2740) for teeth #14 & #18 to be provided by a participating provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the flexible protective covering described by code 
L5962 for use with an approved lower limb prosthesis. 
 
You asked the Plan to pre-approve the L5962 protective covering. You say that the requested items are 
medically necessary. The Plan denied your request. The Plan says all requested items have been approved aside 
from L5962 which is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that prosthetic coverings described by L5962 are covered 
for enrollees who require special protection against unusually harsh environmental conditions. 
 
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 L5962 protective covering.  Our reviewer says that the documentation does not support the need for the requested L5962 covering. Our 
physician reviewer found the record does not indicate that the enrollee has special needs for protection against 
unusually harsh environmental situations.  The record does not indicate that the requested service is necessary 
to protect the lower limb prosthesis beyond the level of protection that is afforded by L5704, L5705, L5706, 
and L5707.  The elements of the coverage criteria are not satisfied.  
 
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 L5962 protective covering have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the flexible protective covering described by code L5962 for use with an 
approved lower limb prosthesis.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) 
provided on November 22, 2021. 
 
You asked the Plan to pay for the problem focused limited oral evaluation. You say that you would like the 
Plan to reconsider their decision and cover the cost of this necessary treatment. The Plan denied your request. 
The Plan says this service exceeds the frequency limitation in your benefit 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, problem focused limited oral 
evaluation (D0140) is limited to one procedure per plan year. The record shows that you received a problem 
focused limited oral evaluation (D0140) on July 1, 2021 and your problem focused limited oral evaluation 
(D0140) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the problem 
focused limited oral evaluation (D0140) provided on November 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the palliative treatment of dental pain (D9110) provided on 
October 25, 2021. 
 
You asked the Plan to pay for the dental service. You say that according to the Evidence of Benefits, this 
service should be covered. The Plan denied your request. The Plan says palliative treatment of dental pain is 
not a preventive service and therefore is not covered. 
 
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 palliative treatment of dental pain 
is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
palliative treatment of dental pain (D9110) provided on October 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal scalings and root planings (D4341) of all four 
quadrants provided on November 18, 2021. 
 
You asked the Plan to pay for the scalings and planings. You say that you received two completely different 
cleanings between the two providers. You also say that you would remember if you had the same cleaning done 
by the previous dentist. The Plan denied your request. The Plan says your benefits for these services have been 
satisfied and the frequency limitation has been exceeded. The Plan also says that you did contact the Plan prior 
to the date of service to verify benefits, and you were sent you a copy of your benefits which shows the 
frequency limitations for periodontal scaling and root planing. 

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, scaling and root planing is limited to 
one procedure code every three years, per quadrant. The record shows that you received periodontal scalings 
and root planings (D4341) of all four quadrants on December 22, 2020 and your periodontal scalings and root 
planings (D4341) benefit for all four quadrants has been exhausted. Therefore, we decided that the Plan does 
not have to pay for the periodontal scalings and root planings (D4341) of all four quadrants provided on 
November 18, 2021.  
 
Your complaint about the previous provider not being nice and lying is not a valid appeal for medical coverage. 
This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to 
make a decision about these types of complaints.