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

 
We decided that the Plan does not have to pre-approve a lower partial denture, cast metal framework with resin 
denture base (D5214). 
 
You asked the Plan to pre-approve the dental item. You say that partial dentures are covered under your dental 
benefit. The Plan denied your request. The Plan says the service denied correctly. 
 
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 lower partial denture, 
cast metal framework with resin denture base, is not among those covered under this benefit. Therefore, we 
decided that the Plan does not have to pre-approve a lower partial denture, cast metal framework with resin 
denture base (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve retainer crowns - porcelain fused to high noble metal 
(D6750) for teeth 29, 31 and a pontic - porcelain fused to high noble metal (D6240) for tooth 30 for a bridge. 
 
You asked the Plan to pre-approve a bridge. You say that you would like a fixed bridge. The Plan denied your 
request. The Plan says the bridge is not covered because you are missing too many teeth. 
 
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. The Plan covers a bridge when 
you are missing only one upper front tooth or only two adjacent lower front teeth. You also cannot be missing 
any of your back teeth. 
 
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 a bridge. Our reviewer says that a fixed 
bridge replacing missing tooth 30 does not meet the criteria for coverage. Our physician reviewer found that in 
this case tooth #30 is a posterior tooth and additional posterior mandibular teeth are missing (teeth 18 and 19). 
Therefore, you do not meet the Plan's criteria for coverage of a bridge. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of a bridge have not been met. Therefore, we decided that the Plan does not have 
to pre-approve retainer crowns - porcelain fused to high noble metal (D6750) for teeth 29, 31 and a pontic - 
porcelain fused to high noble metal (D6240) for tooth 30 for a bridge.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical removal of implant body (D6100) provided 
October 28, 2021. 
 
You asked the Plan to pay for the surgical removal of an implant. You say that it was medically necessary to 
remove the implant because it was infected. The Plan denied your request. The Plan says this service is not 
covered under your 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 
surgical removal of implant body (D6100) provided October 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a surgical placement of implant body: endosteal implant 
(D6010). 
 
You asked the Plan to pre-approve the endosteal implant. You say that you would like the implant to be 
approved for coverage. The Plan denied your request. The Plan says this service is not covered under your 
benefit package. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 
surgical placement of implant body: endosteal implant (D6010).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a second unit of subsequent hospital care (99233) billed for 
July 25, 2021. 
 
You asked the Plan to pay for subsequent hospital care. You say that these services were billed appropriately 
and should be paid. The Plan denied your request. The Plan says they have agreed to pay for one unit of 99233 provided on July 25, 2021; however, two units were billed on two separate claim lines. It has been determined 
that the second line billed is a duplicate claim, and a second unit of 99233 cannot be paid because this service 
is only billable once per day. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Medicare rules state that services which are deemed to be a duplicate with respect to certain elements are 
rejected and do not have appeal rights. 
 
We find that CPT code 99233 is not supported in the medical record. Specifically, this claim appears to be a 
duplicate of another claim line which has previously been paid. There is no documentation to support that this 
service was performed twice on the date in question. Based on this information, we decided that Medicare rules 
for coverage of subsequent hospital care have not been met. Therefore, we decided that the Plan does not have 
to pay for a second unit of subsequent hospital care (99233) billed for July 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the 2D oral/facial photographic image obtained intra-orally 
or extra-orally (D0350) and oral hygiene instructions (D1330) provided December 14, 2021. 
 
You asked the Plan to pay for the 2D oral photographs and oral hygiene instructions. You say that your dentist 
sent you estimates that were lower than what is being charged. You would not have had the work done if you 
had known the services would be denied. The Plan denied your request. The Plan says these services are not 
covered under your 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 2D 
oral/facial photographic image obtained intra-orally or extra-orally (D0350) and oral hygiene instructions 
(D1330) provided December 14, 2021.  
 
Your complaint about your pre-estimate being lower than the amount you are responsible for 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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a dental restoration (D0364) provided January 24, 2022. 
 
You asked the Plan to pay for the dental service. You say that the services were medically necessary. The Plan 
denied your request. The Plan says this 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 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 dental 
restoration (D0364) provided January 24, 2022.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to issue additional reimbursement for the intraoral-periapical first radiographic 
image (D0220) and the porcelain/ceramic crown (D2740) provided on January 11, 2022.  We also decided 
that the Plan does not have to issue reimbursement in the amount of 40% of the cost of the 
intraoral-periapical first radiographic image (D0220), the porcelain/ceramic crown (D2740), and the 
unspecified procedure (D1999) provided.  
 
You asked the Plan to issue additional reimbursement. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan says that the claim for these services has been processed correctly.  
 
We decided that the Plan has to issue additional reimbursement for the intraoral-periapical first 
radiographic image (D0220) and the porcelain/ceramic crown (D2740) provided on January 11, 2022. 
The radiographic image provided in this case has been denied by the Plan without rationale; however, this 
service is a covered benefit. The Plan contract does not indicate that the 80% coinsurance liability would be 
applied to anything other than the full cost of the services provided. The rules say that Medicare plans must 
make reasonable and diligent efforts to gather and forward information to the Independent Review Entity 
(IRE). The Plan has not followed this rule. The total cost of the billed charges for these services is  
$1,556 x 20% Plan liability= $311.20. You were originally reimbursed in the amount of $123.68. Therefore, 
we decided that the Plan has to issue additional reimbursement to you in the amount of $187.52. 
 
We also decided that the Plan does not have to issue reimbursement in the amount of 40% of the cost for 
the intraoral-periapical first radiographic image (D0220), the porcelain/ceramic crown (D2740), and the 
unspecified preventive procedure (D1999) provided on January 11, 2022. The Plan contract states that 
enrollees must pay an 80% coinsurance for exams, cleanings, dental x-rays, restorative services, endodontics, 
periodontics, prosthodontics, oral/maxillofacial surgery, and other services rendered by an out-of-network 
provider. Additionally, the unspecified preventive procedure (D1999) is not a separately payable service. 
Therefore, we decided that the Plan does not have to issue reimbursement to you in the amount of 40% of the 
cost for the intraoral-periapical first radiographic image (D0220), the porcelain/ceramic crown (D2740), and 
the unspecified preventive procedure (D1999) provided on January 11, 2022. 
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home therapy; enteral nutrition via bolus; administrative 
services provided from May 25, 2021, through June 23, 2021. 
 
You asked the Plan to pay for home therapy; enteral nutrition via bolus; administrative services. The Plan 
denied your request. The Plan says the Plan did not receive a valid Waiver of Liability prior to the Plan's 
dismissal of the case. 
 
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. 
 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 home therapy; enteral nutrition via 
bolus; administrative services provided from May 25, 2021, through June 23, 2021 have been met. No medical 
records were submitted to corroborate the documentation in the enrollee's medical documentation and confirm 
that Medicare coverage criteria have been met. Therefore, we decided that the Plan does not have to pay for 
home therapy; enteral nutrition via bolus; administrative services provided from May 25, 2021, through June 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81206 and 81292) provided on 
September 29, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed based 
on the medical records. The Plan denied your request. The Plan says this claim has not been billed in 
accordance with Medicare billing regulations. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
 
We looked at the file and Medicare rules. In this case, the services provided should have been billed as a single 
procedural service. Based on this information, we decided that Medicare rules for coverage of the laboratory 
services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services 
(81206 and 81292) provided on September 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the power seat elevation (CPT code E2300). 
 
You asked the Plan to pre-approve the power seat elevation. You say that the item is medically necessary. The 
Plan denied your request. The Plan says the power seat elevation (E2300) is not covered by the health plan or 
Medicare. The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this 
information, we decided that Medicare rules for coverage of the power seat elevation have not been met. The 
power seat elevation (E2300) is a non-covered accessory because it is not primarily medical in nature. 
Therefore, we decided that the Plan does not have to pre-approve the power seat elevation (CPT code E2300).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bilateral lower eyelid blepharoplasty. 
 
You asked the Plan to pre-approve bilateral lower eyelid blepharoplasty. You say that this procedure is 
medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for 
coverage have not been met for the requested bilateral lower eyelid blepharoplasty. 
 
The Plan follows Medicare rules. Medicare rules say that blepharoplasty services are subject to the criteria 
listed 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 bilateral lower eyelid blepharoplasty. 
Our reviewer says that the requested bilateral lower eyelid blepharoplasty services are not medically reasonable 
and necessary. Our physician reviewer found that the enrollee has Dermatochalasis of the right and left upper 
eyelids, Bilateral brow ptosis, and Unspecified visual field defects. On February 10, 2022, the enrollee noted 
that her left upper eyelid will be droopy when reading. Visual field testing documented that the enrollee's brow 
and lid position abnormalities are visually significant, and supported the medical necessity of bilateral direct 
brow lift and bilateral upper eyelid blepharoplasty. In this case, the clinical documentation, including 
photographs, does not support that the coverage criteria for bilateral lower eyelid blepharoplasty are satisfied in 
this case. It has not been demonstrated that the lower eyelids interfere with the enrollee's vision. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bilateral lower eyelid blepharoplasty have not been met. Therefore, we decided 
that the Plan does not have to pre-approve bilateral lower eyelid blepharoplasty.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the custom fabricated abutment  includes placement 
(D6057) and abutment supported porcelain fused to metal crown (high noble metal) (D6059) provided January 
21, 2021. 
 
You asked the Plan to pay for the custom fabricated abutment and abutment supported crown. You say that you 
thought you were being signed up for dental benefits. The Plan denied your request. The Plan says these 
services are not covered under your 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 
custom fabricated abutment  includes placement (D6057) and abutment supported porcelain fused to metal 
crown (high noble metal) (D6059) provided January 21, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for arthrocentesis, aspiration, and/or injection of a major joint or 
bursa (20610) and ultrasonic guidance for needle placement (76942) provided on September 22, 2021. 
 
You asked the Plan to pay for arthrocentesis, aspiration, and/or injection of a major joint or bursa and 
ultrasonic guidance for needle placement. You say that you have provided medical records to support the 
services billed. The Plan denied your request. The Plan says rules for payment have not been met. 
 
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 20610 is "Arthrocentesis, aspiration and/or injection, 
major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); without ultrasound guidance"; and of code 
76942 is "Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), 
imaging supervision and interpretation." 
 
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 arthrocentesis, aspiration, and/or injection of a major joint or 
bursa and ultrasonic guidance for needle placement. Our reviewer says that the CPT codes at issue do not meet 
criteria for payment. Our reviewer found that the procedure report does not describe CPT code 20610, 
arthrocentesis performed without ultrasound guidance. In this case this procedure code cannot be verified as 
there is a more appropriate code to report for service provided. Furthermore, CPT code 76942 is being reported 
in addition to CPT code 20610. Ultrasonic guidance would not be reported with a procedure code that 
represents "without ultrasound guidance." There is a more appropriate code to report for arthrocentesis with 
ultrasound guidance. Therefore, these procedures 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 arthrocentesis, aspiration, and/or injection of a major joint or bursa and 
ultrasonic guidance for needle placement have not been met. Therefore, we decided that the Plan does not have 
to pay for arthrocentesis, aspiration, and/or injection of a major joint or bursa (20610) and ultrasonic guidance 
for needle placement (76942) provided on September 22, 2021.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for computed tomography (CT) of the head or brain (70450) provided on October 17, 2021.
You asked the Plan to pay for the CT of the head or brain. You say that you have included supporting records with this request, and this claim is being denied as a duplicate in error. The Plan denied your request. The Plan says that this claim is a duplicate of another claim which was previously submitted.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, while this claim was denied as a duplicate, the Plan did not provide documentation to show that this claim has been submitted twice and that the first claim has been paid. While a repeat submission of a paid claim may be denied as a duplicate, a repeat submission of an unpaid claim would be processed as an appeal. The Plan does not prove that a first submission of this claim has been paid, and they do not give another reason for the denial in this case. Medical records to support this service were provided with the appeal. Therefore, we decided that the Plan has to pay for computed tomography (CT) of the head or brain (70450) provided on October 17, 2021.
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 pre-approve additional routine transportation trips (A0100). 
 
You asked the Plan to pre-approve additional trips. You say that you need more trips to receive your treatments 
3 times per week. The Plan denied your request. The Plan says additional trips beyond the 24 allowed trips per 
year are not covered. 
 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 pre-approve additional routine transportation trips (A0100).