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

 
We decided that the Plan does not have to pre-approve an interim partial denture (D5820), bone replacement 
graft for ridge preservation - per site (D7953), retainer crown - porcelain/ceramic (D6740), pontic - 
porcelain/ceramic (D6245) and guided tissue regeneration - resorbable barrier, per site (D4266). 
 
You asked the Plan to pre-approve the dental services represented by codes D5820, D7953, D6740, D6245, and 
D4266. You say that you have a plastic tooth and now your food is falling in there. You also say that part of 
your mouth is brown and decaying. The Plan denied your request. The Plan says these services are not covered 
under the 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 an 
interim partial denture (D5820), bone replacement graft for ridge preservation - per site (D7953), retainer 
crown - porcelain/ceramic (D6740), pontic - porcelain/ceramic (D6245) and guided tissue regeneration - 
resorbable barrier, per site (D4266).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve mechanical traction therapy (97012). 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says this service is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pre-approve mechanical traction therapy (97012).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an unspecified periodontal procedure, by report (D4999), and 
sinus augmentation with bone or bone substitutes via a lateral open approach (D7951) provided on February 
19, 2019. 
 
You asked the Plan to pay for codes D4999, and D7951. You say that you are asking for reimbursement for 
your sinus lift via oral surgery. The Plan denied your request. The Plan says these are not a covered services 
according to your plan 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 an 
unspecified periodontal procedure, by report (D4999), and sinus augmentation with bone or bone substitutes 
via a lateral open approach (D7951) provided on February 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 94060, 95004, 95024 rendered on June 27, 
2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services 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, the CPT Code Manual definition of the denied codes is: 
 
CPT 94060: 
 
Bronchodilation responsiveness, spirometry as in 94010, pre- and post-bronchodilator administration 
 
CPT 95004: 
 
Percutaneous tests (scratch, puncture, prick) with allergenic extracts, immediate type reaction, including test interpretation and report, specify number of tests 
 
CPT 95024: 
 
Intracutaneous (intradermal) tests with allergenic extracts, immediate type reaction, including test interpretation 
and report, specify number of tests 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the medical record does not 
include enough documentation to confirm that these procedures were performed. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 94060, 95004, 95024 rendered on June 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom fabricated abutment (D6057) and an abutment 
support to crown (D6059) for tooth #6. 
 
You asked the Plan to pre-approve the dental services. You say that you would like the services authorized 
because you have $5,000 of coverage per year and the procedure is covered. The Plan denied your request. The 
Plan says your benefit for the requested items or services 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 authorized 2 implant services on February 14, 2023; therefore, your benefit for the requested 
items or services was exhausted on the date of approval of February 14, 2023. Therefore, we decided that the 
Plan does not have to pre-approve a custom fabricated abutment (D6057) and an abutment support to crown 
(D6059) for tooth #6.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the nitrous oxide (D9230). 
 
You asked the Plan to pre-approve the dental service. You say that you are having sinus issues and the gas is 
needed for pain relief. The Plan denied your request. The Plan says the denial of authorization for this service is 
correct, because the nitrous oxide is not covered by the 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, the requested item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
nitrous oxide (D9230).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Optimizer smart system. 
 
You asked the Plan to pre-approve an Optimizer smart system. 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 an Optimizer smart system. 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 an Optimizer smart system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an Optimizer smart system.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and the refraction provided on October 14, 
2022. 
 
You asked the Plan to pay for the refraction. You say that you are appealing these services. The Plan denied 
your request. The Plan says the service is not a covered benefit. 
 
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 did not pre-approve the 
office visit. We found no exception that would require the Plan to pay for the office visit. 
 
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 these services when provided by network providers. 
 
We looked at the file and the Plan's rules. Specifically, the provider was out-of-network 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 October 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for tooth extractions provided on April 6, 2021, to November 9, 
2021. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the charges and were told differently by the plan. The Plan denied your request. The Plan says the services 
denied correctly as they do not fall within your dental benefits. The record does not indicate you contacted the 
Plan prior to the services rendered to confirm coverage. 
 
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 tooth 
extractions provided on April 6, 2021, to November 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extractions, of an erupted tooth requiring removal of 
bone and/or sectioning of tooth (D7210 x 2) and the bone replacement grafts for ridge preservation-per site 
(D7953 x 2) provided on August 10, 2022. 
 
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 these services are not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  
Though the Plan offers a dental benefit in excess of Medicare coverage, the services provided are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the extractions, 
of an erupted tooth requiring removal of bone and/or sectioning of tooth (D7210 x 2) and the bone replacement 
grafts for ridge preservation-per site (D7953 x 2) provided on August 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal scaling and root planing - four or more teeth per 
quadrant (D4341 x2) provided on July 26, 2022. 
 
You asked the Plan to pay for the dental services. You say that you don't have the funds and would like the 
Plan to help you pay for the services. The Plan denied your request. The Plan says your benefit for the 
requested service $1,400 dollar limit was met. 
 
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 - four or more teeth per quadrant $1,400 dollar 
limit was met on date of service April 11, 2022. Therefore, we decided that the Plan does not have to pay for 
periodontal scaling and root planing - four or more teeth per quadrant (D4341 x2) provided on July 26, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Inflectra. 
 You asked the Plan to pre-approve Inflectra. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Inflectra. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the documentation does not support that 
Enbrel, Humira, Kevzara, Rinvoq, Xeljanz or Xeljanz XR would likely be less effective, and/or would likely 
have adverse effects for the enrollee in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Inflectra have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Inflectra.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on December 7, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were not able to see the dentist for 2 years 
due to COVID-19, so the requested services should be approved. 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 $927 for date of service May 18, 2022, and $573 for date of service August 18, 2022 ($927 
+ $573 = $1,500), therefore, your benefit was exhausted on date of service August 18, 2022. Therefore, we 
decided that the Plan does not have to pay for dental services provided on December 7, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service November 
30, 2022. 
 You asked the Plan to pay for procedure code 70450. You say that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for code 
70496. 
 
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 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. 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 70450 billed for date of service November 30, 
2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76642 billed for date of service September 
29, 2022. 
 You asked the Plan to pay for procedure code 76642. You say that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 76642 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
Based on this information, we decided that Medicare rules for coverage of procedure code 76642 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 76642 billed for date of 
service September 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hearing aids to be rendered by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says there are in-network providers available to render the 
requested items.  
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when purchased through the Plans select hearing aid provider.  
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically, the Plans contract says that coverage is only provided 
for hearing aids purchased through the Plans select hearing aid provider. Therefore, we decided that the Plan 
does not have to pre-approve hearing aids to be rendered 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 pontic (D6245) and a tooth retainer crown (D6750) for 
tooth #26 and #27. 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing the denied dental 
procedures. The Plan denied your request. The Plan says your benefit for the requested items or services 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 approved 4 pontics and tooth retainer crowns on February 18, 2023; therefore, your benefit for 
the requested items or services was exhausted on the date of approval of February 18, 2023. Therefore, we 
decided that the Plan does not have to pre-approve a pontic (D6245) and a tooth retainer crown (D6750) for 
tooth #26 and #27.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the deluxe frames, the deluxe lens, and the anti-reflective 
coating provided on May 16, 2022. 
 
You asked the Plan to pay for the vision items. You say that the clinic is on the list of network providers. The 
Plan denied your request. The Plan says the services are not covered benefits.  
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 does not cover these services. 
 
We looked at the file and the Plan's rules. Specifically, the vision items are not covered benefits. Based on this 
information, we decided that the Plan's rules for coverage of the vision items have not been met. Therefore, we 
decided that the Plan does not have to pay for the deluxe frames, the deluxe lens, and the anti-reflective coating 
provided on May 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6533. 
 
You asked the Plan to pre-approve the compression stockings. You say that the requested item is medically 
necessary. The Plan denied your request. The Plan says the requested item is a non-covered item. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6533 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
  Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6533.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endodontic therapy (D3310). 
 
You asked the Plan to pre-approve the dental services. You say that you would like the Plan to pay for this. The 
Plan denied your request. The Plan says dental services from an out-of-network provider 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. 
 
You are requesting 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 pre-approve endodontic 
therapy (D3310).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hearing aids to be rendered by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says hearing aids rendered by an out-of-network provider are 
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 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 at issue in this appeal. We found no exception that would require the Plan 
to pre-approve these items. Therefore, we decided that the Plan does not have to pre-approve hearing aids to be 
rendered by an out-of-network (OON) provider.