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

 
We decided that the Plan does not have to pay for the radiology services provided on July 30, 2021. 
 
You asked the Plan to pay for the services provided. You say that the primary code was submitted under a 
different claim. The Plan denied your request. The Plan says the qualifying service has not been received. 
 
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 76937 is ultrasound guidance for vascular access 
requiring ultrasound evaluation of potential access sites, documentation of selected vessel patency, concurrent 
real time ultrasound visualization of vascular needle entry, with permanent recording and reporting (List 
separately in addition to code for primary procedure).  
 The CPT Code Manual definition of code 77001 is fluoroscopic guidance for central venous access device 
placement, replacement (catheter only or complete), or removal (includes fluoroscopic guidance for vascular 
access and catheter manipulation, any necessary contrast injections through access site or catheter with related 
venography radiologic supervision and interpretation, and radiographic documentation of final catheter 
position) (List separately in addition to code for primary procedure), 
 
We find that CPT codes 77001 and 76937 are not supported. The codes at issue were not billed with a primary 
procedure. Based on this information, we decided that Medicare rules for coverage have not been met. 
Therefore, we decided that the Plan does not have to pay for the radiology services provided on July 30, 2021.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve 2 fractions of multi-fraction cranial stereotactic radiosurgery 
(SRS) image guided radiation therapy. 
 
You asked the Plan to pre-approve 2 fractions of multi-fraction cranial SRS image guided radiation therapy. 
You say that the services are necessary. The Plan denied your request. The Plan says that medical necessity has 
not been established. Therefore, coverage criteria have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 2 fractions of multi-fraction cranial 
SRS image guided radiation therapy. Our reviewer says that the requested items/services are considered 
medically reasonable and necessary in this case. Our physician reviewer found this treatment is within accepted 
standards of medical practice for patients with medically refractory obsessive-compulsive disorder (OCD) and 
major depression and is medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 2 fractions of multi-fraction cranial SRS image guided radiation therapy have 
been met. Therefore, we decided that the Plan has to pre-approve 2 fractions of multi-fraction cranial 
stereotactic radiosurgery (SRS) image guided radiation therapy.  
 
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 the limited oral evaluation (D0140), provided on 
November 23, 2021. 
 
You asked the Plan to pre-approve the limited oral evaluation. You say that the service should be covered. 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. Specifically, this service is not listed in the Plan's benefit chart. 
Therefore, we decided that the Plan does not have to pre-approve the limited oral evaluation (D0140), provided 
on November 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction (D7140), and limited oral evaluation (D0140), 
provided on December 6, 2021. 
 
You asked the Plan to pay for the extraction and limited oral evaluation. You say that the services should be 
covered. The Plan denied your request. The Plan says these are not covered services. 
 
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. Specifically, the services received are not listed in the Plan's benefit 
chart.  Therefore, we decided that the Plan does not have to pay for the extraction (D7140), and limited oral evaluation 
(D0140), provided on December 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for the 2-surface filling (D2392), core 
build up (D2950 x 5), crown (D2751), and 1-surface filling (D2330 x 3) provided from November 3, 2021, to 
December 15, 2021. 
 
You asked the Plan to pay an additional amount for the dental services. You say that you were having issues 
with your crowns. You say that you should not be responsible for the providers screw ups. You say that you 
tried to straighten things out with the office. You say that they were dismissive and rude. You also say that you 
feel like you were taken advantage of because of your age. The Plan denied your request. The Plan says there is 
a 50% coinsurance for comprehensive dental services. The Plan also says that the claim processed 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 and the fillings and crowns are listed as 
covered, there is a 50% coinsurance that applies to comprehensive dental services. This is a contractual 
obligation you agreed to when you enrolled in the Plans dental coverage. Therefore, we decided that the Plan 
does not have to pay an additional amount for the 2-surface filling (D2392), core build up (D2950 x 5), crown 
(D2751), and 1-surface filling (D2330 x 3) provided from November 3, 2021, to December 15, 2021.  
 
Your complaint about being taken advantage of by the dental office 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 reimburse you for the core build up (D2950), porcelain crown 
(D2740), and filling (D2394) provided on April 21, 2021. 
 
You asked the Plan to reimburse you for the dental services. You say that it is your understanding that you 
2021 dental coverage included $2,000, no matter what the work or who the dentist is. You say that in the past 
you were reimbursed 50% for dental services. You also say that you have not received reimbursement for the 
services in this case. The Plan denied your request. The Plan says core build up and porcelain crown are not 
listed as covered services. The Plan also says that you pay a 50% coinsurance for fillings received out of 
network. 
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 core build up and crown are not 
among those covered under this benefit. Additionally, you pay 50% coinsurance for fillings received in 
network. This is a contractual obligation you agreed to when you enrolled in the Plan's dental coverage. 
Therefore, we decided that the Plan does not have to reimburse you for the core build up (D2950), porcelain 
crown (D2740), and filling (D2394) provided on April 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral hygiene instructions (D1330) and nutritional 
counseling for control of dental disease (D1310) provided on December 14, 2021. 
 
You asked the Plan to pay for the oral hygiene instructions and nutritional counseling. You say that your dental 
plan is a joke because every time you go to the dentist, nothing is paid. The Plan denied your request. The Plan 
says oral hygiene instructions is not a covered benefit under your dental plan. The Plan also says that the 
nutritional counseling 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 Plan's coverage rules apply in this case. 
Though the Plan offers a dental benefit in excess of Medicare coverage, oral hygiene instructions (D1330) are 
not among those covered under this benefit. The contract says that nutritional counseling for control of dental 
disease (D1310) is limited to one procedure per plan year. The record shows that you received nutritional 
counseling for control of dental disease (D1310) on April 29, 2021 and your nutritional counseling for control 
of dental disease (D1310) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay 
for the oral hygiene instructions (D1330) and nutritional counseling for control of dental disease (D1310) 
provided on December 14, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient hospital services. 
 
You asked the Plan to pre-approve inpatient hospital services. You say that these services are medically 
necessary. The Plan denied your request. The Plan says that there is no documentation provided to support the 
expectation you will require a greater than 2 midnight stay. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve inpatient hospital services. Our 
reviewer says that inpatient hospital services are not medically reasonable and necessary. You are undergoing a 
planned lumbar laminectomy. You are medically stable and have been provided medical clearance to undergo 
this elective procedure. The planned procedure is not listed on the Inpatient Only List. The procedure is 
currently approved as an ambulatory procedure. There is no documentation provided to support the expectation 
that you will require a greater than 2 midnight stay. Our physician reviewer found that your condition does not 
meet Medicare criteria for inpatient hospital services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient hospital services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve inpatient hospital services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periapical first radiographic images (D0220), and 
palliative treatment (D9110), provided on October 4, 2021. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered. The Plan denied 
your request. The Plan says non-network dentists have not agreed to provide services at contracted fees. If you 
see an out-of-network dentist, the coinsurance level will apply to the average negotiated in-network fee 
schedule (INFS) in your area. You are responsible for the difference between the INFS and dentists' charged 
fees when visiting an out-of-network dentist. 
 
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 
periapical first radiographic images (D0220), and palliative treatment (D9110), provided on October 4, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Folic acid (82746) Magnesium (83735) Serum Iron Studies 
(82728) cyanocobalamin, vitamin B-12 (82607) provided August 5, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you have attached the medical records for 
review to show and support medical necessity. Please reprocess this claim. The Plan denied your request. The 
Plan says these services are not covered by Medicare. 
 
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 find that CPT codes 82607, 82728, 82746 and 83735 are not supported in the medical record. Specifically, these codes are not a benefit for the diagnoses listed on the claim and are done for screening 
purposes. Tests with no relation to a diagnosis for the health of a patient are not a benefit. 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 Folic acid (82746) Magnesium (83735) Serum 
Iron Studies (82728) cyanocobalamin, vitamin B-12 (82607) provided August 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the guided tissue regeneration (D4266) and osseous, 
osteoperiosteal, or cartilage graft (D7950) provided on December 8, 2021. 
 
You asked the Plan to pay for the guided tissue regeneration and osseous, osteoperiosteal, or cartilage graft. 
You say that you have experienced many dental issues over the past few decades and have not been able to 
afford treatment or pay your existing dental bills due to financial difficulties. You also say that you would like 
this claim to be reviewed and the charges applied as your responsibility to be removed. The Plan denied your 
request. The Plan says you fully exhausted your $1,600.00 ($400.00 x 4) comprehensive dental allowance for 
the 2021 calendar year. 
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 Plan offers up to a $400.00 
allowance for covered comprehensive dental services every quarter. The contract says that after plan paid 
benefits for comprehensive dental services, you are responsible for the remaining costs. The record shows that 
you met the annual maximum benefit on October 25, 2021 and your annual maximum benefit has been 
exhausted. Therefore, we decided that the Plan does not have to pay for the guided tissue regeneration (D4266) 
and osseous, osteoperiosteal, or cartilage graft (D7950) provided on December 8, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room services provided on October 2, 2021. 
 
You asked the Plan to pay for the services provided. You say that the records support the procedures. The Plan 
denied your request. The Plan says the documentation does not support additional services. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
The file shows that the enrollee received an electrocardiogram during an emergency room visit. We looked at 
the file and the rules. The records show that the services were previously billed and paid for on a separate 
claim. There is no documentation indicated that additional services were provided to the enrollee.  
 
 Based on this information, we decided that Medicare rules for coverage of the services provided have not been 
met. Therefore, we decided that the Plan does not have to pay for the emergency room services provided on 
October 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implants (D6010 x 6), implant supported crowns 
(D6065 x 6), and prefabricated abutments (D6056 x 6). 
 
You asked the Plan to pre-approve the dental services. You say that you have no teeth in the back part of your 
mouth. You say that you have problems eating. You also say that you cannot eat well and are losing weight. 
The Plan denied your request. The Plan says implants are covered when a single tooth is missing per arch. The 
Plan says that there are more than 1 tooth missing per arch and therefore are not covered. The Plan also says 
that since the implants are not covered, the related abutments and implant supported crowns are not covered 
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, implants are not covered when there 
are more than 1 tooth missing per arch. Additionally, because the implants are not covered, the related implant 
services are not covered either. Therefore, we decided that the Plan does not have to pre-approve implants 
(D6010 x 6), implant supported crowns (D6065 x 6), and prefabricated abutments (D6056 x 6).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided at 24-hour facility, in addition to basic 
service (99053) provided on September 4, 2021. 
 
You asked the Plan to pay for the services provided at 24-hour facility, in addition to basic service (99053). 
You say that all medical records have been attached and your coders show all 3 key components met. You say 
that the claim should be reviewed and reprocessed to pay. The Plan denied your request. The Plan says CPT 
code 99285 was approved and CPT code 99053 remains denied as bundled services are not eligible for separate 
payment. 
 
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 99053 is service(s) provided between 10:00 PM and 8:00 
AM at 24-hour facility, in addition to basic service. 
 
We find that CPT code 99053 is not supported in the medical record. Specifically, CPT code 99053 has a status 
indicator of B. This means that CPT code 99053 is considered bundled and not separately payable. Based on 
this information, we decided that Medicare rules for coverage of the services provided at 24-hour facility, in 
addition to basic service (99053) have not been met. Therefore, we decided that the Plan does not have to pay 
for the services provided at 24-hour facility, in addition to basic service (99053) provided on September 4, 
2021.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your 
request. The Plan says that based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
services are medically necessary. Our physician reviewer found you did not have documented skilled nursing 
needs. You did have documented skilled therapy needs. You were functioning below your baseline. Daily 
skilled services were required to establish a maintenance program or to prevent deterioration of your condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oral hygiene instruction (dental code D1330) you received on 
July 27, 2021. 
 
You asked the Plan to pay for code D1330. You say that you were told that your dental work would be covered 
in full. The Plan denied your request. The Plan says this service is not covered under your dental benefits. All 
of the other dental services you received have been paid. 
 
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's dental benefit 
includes coverage only for those dental codes explicitly listed in your dental benefits chart. Code D1330 is not 
listed as a covered service in this chart. 
 
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 oral 
hygiene instruction (dental code D1330) you received on July 27, 2021.