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

 
We decided that the Plan does not have to pre-approve gum medication and a periodontal procedure (D4999, 
D4381) 
 
You asked the Plan to pre-approve the gum medication and a periodontal procedure. You say that the services 
should be covered as you disagree with the denial. The Plan denied your request. The Plan says the services 
denied correctly as they do not fall within your dental 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 gum 
medication and a periodontal procedure (D4999, D4381)
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve Infuse BMP-2 Allograft (CPT code 20931). 
 
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says that the clinical value and effectiveness of the Infuse BMP-2 Allograft in the setting of 
posterior lumbar spine fusion surgery have not been demonstrated in the peer-reviewed literature. 
 
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 the service. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found there is some literature to support the use of BMP in revision surgery in the posterior spine to 
lessen the scope of the surgery. It should be approved in this particular 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 the service have been met. Therefore, we decided that the Plan has to pre-
approve Infuse BMP-2 Allograft (CPT code 20931).  
 
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found clinical documentation shows that the enrollee has functional impairments and evaluating therapists do recommend intensive therapy. However, there are no listed active comorbidities or hospital complications that would require close medical monitoring on an inpatient basis during rehabilitation.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service November 
16, 2021. 
 You asked the Plan to pay for procedure code 99100. You say that you disagree with the denial. The Plan 
denied your request. The Plan says procedure code 99100 is considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service November 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two guided tissue regenerations (D4266 x2) and two 
bone replacement grafts for ridge preservation (D7953 x2). 
 
You asked the Plan to pre-approve the guided tissue regenerations and bone replacement grafts. You say that 
you believe these services are necessities, not cosmetic, and are part of your livelihood. The Plan denied your 
request. The Plan says these services are not covered under 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, 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 two 
guided tissue regenerations (D4266 x2) and two bone replacement grafts for ridge preservation (D7953 x2).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 85018, 85014, 85027 and 85049 billed for 
date of service March 5, 2019. 
 
You asked the Plan to pay for procedure codes 85018, 85014, 85027 and 85049. You say that you would like 
this claim reprocessed and approved for payment. The Plan denied your request. The Plan says payment for 
codes 85018, 85014, 85027 and 85049 is bundled into payment for code 85025. 
 
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 codes 
85018, 85014, 85027 and 85049 are column II codes to column I code 85025. 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 codes 85018, 85014, 
85027 and 85049 billed for date of service March 5, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on May 24, 2022. 
 
You asked the Plan to pay for the dental services. You say that you contacted the providers office, and you 
were told they accepted your plan, and they are in-network. The Plan denied your request. The Plan says the 
dental services were received from an out-of-network provider and are not covered by your supplemental 
benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested dental services are not covered under this 
benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have to 
pay for dental services provided on May 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prophylaxis (D1110), resin-based composites (D2331 and 
D2392), and a periodic oral evaluation (D0120), provided by an out-of-network provider on April 10, 2022, to 
May 10, 2022. 
 
You asked the Plan to pay for the dental services. You say that these services should be covered. You say that 
you have been going to this dentist for years. The Plan denied your request. The Plan says the dental services 
were received from an out-of-network provider and are not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for prophylaxis (D1110), resin-based composites (D2331 and D2392), and a periodic oral evaluation 
(D0120), provided by an out-of-network provider on April 10, 2022, to May 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on April 12, 2022. 
 
You asked the Plan to pay for the lab services. You say that the lab tests for prescribed drugs and drugs of 
abuse. The Plan denied your request. The Plan says the code is not separately reimbursed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 We looked at the file and Medicare rules. We find that the testing described by billed code 83789 is considered 
specimen validity testing which is not separately payable. Based on this information, we decided that Medicare 
rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to 
pay for the lab services provided on April 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete denture - mandibular (D5120), complete denture 
- maxillary (D5110), and unspecified removable prosthodontic procedure (D5899) provided on May 24, 2022. 
 
You asked the Plan to pay for the dental services. You say that you went to the provider, they pulled all of your 
teeth and gave you a pair of teeth that were good for only six months. You say that you asked the Plan if you 
could go to another dental practice and they said yes. The Plan denied your request. The Plan says your benefit 
for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service October 25, 2021. 
Therefore, we decided that the Plan does not have to pay for a complete denture - mandibular (D5120), 
complete denture - maxillary (D5110), and unspecified removable prosthodontic procedure (D5899) provided 
on May 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2740) and a core build-up (D2950) provided by 
an out-of-network provider on May 5, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were told that the provider accepted your 
insurance. The Plan denied your request. The Plan says the dental services were received from an out-of-
network provider and are not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a crown (D2740) and a core build-up (D2950) provided by an out-of-network provider on May 5, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on January 24, 2022. 
 
You asked the Plan to pay for the services provided. You say that the lab tests for prescribed drugs and drugs of 
abuse. The Plan denied your request. The Plan says the test cannot be separately reimbursed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 We looked at the file and Medicare rules. We find that the testing described by billed code 83789 is considered 
specimen validity testing which is not separately payable. 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 lab services provided on January 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lower partial denture (D5214) provided on June 2, 2022. 
 
You asked the Plan to pay for lower partial denture (D5214). You say that you are on a fixed income, and you 
are unable to pay for dental services. The Plan denied your request. The Plan says this service is not covered 
under your 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for lower 
partial denture (D5214) provided on June 2, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the OsteoCel Allograft (CPT code 20930). 
 
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says the clinical value and effectiveness of the OsteoCel Allograft in the setting of a lumbar 
spine fusion surgery have not been demonstrated in the peer-reviewed literature. 
 
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 the service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found Osteocell allograft is experimental for use in spine surgery. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the OsteoCel Allograft (CPT code 20930).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a resin-based composite (D2391 and D2393), bitewings 
(D0270), and an intraoral image (D0220), provided by an out-of-network provider on April 20, 2022. 
 
You asked the Plan to pay for the dental services. You say that these services should be covered. The Plan 
denied your request. The Plan says the dental services were received from an out-of-network provider and are 
not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have to pay for a resin-based composite (D2391 and D2393), bitewings (D0270), and an intraoral image (D0220), 
provided by an out-of-network provider on April 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mass spectrometry and tandem mass spectrometry (83789) 
billed for date of service December 22, 2021. 
 
You asked the Plan to pay for mass spectrometry services. You say that these services were necessary and are 
supported in the medical record. The Plan denied your request. The Plan says they have agreed to pay for the 
drug testing services (G0481, 80307); however, code 83789 is not separately payable in this case. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of mass spectrometry services have not been met. Specifically, we find that the testing described by 
the billed code is considered specimen validity testing which is not separately payable. Therefore, we decided 
that the Plan does not have to pay for mass spectrometry and tandem mass spectrometry (83789) billed for date 
of service December 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the fixed partial denture sectioning for the upper right 
quadrant (D9120) to be provided by a network provider. 
 
You asked the Plan to pre-approve the fixed partial denture sectioning for the upper right quadrant (D9120). 
You say that you received a denial for this service and would like to know if the service can be approved. The 
Plan denied your request. The Plan says the service is 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 fixed partial denture sectioning for 
the upper right quadrant (D9120) is not among those covered under this benefit. Therefore, we decided that the 
Plan does not have to pre-approve the fixed partial denture sectioning for the upper right quadrant (D9120) to 
be provided by a network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and a complete 
mandibular denture (D5120). 
 
You asked the Plan to pre-approve the complete dentures. You say that when you received your current 
dentures they did not fit, and they have been fixed twice but still do not fit The Plan denied your request. The 
Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service March 26, 2019. 
Therefore, we decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and a 
complete mandibular denture (D5120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two surgical placements of implant bodies: endosteal 
implants (D6010 x2), two prefabricated abutments (D6056 x2), two bone grafts at time of implant placement 
(D6104 x2), mandibular implant/abutment supported removable denture for edentulous arch (D6111), 
comprehensive oral evaluation (D0150), and complete series of intraoral x-rays (D0210). 
 
  You asked the Plan to pre-approve the endosteal implants, prefabricated abutments, bone grafts, mandibular 
implant/abutment supported removable denture, comprehensive oral evaluation, and complete series of 
intraoral x-rays. You say that you feel the Plan should approve coverage for these services. The Plan denied 
your request. The Plan says endosteal implants, prefabricated abutments, bone grafts, and mandibular 
implant/abutment supported removable denture are not covered under your benefit package. The Plan also says 
the comprehensive oral evaluation and complete series of intraoral x-rays exceed the maximum counts allowed 
per period. 
 
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, surgical placement of implant body: 
endosteal implant (D6010), prefabricated abutment (D6056), bone graft at time of implant placement (D6104), 
and mandibular implant/abutment supported removable denture for edentulous arch (D6111) are not among 
those covered under this benefit. The contract says that comprehensive oral evaluation (D0150) and complete 
series of intraoral x-rays (D0210) are each limited to one procedure every three plan years. The record shows 
that you exhausted these benefits on October 2, 2019. Therefore, we decided that the Plan does not have to pre-
approve two surgical placements of implant bodies: endosteal implants (D6010 x2), two prefabricated 
abutments (D6056 x2), two bone grafts at time of implant placement (D6104 x2), mandibular implant/abutment 
supported removable denture for edentulous arch (D6111), comprehensive oral evaluation (D0150), and 
complete series of intraoral x-rays (D0210).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cone beam imaging (D0365, D0366, D0367). 
 
You asked the Plan to pay for imaging. You say that you disagree with the denial of dental services. The Plan 
denied your request. The Plan says cone beam imaging (D0365, D0366, D0367) is not covered by your dental 
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 cone 
beam imaging (D0365, D0366, D0367).