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

 
We decided that the Plan does not have to pay for a periapical x-ray on tooth #7 (D0220) provided on May 25, 
2022. 
 
You asked the Plan to pay for an x-ray. You say that this service is medically necessary. The Plan denied your 
request. The Plan says a periapical x-ray (D0220) 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 a 
periapical x-ray on tooth #7 (D0220) provided on May 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral imaging (D0230) and a re-cemented crown (D2920) 
provided by a participating provider on May 16, 2022, to May 17, 2022. 
 
You asked the Plan to pay for intraoral imaging (D0230) and a re-cemented crown. You say that due to the 
hard scrapping down at the dentist, your crown popped off. You say that you had to go back and have the 
crown put back on. The Plan denied your request. The Plan says D2920 is not a covered benefit. The Plan says 
that the benefit limit for D0230 has already been met and 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, D2392 is not among those covered 
under this benefit. Two intraoral images were provided on May 16, 2022. The first intraoral image was paid. 
The second provided was correctly denied. Therefore, we decided that the Plan does not have to pay for 
intraoral imaging (D0230) and a re-cemented crown (D2920) provided by a participating provider on May 16, 
2022, to May 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a light kit, enhanced steering, a universal headrest 
adapter and a retractable adjustable height panel bracket (K0108). 
 
You asked the Plan to pre-approve wheelchair accessories. You say that a letter of medical necessity states, the 
light kit is required for the enrollee's safety in dimly lit areas and when outdoors for safety; the enhanced 
steering is programmed by Permobil to give the wheelchair optimal performance with individual adaptations; 
the universal headrest adapter is to allow compatibility of headrest with chair; and the adjustable height panel 
bracket is joystick mounting hardware that can position the joystick and allow it to be cleared from the front of 
the armrest without tools or trouble preserving all functionality of the retractable joystick mount. The Plan 
denied your request. The Plan says the items requested for the enrollee are primarily not medical in nature and 
remain denied due to lack of medical necessity. 
 The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 wheelchair accessories. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found the enrollee requires a power 
wheelchair for mobility and performing his daily activities. However, the requested additional components and 
parts are primarily for convenience and not medical in nature. A wheelchair light kit is not medically necessary 
for operation of the power wheelchair in the home and an adjustable height panel bracket is for convenience. 
There are already components approved for the enrollees power wheelchair headrest and the vendor should 
provide a manual wheelchair that steers and handles in an optimized and safe manner at baseline. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of wheelchair accessories have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a light kit, enhanced steering, a universal headrest adapter and a retractable 
adjustable height panel bracket (K0108).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shower chair and over the bed adjustable height table 
received on from February 7, 2022, to February 14, 2022. 
 
You asked the Plan to pay for the shower chair and over the bed adjustable height table. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says the items received are not a 
covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs and over-bed tables are not 
covered because they are not primarily medical in nature.  
 While a shower chair and over-bed table may have been appropriate in this case, neither the Plan nor Medicare 
offers coverage of this item. Therefore, we decided that the Plan does not have to pay for the shower chair and 
over the bed adjustable height table received on from February 7, 2022, to February 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve reline complete maxillary denture (indirect) (D5750). 
 
You asked the Plan to pre-approve the dental services. You say that your dentures need to be realigned 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 May 20, 2020.  
 
 
 
 
 
  
Therefore, we decided that the Plan does not have to pre-approve reline complete maxillary denture (indirect) 
(D5750).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), and a complete 
series of radiographic images (D0210) provided by a participating provider on June 6, 2022. 
 
You asked the Plan to pay for the dental services. You say that you believe the Plan should pay for this. 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 April 8, 2021. Therefore, 
we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), and a complete 
series of radiographic images (D0210) provided by a participating provider on June 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an endosteal implant (D6010) provided a participating 
provider on July 5, 2022. 
 
You asked the Plan to pay for an endosteal implant. You say that you do not understand why you are being 
charged for this. The Plan denied your request. The Plan says the rendered dental work 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 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 
endosteal implant (D6010) provided by a participating provider on July 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital discharge day management services coded 
99239 provided on August 24, 2021. 
 
You asked the Plan to pay for the hospital discharge day management services. You say that you disagree with 
the Plan's denial. The Plan denied your request. The Plan says the services billed are not supported by the 
documentation. 
 
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 99239 is hospital discharge day management; more than 
30 minutes. 
 
We find that CPT code 99239 is not supported in the medical record. Specifically, the documentation submitted 
did not include a hospital discharge day management note with a recorded duration of time of 31 minutes or 
more for this billed date of service. Based on this information, we decided that Medicare rules for coverage of 
the hospital discharge day management services have not been met. Therefore, we decided that the Plan does 
not have to pay for the hospital discharge day management services coded 99239 provided on August 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2740) provided by a participating provider on 
May 19, 2022. 
 
You asked the Plan to pay for a crown. You say that you feel like this should be covered. The Plan denied your 
request. The Plan says the rendered dental work 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 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 crown 
(D2740) provided by a participating provider on May 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on August 12, 2021 billed with 
codes 81206, 81162, and 81311. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are not separately payable. 
 The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
August 12, 2021 billed with codes 81206, 81162, and 81311.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the lab testing services provided on November 29, 2021. 
 
You asked the Plan to pay for the testing services. You say that the procedures were considered reasonable and 
necessary at the time of service. The Plan denied your request. The Plan says that panels of 6 or more 
pathogens are non-covered. 
 
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. 
 
We looked at the file and the rules. The Plan denied the service based on a CMS rule/guidance. However, the 
Plan did not identify what rule they used in their decision to deny services. There is no way to confirm if the 
rule the Plan used has jurisdiction where the services were provided. The Plan has not made reasonable and 
diligent efforts to gather and forward to us information regarding their decision to deny your request.  
Therefore, we decided that the Plan has to pay for the lab testing services provided on November 29, 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 pay for a partial mandibular denture (D5226) provided on July 25, 
2022. 
 
You asked the Plan to pay for a partial denture. You say that you only have four lower teeth, and it is hard to 
eat. The Plan denied your request. The Plan says a partial mandibular denture (D5226) 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 a partial 
mandibular denture (D5226) provided on July 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an endodontic therapy premolar tooth (D3320) provided by a 
participating provider on June 14, 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 your maximum dental allowance amount of $1,000 has 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 June 14, 2022, with the 
Plan paying $23 to complete the maximum dental allowance amount of $1,000. The remaining balance for June 
14, 2022, is the enrollees responsibility. Therefore, we decided that the Plan does not have to pay for an 
endodontic therapy premolar tooth (D3320) provided by a participating provider on June 14, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for a comprehensive oral evaluation (D0150) and an extraction (D7210) 
provided on February 21, 2022. 
 
You asked the Plan to pay for an evaluation and extraction. You say that you disagree with the denial of dental 
services. The Plan denied your request. The Plan says that your annual dental maximum has been met. 
 
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. The Plan did not provide documentation showing your annual dental maximum 
amount has been met. Therefore, we decided that the Plan has to pay for a comprehensive oral evaluation 
(D0150) and an extraction (D7210) provided on February 21, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a prefabricated abutment (D6056) and an abutment 
supported crown (D6058) provided by a participating provider on April 4, 2022, to April 25, 2022. 
 
You asked the Plan to pay for a prefabricated abutment and an abutment supported crown. You say that you 
believe you should only be responsible for a 50% coinsurance. The Plan denied your request. The Plan says the 
rendered dental services are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a 
prefabricated abutment (D6056) and an abutment supported crown (D6058) provided by a participating 
provider on April 4, 2022, to April 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an oral evaluation and intraoral x-ray (D0140, D0431) and a 
gingival irrigation and periapical x-ray (D0220, D4921) provided on June 15, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your benefit for the requested item or service 
(D0140, D0431) has already been exhausted and gingival irrigation and periapical x-rays (D0220, D4921) 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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service March 28, 2022. 
Therefore, we decided that the Plan does not have to pay for an oral evaluation and intraoral x-ray (D0140, 
D0431) and a gingival irrigation and periapical x-ray (D0220, D4921) provided on June 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core buildup (D2950) on February 22, 2022. 
 
You asked the Plan to pay for core buildup (D2950). You say that you would like to request reconsideration of 
the denied claim. The Plan denied your request. The Plan says core buildup does not meet criteria because the 
enrollee did not have a claim history showing she had a root canal. 
 
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 Plan covers core buildup 
(D2950) when the services are medically necessary and reasonable.  
 
Based on this information, we decided that the Plan's rules for coverage of core buildup (D2950) have not been 
met. Therefore, we decided that the Plan does not have to pay for core buildup (D2950) on February 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 16, 2021, billed 
with codes 81206, 81162, 81292, 81301 and 81311. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says the claim has not been billed in accordance 
with Medicare billing regulations. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
February 16, 2021, billed with codes 81206, 81162, 81292, 81301 and 81311.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical placement of implant body (D6010), the surgical 
removal of implant body (D6100), the extractions (D7210 and D7310), anesthesia (D9222 and D9223), and 
therapeutic drugs (D9612) provided on February 10, 2022, and March 31, 2022. 
 
You asked the Plan to pay for the dental services. You say that it was necessary to have these procedures done. 
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 your benefit for the requested items or services was exhausted on the date of service of February 10, 
2022. Therefore, we decided that the Plan does not have to pay for the surgical placement of implant body 
(D6010), the surgical removal of implant body (D6100), the extractions (D7210 and D7310), anesthesia 
(D9222 and D9223), and therapeutic drugs (D9612) provided on February 10, 2022, and March 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 82435, 84132, and 84295 billed for date of 
service February 11, 2022. 
 
You asked the Plan to pay for procedure codes 82435, 84132, and 84295. You say that you have provided 
documentation to support payment. The Plan denied your request. The Plan says payment for codes 82435, 
84132, and 84295 is bundled into payment for code 80051. 
 
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 
82435, 84132, and 84295 are column II codes to column I code 80051. 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 82435, 84132, and 84295 
billed for date of service February 11, 2022.