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

 
We decided that the Plan does not have to pre-approve 2D oral/facial photographic image obtained intra-orally 
or extra-orally (D0350), a crown for tooth #21 (D2740), extraction of tooth #6 (D7140), and other drugs and/or 
medicaments (D9630). 
 
You asked the Plan to pre-approve the dental services. You say that the services are necessary. The Plan denied 
your request. The Plan says your benefit for the requested extraction has already been exhausted and the 
remaining requested 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, certain limitations apply. The record 
shows your benefit for the requested extraction was exhausted on date of service July 12, 2022. The additional 
requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan 
does not have to pre-approve 2D oral/facial photographic image obtained intra-orally or extra-orally (D0350), a 
crown for tooth #21 (D2740), extraction of tooth #6 (D7140), and other drugs and/or medicaments (D9630).
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for a porcelain crown on tooth #30 (D2740) provided on March 17, 2022. 
 
You asked the Plan to pay for a crown. You say that you do not understand why this procedure was not covered 
at 50% as stated in the policy. The Plan denied your request. The Plan says that you have been charged the 
correct cost sharing amount for the least costly method of treatment. 
 
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 medical records regarding the crown on tooth #30. 
Without the medical records we are unable to determine if the alternative treatment would produce a 
professionally satisfactory result. Therefore, we decided that the Plan has to pay for a porcelain crown on tooth 
#30 (D2740) provided on March 17, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the tube thoracostomy (32551) provided on September 6, 2021. 
 
You asked the Plan to pay for the tube thoracostomy (32551). You say that CPT code 99232 and 32551 are 
separately payable if a proper modifier is appended. The Plan denied your request. The Plan says procedure 
code 99232 has been overturned. The Plan also says procedure code 32551 is inclusive to procedure code 
32100 and cannot be separately reimbursed. 
 
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 32551 is a column II code to column I code 32100; however, 32551 
was billed with a modifier.  
 
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 tube thoracostomy (32551). Our reviewer says that the 
documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer found the 
operative report does not support CPT 32551 as separate procedure. An open thoracotomy was performed 
during the same session and was not performed in the thoracic cavity contralateral to the primary procedure. 
Therefore, modifier -59 cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the tube thoracostomy (32551) have not been met. Therefore, we decided that 
the Plan does not have to pay for the tube thoracostomy (32551) provided on September 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the guided tissue regeneration (D4266) and bone 
replacement graft for ridge preservation (D7953) provided on March 15, 2022. 
 
You asked the Plan to pay for the guided tissue regeneration and bone replacement graft. You say that you feel 
these services should be covered, as it was the only services that could repair your broken tooth. The Plan 
denied your request. The Plan says the periodontal services are not covered when an extraction has been 
performed. The Plan also says that the bone replacement graft for ridge preservation is not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. The record shows that you received a prior authorization for these 
services that was issued on February 2, 2022, advising you that these services would not be covered. Therefore, 
we decided that the Plan does not have to pay for the guided tissue regeneration (D4266) and bone replacement 
graft for ridge preservation (D7953) provided on March 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gingival irrigation - per quadrant (D4921) and drugs or 
medicaments dispensed in the office for home use (D9630) from October 21, 2021, to November 5, 2021. 
 
You asked the Plan to pay for gingival irrigation - per quadrant (D4921) and drugs or medicaments dispensed 
in the office for home use (D9630). You say that you would like to appeal the denial of the claim. The Plan 
denied your request. The Plan says Dental service codes D4921 and D9630 are not covered under the member's 
contract under any normal circumstances. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not  
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for gingival 
irrigation - per quadrant (D4921) and drugs or medicaments dispensed in the office for home use (D9630) from 
October 21, 2021, to November 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation on March 18, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to appeal the denial of the claim. 
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 Plan's 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 February 11, 2022. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation on March 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 86140 billed on March 17, 2022. 
 
You asked the Plan to pay for procedure code 86140. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says there are no modifiers that could be used to 
bypass the NCCI edit. 
 
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 86140 is a column II code to column I code 86141 with a modifier indicator of 0. The column II code is therefore not 
payable. 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 86140 billed on March 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for TheraSkin application after Mohs surgery for
the enrollee.
You asked the Plan to provide coverage for this treatment. You say that this treatment was medically necessary
for the enrollee. The Plan denied your request. The Plan says Medicare coverage criteria were not met.
Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the
correct coverage criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for the application of
TheraSkin. The Maximus Physician Reviewer determined that Medicare rules for coverage of the application
of TheraSkin were met in this case. TheraSkin was determined to be medically necessary, because of the
specifics of the Mohs procedure. The Plan requested a reopen and argues that TheraSkin is unproven, with
insufficient evidence of efficacy. The enrollee is a 75-year-old man who underwent Mohs procedure on March
7, 2022, for a squamous cell carcinoma on his left ring finger. It is documented that "The defect will heal with
secondary intention." The TheraSkin package insert states the following under the heading Indications For
Use: "TheraSkin may be used in applications for the repair of human skin, including but not limited to, use for
treatment of diabetic foot ulcers, venous leg ulcers, pressure ulcers, dehisced surgical wounds, necrotizing
fasciitis, traumatic burns and radiation burns."
The Plan is correct in this case. There is insufficient clinical evidence in published medical literature to support
that TheraSkin is an effective treatment following Mohs micrographic 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 this treatment have not been met. Therefore, we decided that the Plan does not
have to provide coverage for TheraSkin application after Mohs surgery for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown on tooth #30 (D2740). 
 
You asked the Plan to pre-approve the dental services. You say that you cannot eat properly because your 
crown broke. 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 Plan's 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 25, 2020. 
Therefore, we decided that the Plan does not have to pre-approve a crown on tooth #30 (D2740).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gingival irrigation (D4921) for the upper quadrants. 
 
You asked the Plan to pre-approve gingival irrigation. You say that these services are medically necessary. The 
Plan denied your request. The Plan says these services are not covered by the Plan's dental benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
gingival irrigation (D4921) for the upper quadrants.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an amalgam filling on tooth #19 (D2160). 
 
You asked the Plan to pre-approve the dental services. You say that you disagree with the denial of dental 
services. 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 Plan's 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 February 16, 2022. 
Therefore, we decided that the Plan does not have to pre-approve an amalgam filling on tooth #19 (D2160).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infrared therapy (97026) provided on February 24, 2022. 
 
You asked the Plan to pay for the infrared therapy (97026). You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says infrared therapy is not covered by 
Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that the use of infrared therapy devices and any 
related accessories are not reasonable and necessary.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the infrared therapy have not been met. Specifically, infrared therapy is not covered by Medicare. Therefore, we decided that the Plan does not have to pay for the infrared therapy (97026) provided on February 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a partial lower 
denture (D5214). 
 
You asked the Plan to pre-approve the dental items. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says your benefit for the requested items 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 was exhausted on date of service July 7, 2020. Therefore, we 
decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a partial lower 
denture (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cone beam CT capture (D0364) provided on March 29, 2022. 
 
You asked the Plan to pay for the cone beam CT capture (D0364). You say that you would like to appeal the 
denial of the claim. The Plan denied your request. The Plan says the limited oral evaluation (D0140) has been 
paid. The Plan also says the cone beam CT capture (D0364) remains denied as a non-covered benefit. 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 cone beam CT capture (D0364) is 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a 
beam CT capture (D0364) on March 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve complete denture - maxillary (D5110). 
 
You asked the Plan to pre-approve complete denture - maxillary (D5110).. You say that you would like to 
appeal the denial of the claim. The Plan denied your request. The Plan says this benefit includes service D5110 
but it is only covered when there are no erupted teeth remaining in the mouth. X-rays reviewed from the 
provider show the member has erupted teeth. 
 
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 when erupted teeth remain in the mouth. Therefore, we decided that the 
Plan does not have to pre-approve complete denture - maxillary (D5110).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical dental extractions (41899) provided by a 
participating provider. 
 
You asked the Plan to pre-approve surgical dental extractions. You say that this has been an on-going issue, 
and you would like it resolved, The Plan denied your request. The Plan says the requested 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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
surgical dental extractions (41899) provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal scaling and root planing (D4341 x 2) provided 
on March 2, 2022, and periodontal scaling and root planing (D4341 x 2) provided on March 16, 2022. 
 
You asked the Plan to pay for periodontal scaling. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says that periodontal scaling and root planing is not covered by your 
supplemental dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
periodontal scaling and root planing (D4341 x 2) provided on March 2, 2022, and periodontal scaling and root 
planing (D4341 x 2) provided on March 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (36415, 74022, 74176, 80053, 81003, 83690, 
85025, 87040, 87086, 96365, and 99284) provided on August 15, 2021. 
 
You asked the Plan to pay for the services. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. The file shows that the enrollee was treated as inpatient on dates of 
service August 16, 2021, through August 17, 2021. The services provided in this case were included in the 
inpatient payment. Therefore, we decided that the Plan does not have to pay for the services (36415, 74022, 
74176, 80053, 81003, 83690, 85025, 87040, 87086, 96365, and 99284) provided on August 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the 2D oral/facial photographic image (D0350) provided on 
April 5, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit under 
your contractual policy. 
 
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 service provided is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 2D oral/facial 
photographic image (D0350) provided on April 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pontic on tooth #3 and 5 (D6242) and retainer crowns 
on tooth #4 and 6 (D6752). 
 
You asked the Plan to pre-approve pontics and crowns. You say that it is not advisable to do a removable 
denture for two missing teeth. The Plan denied your request. The Plan says that the documentation does not 
show why a denture cannot be used to replace the missing teeth. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers pontics and 
crowns when the services are medically necessary and reasonable.  
 
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 pontics and crowns. Our reviewer says 
that the coverage criteria has not been met. Our physician reviewer found that in the records provided there is 
no documentation of a disorder that would preclude the use of a removable appliance. In this instance, the 
missing teeth (2,3 and 5) could be replaced by a removable appliance. We looked at this physician's review, 
the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of pontics and crowns have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a pontic on tooth #3 and 5 (D6242) and retainer crowns on tooth #4 and 6 (D6752).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone graft at time of implant placement (D6104). 
 
You asked the Plan to pre-approve a bone graft. You say that this service is necessary. The Plan denied your 
request. The Plan says this service is not covered under the enrollee's 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 bone 
graft at time of implant placement (D6104).