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

 
We decided that the Plan does not have to pre-approve dental services (D2751, D5213, D5214). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the services exceed benefit limitations and are not medically necessary. 
 
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 the services 
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 the services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found the records do not 
indicate there is any significant structural loss on tooth #7, and as such there would be no rationale for 
placement of a crown on tooth #7.  Crowns are reserved for situations where the tooth has such significant 
damage that it requires the strength of full coverage to function properly.  The partial dentures may or may not 
require replacement, as it is unclear as to what attempts were made to adjust the appliances to make them 
functional.  If there has been shifting of the teeth such that the frameworks no longer work, then new appliances 
would be indicated, although coverage may not be available under insurance contracts. The plan 
provides that "Dentures (partial, full, immediate) are limited to one set every five (5) years." It also provides 
that crowns are considered where there are four or more surfaces involved and at least 50% of the incisal 
edge. In this instance there was an insignificant noted loss of structure on tooth #7 as evidenced on x-ray, and 
no clear involvement of the incisal edge.  There would be no clear necessity for a crown restoration for tooth 
#7. The 5 year limitation for replacement of partial dentures would make the member ineligible for a 
replacement set of appliances as the prior set were fabricated in 2018. 
 
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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve dental services (D2751, D5213, D5214).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the portion of the genetic testing provided on October 12, 
2021, described by 81479. You asked the Plan to pay for the testing described by code 81479. You say that 
this was medically necessary testing. The Plan denied your request. The Plan says the claim is billed with 
an inappropriate POS code. As such, only 5 out of the 6 billed codes are approved for payment. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the testing described by code 81479 have not been met. Specifically, this claim was billed with the 
laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, 
we decided that the Plan does not have to pay for the portion of the genetic testing provided on October 12, 
2021, described by 81479.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a battery back backup (E1399). 
 
You asked the Plan to pre-approve a battery back backup. You say that the patient alleges that there are 
frequent electric power shortages at home for which she cannot use the CPAP treatment as indicated. The Plan 
denied your request. The Plan says a battery backup is not covered under the enrollee's contract. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
You are requesting a battery backup for the enrollees continuous positive airway pressure (CPAP) machine. A 
battery backup is considered duplicative, and therefore not covered. Therefore, we decided that the Plan does 
not have to pre-approve a battery back backup (E1399).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) 
provided on December 23, 2021. 
 
You asked the Plan to pay for the problem focused limited oral evaluation. You say that the evaluation 
performed by the endodontist was different from the examination performed by your general dentist. The Plan 
denied your request. The Plan says this service 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, problem focused limited oral 
evaluation (D0140) is limited to one procedure per plan year. The record shows that you received a problem 
focused limited oral evaluation (D0140) on December 8, 2021 and your problem focused limited oral 
evaluation (D0140) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for 
the problem focused limited oral evaluation (D0140) provided on December 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay additionally for the prophylaxis (D1110) provided on November 
10, 2021. 
 
You asked the Plan to pay additionally for dental code D1110. You say that you would like the Plan to 
reconsider your request. The Plan denied your request. The Plan says they have already issued $1000 in 
payments for your 2021 non-Medicare covered dental services. The Plan says since you have already utilized 
the full benefit no further payment is due from the plan for your 2021 dental services. 
 
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. 
We looked at the file and the Plan's contract. The Plan pays up to $1000 every year for non-Medicare covered 
preventive and comprehensive dental services combined. You are responsible for any amount above the dental 
coverage limit. The file shows that the Plan has already issued $1000 in payments for your 2021 non-Medicare 
covered dental services. You are only responsible for the remaining $81 for the services received on November 
10, 2021. Therefore, we decided that the Plan does not have to pay additionally for the prophylaxis (D1110) 
provided on November 10, 2021.  
 
Your concern about how the provider bills the insurance company is not a valid appeal for medical coverage. 
This part of your concern is a grievance that must be answered by the Plan. Medicare does not permit us to 
make a decision about these types of concerns.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the periodic oral evaluation (D0120) and child prophylaxis (D1120) 
provided on December 8, 2021. 
 
You asked the Plan to pay for the periodic oral evaluation and child prophylaxis. You say that the Plan has 
always paid this claim in the past. You also say that the dental facility has not changed their policy for 
Medicare patients. The Plan denied your request. The Plan says that you received these services from a 
provider who chose not to receive Medicare funds. The Plan also says that the treating provider is a non-
participating, non-contracting provider and is not eligible to participate with Medicare. 
 
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. 
 
We looked at this the file and Medicare rules. The Plan denied these services saying the treating provider was a 
Medicare opt out provider, and Medicare opt out providers choose not to receive Medicare funds. The record 
shows that the Plan's decision was not based on the correct treating provider. The treating provider listed on the 
documentation is not a Medicare opt out provider, and the screen shots the Plan provided from the Centers for 
Medicare & Medicaid Services Opt Out Affidavits does not show this provider as an opt out provider. The Plan 
also does not clarify if the treating provider is out-of-network. Exams and cleanings are listed as covered 
benefits in the 2021 Evidence of Coverage (EOC). The 2021 EOC does not specify any specific type of 
cleanings that are or are not covered. You reasonably believed these services would be covered because they 
are listed as covered benefits, and the treating provider is not an opt out provider.  
 
Based on this information, we decided that the Plan's rules for coverage of the periodic oral evaluation and 
child prophylaxis have been met. Therefore, we decided that the Plan has to pay for the periodic oral evaluation 
(D0120) and child prophylaxis (D1120) provided on December 8, 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 the problem focused limited oral evaluation (D0140) 
provided on December 20, 2021. 
 
You asked the Plan to pay for the problem focused limited oral evaluation. You say that this dental visit was an 
emergency and not an ordinary exam for cosmetic purposes. The Plan denied your request. The Plan says this 
service 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, problem focused limited oral 
evaluation (D0140) is limited to one procedure per plan year. The record shows that you received a problem 
focused limited oral evaluation (D0140) on August 24, 2021 and your problem focused limited oral evaluation 
(D0140) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the problem 
focused limited oral evaluation (D0140) provided on December 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composite - two surfaces, anterior (D2331), 
resin-based composite - four or more surfaces or involving incisal angle (anterior) (D2335), resin-based 
composite - three surfaces, posterior (D2393), and add tooth to existing partial denture (D5650) provided 
September 29, 2021, and October 14, 2021. 
 
You asked the Plan to pay for the fillings and add tooth to existing partial denture. You say that you do not 
understand why services are covered on some dates of services but not on others. The Plan denied your request. 
The Plan says these services are not covered because you have exhausted your dental allowance. 
 
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 the fillings 
and add tooth to existing partial denture up to $1,000 for non-Medicare covered dental services every year.  
We looked at the file, and Medicare rules. The Plan provided documentation showing that they have paid 
$1,000 towards dental services provided in 2021. Based on this information, we decided that your supplemental 
dental benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the resin-based 
composite - two surfaces, anterior (D2331), resin-based composite - four or more surfaces or involving incisal 
angle (anterior) (D2335), resin-based composite - three surfaces, posterior (D2393), and add tooth to existing 
partial denture (D5650) provided September 29, 2021, and October 14, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the osteogenesis stimulator, electrical, non-invasive, 
other than spinal applications (CPT code E0747). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the Medicare rules have not been met. 
 
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 physician reviewer 
found the detailed documentation is not evident regarding nine (9) months have passed since the fusion 
surgery, dated December 30, 2021. Additionally, the documentation does not demonstrate that fracture healing 
had not progressed and ceased for three (3) or more months. There is no compelling rationale presented or 
extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. 
Therefore, the medical records provided do not meet the requirements listed in the NCD/CLD for Medicare 
coverage. 
 
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 osteogenesis stimulator, electrical, non-invasive, other than spinal applications (CPT 
code E0747).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injection, of diagnostic or therapeutic substances (anesthetic, 
antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter 
placement, interlaminar epidural or subarachnoid, cervical or thoracic (62320) provided November 1, 20211. 
 
You asked the Plan to pay for the injection services. You say that you are appealing the Plan's decision to deny 
payment. The Plan denied your request. The Plan says this provider has not submitted any clinical records to 
support the medical necessity of the services. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare requires that services 
provided/ordered/certified be authenticated by the persons responsible for the care of the beneficiary in 
accordance with Medicare's policies. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the injection services have not been met. Specifically, the documentation submitted does not 
include a valid signature from the persons responsible for the care of the beneficiary. the records that was 
provided is not dated and is not signed by the provider. The Plan made multiple attempts to obtain the 
additional information without success. Therefore, we decided that the Plan does not have to pay for injection, 
of diagnostic or therapeutic substances (anesthetic, antispasmodic, opioid, steroid, other solution), not including 
neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical 
or thoracic (62320) provided November 1, 20211.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided by a physical therapy 
assistant on June 21, 2021. 
  You asked the Plan to pay for physical therapy services. You say that the medical records required to reprocess 
the denied claim are attached. The Plan denied your request. The Plan says the code is not appropriate for the 
service billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the services of a physical therapy assistant (PTA) 
shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they 
do not meet the qualifications of a therapist.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of physical therapy services have not been met. Specifically, the billing provider is a nurse 
practitioner, and not a licensed therapist. As such, PTA services cannot be paid incident to this provider's 
professional services. Therefore, we decided that the Plan does not have to pay for physical therapy services 
provided by a physical therapy assistant on June 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the extraction, erupted tooth requiring removal of bone 
and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210) for teeth 24 and 25. 
 
You asked the Plan to pre-approve the tooth extractions. You say that you need these teeth extracted and you 
won't need any more extractions covered after this. The Plan denied your request. The Plan says you have 
exhausted your benefit for tooth extractions. 
 
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 3 tooth 
extractions per calendar year.  
 
We looked at the file and Medicare rules. The Plan provided documentation showing that 3 tooth extractions 
have been approved. Based on this information, we decided that the Plan's frequency limit for coverage of the 
tooth extractions would be exceeded with the 2 additional extractions. Therefore, we decided that the Plan does 
not have to pre-approve the extraction, erupted tooth requiring removal of bone and/or sectioning of tooth and 
including elevation of mucoperiosteal flap if indicated (D7210) for teeth 24 and 25.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical placement of implant body endosteal implant 
for tooth #22 & tooth #27 and prefabricated abutment for tooth #22 & tooth #27. 
 
You asked the Plan to pre-approve surgical placement of implant body endosteal implant for tooth #22 & tooth 
#27 and prefabricated abutment for tooth #22 & tooth #27. You say that the services are necessary. The Plan 
denied your request. The Plan says the 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, 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 placement of implant body endosteal implant for tooth #22 & tooth #27 and prefabricated abutment for 
tooth #22 & tooth #27.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0676). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that you need this device to 
prevent blood clots after your knee surgery. The Plan denied your request. The Plan says items that are used for 
a preventative service or function are excluded from coverage. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim.  
 
 
 
 
  
 
Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0676).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (CPT code E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that the home ventilator is necessary. The Plan 
denied your request. The Plan says the Medicare rules have not been met. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our physician 
reviewer found a home ventilator is not medically necessary. You were recently hospitalized with acute on 
chronic hypercarbic respiratory failure and improved with (BiPAP). You are severely obese, and there is likely 
a component of obesity-hypoventilation syndrome. There is a diagnosis of chronic obstructive pulmonary 
disease (COPD), but there are no pulmonary function tests for confirmation. There is suspected obstructive 
sleep apnea (OSA), apparently untreated. The chest x-ray (CXR) suggested acute pulmonary edema. There is 
no diagnosis of thoracic restrictive disease or neuromuscular disease. BiPAP, with or without average volume-assured pressure support (AVAPS), has not been tried at home. Medicare does not pay for a ventilator when 
used as BiPAP. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the home ventilator (CPT code E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gauze (A6216 and A6219) provided on December 17, 2021. 
 
You asked the Plan to pay for codes A6216 and A6219. 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.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that codes A6216 and A6219 have a status code of "P" under the Medicare Physicians Fee Schedule 
Database (MPFSDB) and no separate payment is made for these codes under the fee schedule as payment is 
bundled into the payment for the services to which these codes are incident to. Therefore, we decided that the 
Plan does not have to pay for the gauze (A6216 and A6219) provided on December 17, 2021.