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

 
We decided that the Plan has to pre-approve a dental porcelain crown (code D2750) for tooth #10. 
 
You asked the Plan to pre-approve porcelain crown. You say that this service is medically necessary. The Plan 
denied your request. The Plan says that the denial of authorization for this service is correct, because this 
porcelain crown is 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 Plans coverage rules apply in this case. The Plan covers porcelain 
crown when the services are medically necessary and reasonable. Pre-operative periapical radiographs are 
required documentation for coverage. 
 
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 porcelain crown. Our reviewer says that 
the enrollee meets the Plan criteria for the requested porcelain crown. Our physician reviewer found a review 
of the documentation indicates that tooth #10 has a large carious lesion on the distal surface which undermines 
the disto-incisal angle. A crown restoration is medically necessary and reasonable to restore tooth #10 to sound 
functional integrity. 
 
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 porcelain crown have been met. Therefore, we decided that the Plan has to pre-
approve a dental porcelain crown (code D2750) for tooth #10.  
 
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 the in network rate for the cone beam computed tomography 
(CT) capture and interpretation (D0364) provided on February 3, 2022. 
 
You asked the Plan to pay the in network rate for the cone beam CT scan. You say that you were referred to 
this provider. You say that you were in a lot of pain. You also say that you feel the services should be covered. 
The Plan denied your request. The Plan says cone beam CT capture and interpretation is not listed as a covered 
service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.  
Though the Plan offers a dental benefit in excess of Medicare coverage, the cone beam CT capture and 
interpretation is not among those covered under this benefit regardless of the provider's network status. 
Therefore, we decided that the Plan does not have to pay the in network rate for the cone beam computed 
tomography (CT) capture and interpretation (D0364) provided on February 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical placement of implant body: endosteal implant 
(D6010), cone beam computed tomography (CT) capture and interpretation with field of view of one full dental 
arch  maxilla, with or without cranium (D0366), inhalation of nitrous oxide/analgesia, anxiolysis (D9230), 
and panoramic radiographic image (D0330) provided January 24, 2022. 
 
You asked the Plan to pay for the endosteal implant, cone beam CT scan, nitrous oxide and panoramic x-ray. 
You say that this was a medical procedure caused by methotrexate poisoning. The Plan denied your request. 
The Plan says these services are not covered under your 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. 
 We reviewed the file and Medicare rules. The Plan provided documentation showing that a panoramic x-ray 
was previously covered on July 6, 2021. Based on this information, we decided that the frequency limit for 
coverage of the panoramic x-ray has been exceeded. Though the Plan offers a dental benefit in excess of 
Medicare coverage, the endosteal implant, cone beam CT scan and nitrous oxide are not among those covered 
under this benefit. These services also do not qualify for coverage under your medical benefit. Therefore, we 
decided that the Plan does not have to pay for the surgical placement of implant body: endosteal implant 
(D6010), cone beam computed tomography (CT) capture and interpretation with field of view of one full dental 
arch  maxilla, with or without cranium (D0366), inhalation of nitrous oxide/analgesia, anxiolysis (D9230), 
and panoramic radiographic image (D0330) provided January 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the parenteral nutrition supplies provided on August 23, 
2021. 
 
You asked the Plan to pay for the parenteral nutrition supplies. You say that the records support the medical 
need for these supplies. The Plan denied your request. The Plan says there is no proof of delivery for the date of 
service at issue. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we 
decided that the Plan does not have to pay for the parenteral nutrition supplies provided on August 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on September 10, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
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 laboratory services 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 laboratory services provided on September 10, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for presumptive drug testing (80307) definitive drug testing 
(G0480) provided on February 17, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that you are in disagreement on the decision 
made where the claim denied due to mission prior authorization, hence you request reconsideration on the 
claim with the attached supporting documentation. The Plan denied your request. The Plan says enrollees must 
receive their medical services from an in-network provider with the exception being urgent or emergent 
services. Non-emergent services with non-contracted providers require prior authorization before services 
being rendered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for presumptive drug testing (80307) definitive drug 
testing (G0480) provided on February 17, 2022 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (0037U) provided January 19, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that the service was medically necessary. The Plan 
denied your request. The Plan says this service is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that in addition to single gene testing, panels that 
include the FANCC genes are statutorily excluded service.  
 
We looked at the file and Medicare rules. The panel included testing for FANCC genes. Panels that include this 
test are not covered. Based on this information, we decided that Medicare rules for coverage of the genetic 
testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing (0037U) 
provided January 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (code D0140) you received on 
February 1, 2022. 
 
You asked the Plan to pay for the limited oral evaluation. You say that the Plan should have paid more towards 
this dental claim. The Plan denied your request. The Plan says you have exceeded your benefit for this service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan's rules state that 
limited oral exams are covered once per year.  Records show that you had already received a covered limited 
oral exam on January 19, 2022, so you will not be eligible for coverage of another one until January 19, 2023. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
limited oral evaluation (code D0140) you received on February 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve alveoloplasty not in conjunction with extractions - one 
to three teeth or tooth spaces, per quadrant (D7321 x 4). 
 
You asked the Plan to pre-approve the dental service. You say that the services are necessary. The Plan denied 
your request. The Plan says alveoloplasty not in conjunction with extractions - one to three teeth or tooth 
spaces, per quadrant, is not listed as a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested alveoloplasty not in 
conjunction with extractions - one to three teeth or tooth spaces, per quadrant, are not among those covered 
under this benefit. Therefore, we decided that the Plan does not have to pre-approve alveoloplasty not in 
conjunction with extractions - one to three teeth or tooth spaces, per quadrant (D7321 x 4).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve conscious sedation services (D9239, D9243). 
 
You asked the Plan to pre-approve the dental services. You say that you have an infection. You say that you are 
on antibiotics. You say that you have high blood pressure. You also say that you need to be put to sleep in 
order to get these extractions done. The Plan denied your request. The Plan says the services denied correctly. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested conscious sedation 
services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pre-approve conscious sedation services (D9239, D9243).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the maxillary denture (D5225) to be provided by a 
network provider. 
 
You asked the Plan to pre-approve the maxillary denture (D5225). You say that your doctor determined that is 
it necessary to make a new prosthesis and the one you have. You say because a tooth fell out which 
anatomically changes the configuration of the dentures. The Plan denied your request. The Plan says the 
service exceeded the frequency limitation in the 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 Plan also has a maximum benefit 
of dentures that will be considered for replacement after five years. The maxillary denture (D5225) is not 
covered because the Plan paid for a partial maxillary denture (D5213) on March 18, 2021, which exhausted 
your benefit. Therefore, we decided that the Plan does not have to pre-approve the maxillary denture (D5225) to be provided 
by a network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core build-up (D2950) and the porcelain-based crown 
(D2751) provided by a network provider on November 16, 2021, and December 7, 2021. 
 You asked the Plan to pay for the core build-up (D2950) and the porcelain-based crown (D2751). You say that 
the dentist told you the coinsurance would be $119.56 for the crown. The Plan denied your request. The Plan 
says the core build-up (D2950) is not a covered benefit and you have been charged the correct cost sharing 
amount for the crown (D2751). 
 
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 rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for endodontics. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the core build-up (D2950) is not 
among those covered under this benefit. You have also been asked to pay $119.56 which is 20% of the allowed 
amount for the porcelain-based crown (D2950). The allowed amount is $597.81. ($597.81 x 20% = $119.56). 
Therefore, we decided that the Plan does not have to pay for the core build-up (D2950) and the porcelain-based 
crown (D2751) provided by a network provider on November 16, 2021, and December 7, 2021.  
 
Your complaint that the provider is taking advantage of you and the Pan is not a valid appeal for medical 
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not 
permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the implant placement (D6010), the prefabricated 
abutment (D6056), the implant supported porcelain fused to metal crown (D6066), the bone replacement graft 
for ridge preservation (D7953), gum surgery (D4266), and the removable partial denture (D5286) to be 
provided by a network provider. 
 
You asked the Plan to pre-approve the implant placement for tooth #12 (D6010), the prefabricated abutment on 
tooth #12 (D6056), the implant supported porcelain fused to metal crown on tooth #12 (D6066), the bone 
replacement graft for ridge preservation (D7953), gum surgery (D4266), and the removable partial denture 
(D5286). You say that you received an implant last year and now need one of the other side of your mouth. 
You say you cannot eat and function properly. The Plan denied your request. The Plan says the 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 implant placement (D6010), the 
prefabricated abutment (D6056), the implant supported porcelain fused to metal crown (D6066), the bone 
replacement graft for ridge preservation (D7953), gum surgery (D4266), and the removable partial denture 
(D5286) ices are not among those covered under this benefit. Therefore, we decided that the Plan does not have 
to pre-approve the implant placement (D6010), the prefabricated abutment (D6056), the implant supported 
porcelain fused to metal crown (D6066), the bone replacement graft for ridge preservation (D7953), gum 
surgery (D4266), and the removable partial denture (D5286) to be provided by a network provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that this is medically necessary. The Plan denied 
your request. The Plan says that the clinical value and effectiveness of bone marrow aspirate in the setting of 
spinal 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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Detailed 
documentation is not evident regarding a specific indication provided to support the request for bone marrow 
aspirate for the approved surgery. There is a lack of large volume, long-term peer-reviewed outcome studies to 
support the use of bone marrow aspirate for this enrollees medical condition. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. 
Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve bone marrow aspirate for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 2 additional crowns (D2740). 
 
You asked the Plan to pre-approve the dental services. You say that your doctor requested 4 crowns. You also 
say that only 2 were approved. The Plan denied your request. The Plan says the maximum benefit has been 
reached. 
 
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 and the services are listed as covered, 
the annual maximum benefit of $5,000 has been reached. The record shows that the Plan paid $4,000 for a 
fixed bridge that you received on April 3, 2022. The record also shows that the Plan approved 2 of the 4 total 
requested crowns, for $511 each. $4,000 + $511.50 + $511.50 = $5,023. Therefore, we decided that the Plan 
does not have to pre-approve 2 additional crowns (D2740).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a vesibuloplasty (D7350) provided by a participating 
provider. 
 
You asked the Plan to pre-approve a vesibuloplasty. You say that you would like the Plan to approve these 
services. The Plan denied your request. The Plan says the requested 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 pre-approve a 
vesibuloplasty (D7350) provided by a participating provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intracavitary hyperthermia, unlisted chemotherapy 
procedure 96549. 
 
You asked the Plan to pre-approve intracavitary hyperthermia procedure. You say that the medical records 
provided will show proof of medical necessity. The Plan denied your request. The Plan says the medical 
records do not support approval for the enrollee's clinical situation. 
 
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 intracavitary hyperthermia procedure. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the records do not support that the requested service meets the 
Medicare NCD criteria for coverage and the items/services at issue in this case are not medically reasonable or 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of intracavitary hyperthermia procedure have not been met. Therefore, we decided 
that the Plan does not have to pre-approve intracavitary hyperthermia, unlisted chemotherapy procedure 96549.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on December 1, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 87640 is 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 CPT code.  In this case, we have confirmed that code 87640 is a column II code to column I code 87641. This claim has 
not been billed with an appropriate modifier to bypass the edit. The -59 modifier is not supported as a separate 
and distinct procedural service. Based on the claim submitted, Medicare billing criteria have not been met. 
Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on December 1, 
2021.