Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services provided on July 23, 2021, billed with 
two units of 44310. 
 
You asked the Plan to pay for the surgical services as billed. You say that this claim was billed correctly. The 
Plan denied your request. The Plan says the record does not support any number of units for code 44310. 
 
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 44310 is ileostomy or jejunostomy, non-tube. 
 
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 surgical services as billed. Our reviewer says that the 
operative report does not support the billed codes. Our reviewer found the operative report does not support 2 
units for this procedure code. An ileostomy or jejunostomy would be reported with one unit of service. Also, 
the operative report does not include enough documentation to confirm this procedure has been performed. 
Procedure report documents "An ileostomy point was selected. Attempts were made to bring the loop 
ileostomy. The loop ileostomy would not reach the level of the skin without significant tension. The ileostomy 
was matured in a Brooke fashion with everted using 3-0 Vicryl pops. An ileostomy appliance was applied to 
the ileostomy and an ostomy appliance was applied to the right lower quadrant ileal mucous fistual and 
cecostomysite". Documentation does not support this procedure as billed. 
 
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 surgical services as billed have not been met. Therefore, we decided that the 
Plan does not have to pay for the surgical services provided on July 23, 2021, billed with two units of 44310.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the consultation - diagnostic service provided by dentist or 
physician other than requesting dentist or physician (D9310), panoramic radiographic image (D0330) and 
unspecified preventive procedure, by report (D1999) provided October 18, 2021. 
You asked the Plan to pay for the dental consultation, panoramic x-ray and unspecified preventative procedure. 
You say that you were never told that the provider had to be in-network. The Plan denied your request. The 
Plan says these services are not covered because the provider has opted out of Medicare. 
 
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 dental 
consultation, panoramic x-ray and unspecified preventative procedure when you see any licensed dental 
provider who accepts Medicare patients in the United States and has not opted out of Original Medicare. 
 
We looked at the file and Medicare rules. The services at issue in this appeal were provided in a non-urgent, 
non-emergent situation by the provider who has opted out of the Medicare program.  Based on this information, 
we decided that the Plan's rules for coverage of the dental consultation, panoramic x-ray and unspecified 
preventative procedure have not been met. Therefore, we decided that the Plan does not have to pay for the 
consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician 
(D9310), panoramic radiographic image (D0330) and unspecified preventive procedure, by report (D1999) 
provided October 18, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve an oral device. 
 
You asked the Plan to pre-approve an oral device. You say that the requested oral device is medically 
necessary. The Plan denied your request. The Plan says that they were unable to make a determination within 
the allotted time frame. 
 
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. Specifically, it is the plans responsibility to show that its decision to deny 
coverage is correct. Records from a plan provider are considered to be within the control of the plan. In cases 
where the plan has not supplied records from a plan provider that are critical to its decision, we may properly 
find that the denial is not medically appropriate or justifiable. Enrollees should not be penalized for a plans 
failure to obtain records that are within the plans control. The plan did not provide sufficient medical records 
in order to determine if the enrollee meets Medicare criteria for the requested oral device to be considered as a 
medical device. We are unable to determine if the requested device is to be used for a medical purpose or if the 
device is to be used for dental purposes. We find that the Plan has not substantiated their reasoning for the 
denial. Therefore, we decided that the Plan has to pre-approve an oral device.  
 
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 surgical services provided on August 10, 2021, billed 
with codes 14301 and four units of 14302. 
 
You asked the Plan to pay for the services as billed. You say that this should be paid as billed. The Plan denied 
your request. The Plan says the records do not support the reported procedure codes. 
 
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 14301 is Adjacent tissue transfer or rearrangement, any 
area; defect 30.1 sq cm to 60.0 sq cm and 14302 is Adjacent tissue transfer or rearrangement, any area; each additional 30.0 sq cm, or part thereof (List separately in addition to code for primary procedure). 
 
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 services as billed. Our reviewer says that the codes 
reported for this procedure are not supported by the records provided. Our reviewer found the operative report 
does not include a description of flat sections of healthy skin and other tissues being transferred or transplanted 
to the area next to a skin defect. As this is not described, it cannot be confirmed that any area of tissue was 
treated in this manner. 
 
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 services as billed have not been met. Therefore, we decided that the Plan 
does not have to pay for the surgical services provided on August 10, 2021, billed with codes 14301 and four 
units of 14302.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve retainer crowns for teeth 6, 7, 9, and 10 and a pontic for 
tooth 8. 
 
You asked the Plan to pre-approve 4 retainer crowns and a pontic. You say that you need coverage of these 
services The Plan denied your request. The Plan says in this case the services do not comply with the 
established dental clinical criteria that establishes that the requested teeth should be free from periodontal 
problems. Based on the evaluation of the dental panoramic image sent, this patient has an advanced periodontal 
condition and the four retainers D6740 evidence a bone loss of more than 60% of the supporting bone. 
 
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 4 retainer 
crowns and a pontic in accordance with American Dental Association standard of care with x-ray evidence. 
 
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 4 retainer crowns and a pontic. Our 
reviewer says that this service does not meet criteria for coverage.  Our physician reviewer found that the documentation provided does not meet the criteria for coverage for a fixed bridge replacing missing tooth #8 using teeth numberss 6, 7, 9 and 10 as abutment retainers due to the poor periodontal support of these teeth. 
 
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 4 retainer crowns and a pontic have not been met. Therefore, we decided that 
the Plan does not have to pre-approve retainer crowns for teeth 6, 7, 9, and 10 and a pontic for tooth 8.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the sedation services during the injection procedure. 
 
You asked the Plan to pre-approve the sedation services. You say that this procedure is medically necessary. 
The Plan denied your request. The Plan says there is no need for sedation during the epidural steroid injections. 
 
The Plan follows Medicare rules. Medicare rules say that documentation must clearly establish the need for 
such sedation in the specific patient. 
 
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 sedation services. Our reviewer says 
that the requested sedation services are not medically reasonable and necessary. Our physician reviewer found 
the patient does not have an indication for sedation during this procedure. The American Society of 
Anesthesiologists have specifically addressed this issue as has the Anesthesia Patient Safety Foundation. 
Sedation increases the risk here and is therefore not medically reasonable.  
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 sedation services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the sedation services during the injection procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a core buildup, including any pins when required 
(D2950) and a gingivectomy or gingivoplasty (D4212). 
 
You asked the Plan to pre-approve the core buildup and gingivectomy or gingivoplasty. You say that you 
would like to know if these services can be performed by your dentist who is not in the Plan's network. The 
Plan denied your request. The Plan says these 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 pre-approve a 
core buildup, including any pins when required (D2950) and a gingivectomy or gingivoplasty (D4212).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve six prefabricated abutments (D6056 x6). 
 
You asked the Plan to pre-approve the prefabricated abutments. You say that you need dental implants but 
were informed that they are not covered this year. The Plan denied your request. The Plan says this service is 
not covered under your benefit plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 six 
prefabricated abutments (D6056 x6).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two surgical placements of implant bodies (D6010) and 
two semi-precision abutments (D6191). 
 
You asked the Plan to pre-approve the dental services. You say that these services are necessary. The Plan 
denied your request. The Plan says these services are not covered by your dental 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 two 
surgical placements of implant bodies (D6010) and two semi-precision abutments (D6191).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the wheelchair component or accessory, transit kit 
(K0108). 
 
You asked the Plan to pre-approve the transit kit. You say that please review the attached medical 
documentation to support the need of the custom medical equipment being requested. The Plan denied your 
request. The Plan says this item is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  We looked at the file, and Medicare rules. Optional, additional, or deluxe features or accessories to durable medical equipment, corrective appliances, or prosthetics which are primarily for the comfort or convenience of 
the member are not covered under Medicare or the health plan. Based on this information, we decided that Medicare rules 
for coverage of the transit kit have not been met. Therefore, we decided that the Plan does not have to pre-approve the wheelchair component or accessory, transit kit (K0108).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care, first hour (99291) and critical care, additional 
30 minutes (99292) provided on June 19, 2021. 
 
You asked the Plan to pay for critical care. You say that this service was medically necessary and is supported 
in the record. The Plan denied your request. The Plan says the documentation does not include the time spent 
providing this service; therefore, this service is not supported as billed. 
 
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 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. The CPT Code Manual definition of code 99292 is 
critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 
minutes (List separately in addition to code for primary service). We find that CPT codes 99291 and 99292 are not supported in the medical record. Specifically, the time spent providing critical care services on this date is not noted in the record. Based on this information, we decided that Medicare rules for coverage of critical care have not been met. Therefore, we decided that the Plan does not have to pay for critical care, first hour (99291) and critical care, additional 30 minutes (99292) provided on 
June 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two abutment supported retainers for porcelain fused to 
metal fixed partial denture (D6071 x2), a radiographic/surgical implant index (D6190), two surgical placements 
of implant bodies: endosteal implants (D6010 x2), and two custom fabricated abutments (D6057 x2). 
 
You asked the Plan to pre-approve the abutment supported retainers, radiographic/surgical implant index, 
endosteal implants, and custom fabricated abutments. You say that you thought the procedures would be 
covered related to your implant as you have dental coverage of $1,000.00 and feel you are entitled to this 
amount. The Plan denied your request. The Plan says these services are 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. Therefore, we decided that the Plan does not have to pre-approve two 
abutment supported retainers for porcelain fused to metal fixed partial denture (D6071 x2), a 
radiographic/surgical implant index (D6190), two surgical placements of implant bodies: endosteal implants 
(D6010 x2), and two custom fabricated abutments (D6057 x2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve osseous surgery of four or more contiguous teeth or 
tooth bounded spaces per quadrant (D4260). 
 
You asked the Plan to pre-approve osseous surgery. You say that this service is necessary. The Plan denied 
your request. The Plan says this service is not covered by your dental 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 
osseous surgery of four or more contiguous teeth or tooth bounded spaces per quadrant (D4260).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an extraction (D7140), 2 crowns (D2740), core build up 
(D2950), and post and core in addition to a crown (D2954). 
 
You asked the Plan to pre-approve the dental services. You say that the office is in network. The Plan denied 
your request. The Plan says services performed out of network are not covered. 
 
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 extraction and crowns 
are not among those covered under this benefit. Additionally, core build up, and post and core in addition to 
crown are not covered regardless of your network status. Therefore, we decided that the Plan does not have to 
pre-approve an extraction (D7140), 2 crowns (D2740), core build up (D2950), and post and core in addition to 
a crown (D2954).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial lower denture with flexible base (D5226) and 
partial upper denture with flexible base (D5225). 
 
You asked the Plan to pre-approve the dental items. You say that you need these services. The Plan denied your 
request. The Plan says dentures are covered once per arch every 5 years. The Plan also says that the frequency 
limit 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage and dentures are covered once per arch 
every 5 years, the frequency limit has been reached. The record shows that the Plan paid for dentures that you 
received on May 17, 2021. Therefore, we decided that the Plan does not have to pre-approve a partial lower 
denture with flexible base (D5226) and partial upper denture with flexible base (D5225).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical tooth extractions (D7210) provided by a 
participating provider. 
 
You asked the Plan to pre-approve surgical tooth extractions. You say that you need these teeth pulled. The 
Plan denied your request. The Plan says surgical extractions 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 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 
surgical tooth extractions (D7210) provided by a participating provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve allograft services during a lumbar fusion. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
clinical effectiveness has not been demonstrated. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the requested services. Our physician 
reviewer found that the InQu allograft remains experimental. Iliac crest autograft or standard allograft chips 
remain the gold standard. Therefore, the requested service is 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve allograft services during a lumbar fusion.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve moderate sedation services during facet joint interventions. 
 
You asked the Plan to pre-approve moderate sedation services. You say that the clinical information provided 
supports the need for the anesthesia services being requested. The Plan denied your request. The Plan says the 
enrollee does not meet the requirements for approval. The Plan says that there is no evidence that the requested 
anesthesia is medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that general anesthesia is considered not medically 
reasonable and necessary for facet joint interventions.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of moderate sedation services have not been met. Therefore, we decided that the Plan does not have to pre-approve moderate sedation services during facet joint interventions.