Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (93010, 93042, 99053) provided April 8, 
2021. 
 
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the codes billed are 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 codes 
93010 & 93042 are column II codes to column I codes 12052 & 93010. This claim has not been billed with an 
appropriate modifier to bypass the edit. Code 99053 has a status of "B" and is not separately 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 physician services (93010, 93042, 99053) provided April 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on November 
15, 2021. 
 
You asked the Plan to pay for the dental service. You say that the dentist billed for periodontal maintenance. 
You say that your appointment was for a regular cleaning. You also say that this provider is listed as in 
network. The Plan denied your request. The Plan says periodontal maintenance 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 periodontal maintenance 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 for the periodontal maintenance (D4910) provided on November 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Freestyle Lite test strips for the enrollee. 
 
You asked the Plan to pre-approve Freestyle Lite test strips. You say that these are necessary for the enrollee. 
The Plan denied your request. The Plan says that there is no documentation that the member has tried the 
preferred diabetic testing supplies or that the preferred diabetic testing supplies would be less effective than the 
preferred alternatives. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician or treating practitioner must 
document in the beneficiarys medical record the reason why the specific brand or mode of delivery is 
necessary to avoid an adverse medical outcome. 
 
We looked at the file and Medicare rules. The file does not include any documentation stating why the enrollee 
requires this specific brand of test strips. Without this, medical necessity cannot be established. Therefore, we 
decided that the Plan does not have to pre-approve Freestyle Lite test strips for the enrollee.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the rhythm echocardiography report (ECG) (93042) provided 
on October 11, 2021. 
 
You asked the Plan to pay for the rhythm ECG report. You say that this service was billed appropriately and is 
separately payable. The Plan denied your request. The Plan says a National Correct Coding Initiatives (NCCI) 
Procedure to Procedure (PTP) edit exists between 99291 and 93042. This PTP edit has a modifier indicator of 
0, meaning modifiers are not allowed to bypass this edit. This service was not billed as required by Medicare 
coding regulations. 
 
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 93042 
is a column II code to column I code 99291 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 the rhythm echocardiography report (ECG) (93042) provided on October 11, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on November 17, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says this testing is unlikely to impact therapeutic decision-making in the clinical management of the 
patient. 
 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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the documentation demonstrates that the testing was done in the absence of clinical signs and symptoms 
of disease, and does not support that the test results would provide the clinician with information that will 
improve outcomes and/or change the care and treatment of the enrollee in this case. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for laboratory services provided to the enrollee on November 17, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service November 
28, 2021. 
 You asked the Plan to pay for procedure code 70450. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says payment for code 70450 is bundled into 
payment for code 70496. 
 
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 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service November 28, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on December 17, 2021. 
 
You asked the Plan to pay for dental services. You say that you would like the Plan to pay for 50% of this 
crown. The Plan denied your request. The Plan says this claim has been processed 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. 
 
We looked at the file and Medicare rules. Evidence was provided to show that the rendering dentist did not 
become a participating dentist until 2022. Based on this information, we decided that the Plan's rules for 
coverage of dental services have not been met. Therefore, we decided that the Plan does not have to pay for 
dental services provided on December 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a manual wheelchair with a push-rim power assist 
option. 
 
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 requested manual wheelchair with push-rim power assist option is not reasonable or 
necessary, the base manual wheelchair and none of the requested accessories can be covered. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested wheelchair is not medically reasonable or necessary. Our physician reviewer found the requested 
K0005 manual wheelchair with E0986 - Manual wheelchair accessory, push-rim activated power assist system 
(SmartDrive MX2 + Pushtracker E2 shadow) is not medically necessary as it exceeds the patient's medical 
needs. The SmartDrive and E2 shadow Pushtracker have advanced features that are not medically necessary 
such as advanced blue tooth connection, hand gesture activation, performance notifications, and touch screen 
control. For these reasons the entire request for the manual wheelchair with E0986 is not medically 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a manual wheelchair with a push-rim power assist option.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110), and metal 
substructure to acrylic full denture (D5876) provided by an out-of-network provider. 
 
You asked the Plan to pre-approve a complete maxillary denture and metal substructure to acrylic full denture. 
You say that these services are medically necessary. The Plan denied your request. The Plan says this claim has 
been processed 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. The Plan covers one complete 
maxillary denture every five years. The Plan does not cover a metal substructure to acrylic full denture. 
 
We looked at the file and Medicare rules. D5110 was previously provided on December 27, 2019. Based on 
this information, we decided that the Plan's rules for coverage of a complete maxillary denture have not been 
met. Metal substructure to acrylic full denture is not a covered dental benefit. Therefore, we decided that the 
Plan does not have to pre-approve a complete maxillary denture (D5110), and metal substructure to acrylic full 
denture (D5876) provided by an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gel-One. 
 You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Gel-One is covered when specific criteria are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a history of chronic 
low back pain and a diagnosis of unilateral primary osteoarthritis of the right knee. The only submitted medical 
records are an office visit dated April 13, 2022 that deals with low back pain. There are no records addressing 
the enrollee's osteoarthritis. The documentation does not support that the criteria for coverage are met; 
therefore, Gel-One is not reasonable or medically necessary at this time. 
 
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 Gel-One.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve freestyle libre 2 reader device. 
 
You asked the Plan to pre-approve freestyle libre 2 reader device. You say that you test your sugar 8 times a 
day and take insulin 4 or 6 times a day. You take insulin before each meal and before going to bed. You hope 
this is a good reason for the Freestyle Libre 2 glucose monitor. The Plan denied your request. The Plan says the 
records do not support that the enrollee meets the criteria for the requested device. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced in the Medicare rules section. 
 
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 freestyle libre 2 reader device. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee does have diabetes mellitus and the enrollee's diabetes is 
insulin treated with three or more daily administrations of insulin. The provided records do not document that 
the insulin treatment regimen requires frequent adjustment by the enrollee on the basis of blood glucose 
monitor or continuous glucose monitor testing results. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of freestyle libre 2 reader device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve freestyle libre 2 reader device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cone beam computed tomography (CT), both jaws 
(D0383). 
 
You asked the Plan to pre-approve the dental service. You say that you really need this to help with your 
dentures. The Plan denied your request. The Plan says the requested service is not listed as 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 cone beam CT, both 
jaws, is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-
approve a cone beam computed tomography (CT), both jaws (D0383).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dental implant placement (D6010) for tooth #9. 
 
You asked the Plan to pre-approve a dental implant. 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 a 
dental implant placement (D6010) for tooth #9.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone replacement grafts (D4263 x 3, D4264 x 2), 
guided tissue regeneration (D4266 x 3), and biologic materials to aid in tissue regeneration (D4265 x 4). 
 
You asked the Plan to pre-approve the dental services. You say that the periodontal services are necessary to 
prevent your teeth from worsening, including bone loss. The Plan denied your request. The Plan says the 
requested services are not covered under your dental 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 requested periodontal services are 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
bone replacement grafts (D4263 x 3, D4264 x 2), guided tissue regeneration (D4266 x 3), and biologic 
materials to aid in tissue regeneration (D4265 x 4).
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve dental services (D6011, D6192, D5731). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the dentist's notes and x-rays do not show that this dental work is 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 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 medically reasonable and necessary. Our physician reviewer found that a review of the 
documentation indicates that implant bodies in areas #22 and 27 appear fully integrated. It is medically 
reasonable to complete the treatment for an implant supported complete denture which involves the second 
stage implant surgery, placement of the attachments and reline to accept the attachments. 
 
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 been met. Therefore, we decided that the Plan has to pre-
approve dental services (D6011, D6192, D5731).  
 
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 pre-approve a complete upper denture (D5110) and partial lower 
denture (D5212). 
 
You asked the Plan to pre-approve dentures. You say that you want to get dentures. You say that you do not 
have any teeth. You also say that it is difficult for you to eat and talk. The Plan denied your request. The Plan 
says dentures are not listed as 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 dentures are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a complete 
upper denture (D5110) and partial lower denture (D5212).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve the continuous glucose monitor.. You say that the continuous glucose 
monitor is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
the continuous glucose monitor. have not been met. Therefore, we decided that the Plan does not have to pre-
approve a continuous glucose monitor.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64447 billed for date of service January 10, 
2022. 
 
You asked the Plan to pay for procedure code 64447. You say that this claim should not have been denied 
based on frequency of services because you billed with a -59 modifier. The Plan denied your request. The Plan 
says you did not bill with a modifier to satisfy the bilateral indicator requirement. 
 
The Plan must follow Medicare rules. Medicare rules say that services with a bilateral indicator of 1 on the 
Medicare Physician Fee Schedule are required to have either the -50 modifier appended (to indicate the 
procedure was performed bilaterally), or a LT or RT modifier to indicate the procedure was performed 
unilaterally and on which side of the body the procedure was performed. In this case, you billed code 64447.  
This code has a bilateral indicator of 1 on the Medicare Physician Fee Schedule.  This means that you needed 
to bill with either a modifier -50 indicating that the procedure was performed bilaterally, or either modifier LT 
or RT to indicate it was performed unilaterally.  You did not bill with any of these modifiers, so appropriate 
payment for this service cannot be determined.   
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of procedure code 64447 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 64447 billed for date of service January 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core build up (D2950), crown (D2740), and filling 
(D2332) provided on October 5, 2021. 
 
You asked the Plan to pay for the dental services. You say that not being reimbursed is unfair. You say that you 
have not been to the dentist in a year and a half due to the coronavirus. You also say that you received notice 
about changes to dental coverage for 2022. The Plan denied your request. The Plan says the provider in this 
case has opted out of Medicare. The Plan also says payment cannot be made for services provided by a dentist 
that 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, dental services received by an opt out 
provider are not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pay for the core build up (D2950), crown (D2740), and filling (D2332) provided on October 5, 2021.