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

 
We decided that the Plan does not have to pay for teeth cleaning (D1110) provided on December 18, 2021. 
 
You asked the Plan to pay for the dental services. You say that this service was not done by the provider. The 
Plan denied your request. The Plan says your benefit for the requested item or service has already been 
exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service August 31, 2021. 
Therefore, we decided that the Plan does not have to pay for teeth cleaning (D1110) provided on December 18, 
2021.  
 
Your complaint about the service not being done 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 implant supported crowns (D6065) and prefabricated 
abutments (D6056). 
 
You asked the Plan to pre-approve implant supported crowns and prefabricated abutments. You say that the 
services are medically necessary, and you are having difficulty eating and chewing. The Plan denied your 
request. The Plan says the services at issue 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 
implant supported crowns (D6065) and prefabricated abutments (D6056).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a resin-based composite filling on tooth #11 (D2330) 
and a resin-based composite filling on tooth #21 (D2391).  
 
You asked the Plan to pre-approve the dental services. You say that you want your benefits returned so you can 
get these services done with a different dentist. The Plan denied your request. The Plan says your benefit for 
the requested items or services has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows the Plan pre-approved two fillings on this authorization request. Therefore, your benefit for resin-based 
composite fillings was exhausted. We decided that the Plan does not have to pre-approve a resin-based 
composite filling on tooth #11 (D2330) and a resin-based composite filling on tooth #21 (D2391).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the enrollee was approved for a 
reverse total shoulder arthroplasty and will need inpatient admission after surgery. The Plan denied your 
request. The Plan says there is no documentation provided to support the expectation the enrollee will require a 
greater than 2 midnight stay. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.   
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case. Our physician reviewer found the enrollee is approved for a reverse total shoulder arthroplasty. The 
record does not document that the treating physician has a reasonable expectation of a length of stay spanning 2 
or more midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental implants on tooth #13, 14, 15, 30, and 31 
(D6010). 
 
You asked the Plan to pre-approve implants. You say that you disagree with the denial of dental services. The 
Plan denied your request. The Plan says dental implants (D6010) are not covered by your dental 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 
dental implants on tooth #13, 14, 15, 30, and 31 (D6010).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76770 (line 2) provided on April 13, 2022. 
 
You asked the Plan to pay for procedure code 76770 (line 2). You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says you billed two units of code 
76770; however, the records do not show that there was more than one image taken on April 13, 2022. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
We find that 2 units of CPT code 76770 are not supported in the medical record. The medical record only 
supports 1 unit of CPT code 76770. Based on this information, we decided that Medicare rules for coverage of 
procedure code 76770 (line 2) have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 76770 (line 2) provided on April 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for extractions (D7210 x9) provided on December 7, 2021, 
through December 28, 2021. 
 
You asked the Plan to pay for the dental services. You say that you want the Plan to pay. The Plan denied your 
request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service December 7, 2021. 
Therefore, we decided that the Plan does not have to pay for extractions (D7210 x9) provided on December 7, 
2021, through December 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2740) provided on June 14, 2022. 
 
You asked the Plan to pay for a crown. You say that the service was medically necessary. The Plan denied your 
request. The Plan says the service at issue 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 pay for a crown 
(D2740) provided on June 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on April 
20, 2022. 
 
You asked the Plan to pay for the dental services. You say that you believed all services were covered as you 
were way under your limit for dental services. The Plan denied your request. The Plan says your benefit for the 
requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service April 4, 2022. Therefore, 
we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on April 
20, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve crowns for teeth numbers nine and ten (D2740). 
 
You asked the Plan to pre-approve crowns for teeth numbers nine and ten (D2740). You say that the 
endodontic treatment on these teeth, according to the patient, is over 15 years old. You also say that the teeth 
are asymptomatic and show no signs of apical infection. The Plan denied your request. The Plan says that this 
service 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 crowns for 
teeth numbers nine and ten (D2740) 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 crowns for teeth numbers nine and ten 
(D2740). Our reviewer says that the documentation provided meets the criteria for crown restorations (D2740) 
for teeth numbers nine and ten. Our physician reviewer found a review of the documentation indicates that 
teeth numbers nine and ten have severe coronal breakdown due to caries or fracture. Our physician reviewer 
also found that although the root canal fill is short of the apex on tooth number nine, due to the amount of time 
that has elapsed (15 years) and lack of apical pathology or clinical symptoms, crown restorations for these teeth 
are medically reasonable and necessary. 
 
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 crowns for teeth numbers nine and ten (D2740) have not been met. Therefore, 
we decided that the Plan has to pre-approve crowns for teeth numbers nine and ten (D2740).  
 
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 waive the cost share for a mandibular partial denture (D5214) 
provided on February 22, 2022. 
 
You asked the Plan to waive the cost share for a partial denture. You say that you were never told this service 
would not be fully covered. The Plan denied your request. The Plan says your annual dental maximum amount 
has been exhausted. 
 
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 have a $1,000 annual dental maximum.  
 
The record shows your annual dental maximum amount was exhausted during the processing of this claim. You 
have been asked to pay $60 for a partial denture. A partial denture falls within the Dental Services benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the cost share for a mandibular partial denture (D5214) provided 
on February 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 88365 and 88342 billed for date of service 
January 7, 2022. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says an 
appropriate modifier was not 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, we have confirmed that code 88365 is a column II code to column I code 88377, and code 88342 is 
a column II code to column I code 88189. The services at issue have 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 codes 88365 and 88342 billed for date 
of service January 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care supplies (A6212, A6196) provided on February 
28, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the wound care supplies. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they were 
non-emergent and prior authorization was not obtained. 
 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 wound care supplies (A6212, A6196) provided on 
February 28, 2022 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the 4 porcelain crowns (D2740) provided on March 17, 2022. 
 
You asked the Plan to pay for the dental services. You say that a treatment plan was presented to the enrollee. 
You say that crowns were fabricated for the enrollees teeth. You also say that the crowns were necessary. The 
Plan denied your request. The Plan says the crowns were not medically necessary. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
You are a contract provider. The file does not show that the plan provided notice that the dental services would 
not be covered. Under Medicare rules, this means the dental services is considered approved by the plan. 
Therefore, we decided that the Plan has to pay for the 4 porcelain crowns (D2740) provided on March 17, 
2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on January 31, 2022, billed with 
codes 81225, 81227, 81230, 81231, 81232, 81291, 81306, 81355, 81335, 0031U, 0032U, 0033U, 81407 and 
81238. 
 
You asked the Plan to pay for the genetic testing billed. The Plan denied your request. The Plan says the 
services were billed incorrectly. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
January 31, 2022, billed with codes 81225, 81227, 81230, 81231, 81232, 81291, 81306, 81355, 81335, 0031U, 
0032U, 0033U, 81407 and 81238.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that admission is necessary. The Plan denied your 
request. The Plan says the requested admission is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the provided documentation does not indicate that you have complex nursing or 
rehabilitation needs. The reviewer found that while you have a need for therapy, there is no documentation of a need for an intensive rehabilitation program. The reviewer also found that there is not a reasonable expectation 
that you would be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. Therefore, the reviewer found that the requested IRF admission 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. 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 Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not medically necessary. Our physician reviewer found the enrollee presented to the 
hospital on August 24, 2022 with a fall and confusion. He was treated with intravenous (IV) antibiotics for a 
urinary tract infection and he is now stabilized. He is walking 400 feet with a rolling walker and contact guard 
assistance. He needs contact guard assistance for transfers. He needs assistance with activities of daily living. 
He has no skilled nursing needs. He has skilled therapy needs but does not require skilled therapy on a daily 
basis. As a practical matter, the enrollee does not require the necessary services on an inpatient basis at the SNF 
level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2313, E2377, E2311) and 
power seat elevation feature (E2300). 
 
You asked the Plan to pre-approve an expandable controller and power seat elevation feature. You say that this 
equipment is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the 
criteria for coverage have not been met for this equipment. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. Medicare rules say that a power seat elevation feature (E2300) is statutorily non-
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 an expandable controller and power 
seat elevation feature. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found that the enrollee does not require 
additional accessories in order to properly operate a powered wheelchair. He has adequate strength to operate 
the power options. Per Medicare rules, DME is not covered if it is unnecessary to meet the enrollee's needs. 
The accessory is unnecessary based on the enrollees condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an expandable controller and power seat elevation feature have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2313, E2377, 
E2311) and power seat elevation feature (E2300).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tramadol. 
 
You asked the Plan to pre-approve Tramadol. You say that this drug is medically necessary for the enrollee's 
condition. The Plan denied your request. The Plan says this drug is not covered under the enrollee's medical 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Tramadol.  
 
Benefits for Tramadol may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.