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

 
We decided that the Plan does not have to pre-approve a full mouth x-ray of teeth (70320) to be rendered in a 
hospital. 
 
You asked the Plan to pre-approve a full mouth x-ray. You say that you were told the enrollee's mouth is too 
small for the x-ray machines at their dentist, and advised that the enrollee receive the work in a hospital. The 
Plan denied your request. The Plan says dental services are not a Medicare covered benefit and are excluded 
from coverage under the enrollee's 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 full mouth x-ray cannot be covered 
when it is provided at a hospital because hospitals are not considered Plan contracted dental providers. 
Therefore, we decided that the Plan does not have to pre-approve a full mouth x-ray of teeth (70320) to be 
rendered in a hospital.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9500 billed for dates of service October 30, 
2021, to November 5, 2021. 
 
You asked the Plan to pay for procedure code S9500. You say that this claim should be paid as in-network. The 
Plan denied your request. The Plan says the code billed is not valid. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code S9500 has a Status Indicator of I on the Physician Fee Schedule. This means that CPT 
code S9500 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure code S9500 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code S9500 billed for dates of service October 30, 2021, to November 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140), extraction (D7210), 
bone replacement graft (D7953), and guided tissue regeneration (D4266) provided on January 19, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered. The Plan denied 
your request. The Plan says extraction, bone replacement graft, and guided tissue regeneration are not listed as 
covered. The Plan also says that the frequency limit for limited oral evaluation has been exceeded. 
 
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 limited oral evaluation is covered 
once per plan year, the frequency limit has been exceeded. The record shows that this service was listed on the 
claim twice and the Plan paid for one. Additionally, the extraction, bone replacement graft, and guided tissue 
regeneration are not among those covered under this benefit. Therefore, we decided that the Plan does not have 
to pay for the limited oral evaluation (D0140), extraction (D7210), bone replacement graft (D7953), and guided 
tissue regeneration (D4266) provided on January 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for needle electromyography; limited study of muscles in 1 
extremity or non-limb (axial) muscles (unilateral or bilateral), other than thoracic paraspinal, cranial nerve 
supplied muscles, or sphincters (CPT code 95870-26 XU) provided on August 3, 2021. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the services are not supported by the records. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We 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. Our reviewer found the documentation shows 
this test being performed once and not twice as requested. There was no clear justification made for submitting 
the code twice as one code covers bilateral testing. Therefore, this request for such will be considered not 
medically necessary as submitted. 
 
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 have not been met. Therefore, we decided that the Plan does not 
have to pay for needle electromyography; limited study of muscles in 1 extremity or non-limb (axial) muscles 
(unilateral or bilateral), other than thoracic paraspinal, cranial nerve supplied muscles, or sphincters (CPT code 
95870-26 XU) provided on August 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildup, including any pins when required (D2950) 
for teeth 11 and 14, pontic - resin with high noble metal (D6250) for tooth 12 and retainer crown - porcelain 
fused to high noble metal (D6750) for 12 and 14. 
 
You asked the Plan to pre-approve core buildup, pontic and retainer crowns. You say that you need these 
services. 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. 
 
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 core buildup, including any pins when required (D2950) for teeth 11 and 14, pontic - resin with high noble metal 
(D6250) for tooth 12 and retainer crown - porcelain fused to high noble metal (D6750) for 12 and 14.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 10 physical therapy (PT) visits. 
 
You asked the Plan to pre-approve an additional 10 PT visits. You say that the requested services are medically 
necessary. The Plan denied your request. The Plan says the services at issue are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
   
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 additional 10 PT visits. Our reviewer 
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of your 
condition. Our physician reviewer found you have previously been treated with outpatient therapies and should 
be independent with a home exercise program. There is no documentation of a recent injury or decline in 
function. The additional therapy services are not an appropriate duration and frequency for treatment of your 
medical condition and therefore are 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 an additional 10 PT visits have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an additional 10 physical therapy (PT) visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scalings and root planings (D4341) of all 
four quadrants. 
 
You asked the Plan to pre-approve the scalings and planings. You say that you are in pain and the deep 
cleaning is the only thing that helps you. The Plan denied your request. The Plan says these services exceed the 
maximum count allowed per period. 
 
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, periodontal scaling and root planing 
(D4341) is limited to one procedure per quadrant every two plan years. The record shows that you received 
periodontal scalings and root planings (D4341) of two quadrants on September 29, 2021, and periodontal 
scalings and root planings (D4341) of two quadrants on October 12, 2021, and your periodontal scalings and 
root planings (D4341) benefit for all four quadrants has been exhausted. Therefore, we decided that the Plan 
does not have to pre-approve periodontal scalings and root planings (D4341) of all four quadrants.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from May 31, 2022, forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from May 31, 2022, forward. You say that the 
services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue are 
not medically necessary.  
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric care from May 31, 
2022, forward. Our reviewer says that the enrollee does not meet the criteria for acute inpatient mental health 
treatment beyond the date in question of May 31, 2022, forward. Our physician reviewer found the enrollee did 
not require inpatient mental health treatment beyond May 31, 2022, as he was not a danger to himself or others 
and did not have any delusions, auditory or visual hallucinations. It did not appear that active treatment was 
taking place beyond the date in question. It did not appear that the services for the dates in question were 
reasonably expected or medically necessary to improve the enrollees condition or for the purpose of diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care from May 31, 2022, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from May 31, 2022, 
forward.
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 IRF care is medically necessary as you want to 
return home and get back to your normal day to day life. The Plan denied your request. The Plan says IRF care 
is not medically necessary and your needs can be met at a lower level of care such as at a skilled nursing 
facility. 
 
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 that while you have a need for physical and/or occupational therapy, there is no 
documentation of a need for an intensive rehabilitation program such as an IRF. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildup, including any pins when required (D2950) 
and crowns - porcelain fused to high noble metal (D2750) for teeth 18 and 19. 
 
You asked the Plan to pre-approve core buildup and crowns. You say that you need these services. 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. 
 
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 core 
buildup, including any pins when required (D2950) and crowns - porcelain fused to high noble metal (D2750) 
for teeth 18 and 19.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dopamine Transporter Scan (DaT scan.) 
 
You asked the Plan to pre-approve a DaT scan. You say that there is concern for a possible underlying 
synucleinopathy causing his symptoms and the requested scan is necessary to aide in providing the appropriate 
diagnosis. The Plan denied your request. The Plan says the records do not show that the enrollee has long-
standing essential tremor that evolved to have characteristics of Parkinson's but fails to respond to optimized 
medication dose. 
 
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 a DaT scan. Our reviewer says that a 
DaT scan is not considered medically reasonable and necessary in this case. Our physician reviewer found a 
DaT scan is generally performed in order to differentiate between patients with a tremor and suspected 
Parkinson's Disease, where a diagnosis cannot be made on clinical grounds. In this case the information 
provided for review did not readily support that the enrollee had a clinical presentation on examination that 
would readily be consistent with Parkinson's Disease that needed differentiated from essential tremor. Nor has the requested service been demonstrated to yield sufficient specificity in diagnoses of possible 
synucleinopathy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a DaT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Dopamine Transporter Scan (DaT scan.)
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve porcelain/ceramic crowns (D2740) for teeth #7, #9, #10, 
#11, and #18. 
 
You asked the Plan to pre-approve crowns. You say that these services are necessary. The Plan denied your 
request. The Plan says these teeth do not appear to have significant breakdown due to decay or trauma. 
Therefore, these crowns are not medically necessary. In addition, you previously had a crown provided for 
tooth #18 on September 22, 2021, which was covered by the Plan at that time. Crowns are only covered once 
per 84 months per tooth. 
 
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 crowns when 
the services are medically necessary and reasonable. The Plan also limits coverage to one crown per patient per 
tooth every 84 months. Though the Plan offers a supplemental benefit in excess of Medicare coverage, the documentation shows that you previously had a crown provided for tooth #18 in September 2021, which is less than 84 months before this 
request. The crown for tooth #18 is requested in a frequency that is not covered by your dental benefit. 
 
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 #7, #9, #10 and #11. 
Our reviewer says that the documentation provided does not meet the criteria for coverage for crown 
restorations for these teeth. Our physician reviewer found the documentation indicates that these teeth do not 
exhibit significant coronal breakdown due to caries or fracture to warrant crown restorations. 
 
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 have not been met. Therefore, we decided that the Plan does not have to 
pre-approve porcelain/ceramic crowns (D2740) for teeth #7, #9, #10, #11, and #18.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home health visit provided on September 14, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the home health visit. You say that there was a valid authorization, and you 
would like the claim processed based on medical necessity. The Plan denied your request. The Plan says the 
rendering provider is an OON provider, and the authorization was reviewed and it did not reference the 
rendering provider on it. Also, the service rendered was not urgent or emergent and the services rendered could 
have been provided by an in-network provider. 
 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 a home health visit provided on September 14, 
2021, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on December 29, 2021. 
 
You asked the Plan to pay for the services provided. You say that 911 was called due to the enrollee's 
condition. The Plan denied your request. The Plan says the claim submitted is missing the mileage code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 We looked at the file and the rules. The claim information does not show that the ambulance services were 
billed according to Medicare guidelines. Therefore, we decided that the Plan does not have to pay for the 
ambulance services provided on December 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the correction of trichiasis (67820) provided on January 18, 
2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the correction of trichiasis. You say that no authorization or referral is needed for 
the correction of trichiasis (67820). You also say that you cannot hold the patient liable for this service because 
it was provided in good faith, and you deserve to be reimbursed. The Plan denied your request. The Plan says 
this service was not urgent or emergent, and no contact was made to the Plan prior to the service being 
rendered to request an OON exception. The Plan also says that Medicare-covered vision services are not listed 
as one of the services that are covered from OON providers due to the Point of Service option. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when the enrollee's Point-of-Service (POS) applies to the services 
provided. 
 
We looked at the file and the Plan's rules. Specifically, the enrollee's 2022 Evidence of Coverage does not 
provide a POS benefit for vision care. Based on this information, we decided that the Plan's rules for coverage 
of the correction of trichiasis have not been met. Therefore, we decided that the Plan does not have to pay for 
the correction of trichiasis (67820) provided on January 18, 2022 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and to 
pay more for the re-cement of a fixed partial denture (D6930) provided on January 24, 2022. 
 
You asked the Plan to pay for the problem focused limited oral evaluation or pay more for the re-cement of a 
fixed partial denture. You say that you would like these charges to be reconsidered because they are not valid. 
The Plan denied your request. The Plan says the problem focused limited oral evaluation is not a covered 
service, and the cost share for the re-cement of a fixed partial denture processed correctly. The Plan also says 
that you signed a pay agreement with the provider's office verifying that you agreed to be responsible for all of 
the services rendered on your behalf. 
 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, problem focused limited oral 
evaluation (D0140) is not among those covered under this benefit. The contract clearly states that you are 
responsible for a 50% coinsurance for the re-cement a fixed partial denture (D6930). Therefore, we decided 
that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and to pay more for 
the re-cement of a fixed partial denture (D6930) provided on January 24, 2022.