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

 
We decided that the Plan does not have to pay for an intraoral imaging (D0220), and a limited oral evaluation 
(D0140) provided by a participating provider on December 21, 2021, and December 30, 2021. 
 
You asked the Plan to pay for an intraoral imaging (D0220), and a limited oral evaluation. You say that you 
have worn your dentures down because you are having to chew a lot more. You say that this is because you had 
a gastro-band. The Plan denied your request. The Plan says the benefit limit for D0220 has already been met 
and exhausted. The Plan says that D0140 is not a covered 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. The Plan covers an intraoral imaging once per calendar year. The Plan does not include a limited oral evaluation.  
 
We looked at the file and Medicare rules. Evidence was provided to show that D0220 was previously provided 
on September 16, 2021. Based on this information, we decided that the Plan's rules for coverage of an intraoral 
imaging (D0220) have not been met. A limited oral evaluation is not a covered benefit. Therefore, we decided 
that the Plan does not have to pay for an intraoral imaging (D0220), and a limited oral evaluation (D0140) 
provided by a participating provider on December 21, 2021, and December 30, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a carotid stent and an inpatient hospital stay. 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the enrollee's request is percutaneous Transluminal Angioplasty and request for inpatient 
hospital stay, because the enrollee's records show they do not have symptoms with the enrollee's 75% 
narrowing of the blood vessel and because the procedure is not meeting criteria the inpatient hospitalization. 
 
The Plan must follow Medicare rules. 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 documentation does not support that the criteria for inpatient payment are 
met in this case. Our physician reviewer found the documentation does not support the medical necessity of the 
treatment in question. The enrollee's carotid stenosis has been determined to be asymptomatic by the provider. A computed tomography angiography (CTA) was obtained to determine the degree of stenosis. The medical 
records describe the computed tomography (CT) finding on the left as moderate to severe stenosis. There is no 
documentation that the enrollee is at high risk for carotid endarterectomy - in fact, carotid endarterectomy is 
listed as one of the potential options for this enrollee. For carotid stenting to be considered medically necessary 
for an asymptomatic patient, there would have to be documentation of critical, 80-99% stenosis in an enrollee 
considered high risk for carotid endarterectomy. 
 
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 carotid stent and an inpatient hospital stay.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the alveoloplasty in conjunction with extractions - one to 
three teeth or tooth spaces, per quadrant (D7311) and extraction, erupted tooth requiring removal of bone 
and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210) provided April 
13, 2021. 
 
You asked the Plan to pay for the alveoloplasty and dental extractions. You say that these services were 
medically necessary. The Plan denied your request. The Plan says that these services are dental in nature and 
do not qualify for coverage under your medical benefit. The Plan also say that you have met your maximum 
dental allowance for 2021 and alveoloplasty is not a covered service 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.  The Plan covers the dental extractions up to a $1,000 maximum benefit.  
 
We looked at the file and Medicare rules. The Plan provided documentation showing that you have exhausted 
your $1,000 dental benefit. Additionally, alveoloplasty is not a covered service.  Therefore, we decided that the 
Plan does not have to pay for the alveoloplasty in conjunction with extractions - one to three teeth or tooth 
spaces, per quadrant (D7311) and extraction, erupted tooth requiring removal of bone and/or sectioning of 
tooth and including elevation of mucoperiosteal flap if indicated (D7210) provided April 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the occlusal guard (D9999) provided November 9, 2021. 
 
You asked the Plan to pay for the night guard. You say that the night guard is necessary to prevent grinding 
your teeth at night. The Plan denied your request. The Plan says you have exhausted your dental allowance for 
2021. 
 
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 night 
guard up to a $1,000 maximum dental allowance.  
 
We looked at the file and Medicare rules. The Plan provided documentation showing that your full $1,000 
dental allowance has been applied to your dental benefits in 2021. The service provided November 9, 2021, 
exceeds the dental coverage limit. Therefore, we decided that the Plan does not have to pay for the occlusal 
guard (D9999) provided November 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the immediate upper denture (D5130) provided on 
September 7, 2021. 
 
You asked the Plan to pay for the dental item. You say that you were advised by a plan representative that 
dentures were covered at 50%. You say that you received a bill for an additional $867. You say that you do not 
feel you are responsible for this bill. You also say that you were given incorrect information from the plan 
representative. The Plan denied your request. The Plan says immediate upper denture 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the immediate upper denture is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
immediate upper denture (D5130) provided on September 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crowns (D2750) for tooth #'s 10, 11, and 12. 
 
You asked the Plan to pre-approve the crowns. You say that you need these services for tooth #'s 10 and 11 
because your gums are bleeding. You also say that you did not receive a crown on tooth #12 within the last 5 
years. The Plan denied your request. The Plan says these services exceed the benefit allowance. 
 
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, single crown restorations are limited to 
once every 60 months. The record shows that you received a crown (D2750) on tooth #12 on October 2, 2019, 
a crown (D2750) on tooth #11 on October 16, 2019, and a crown (D2750) on tooth #10 on November 26, 2019 
and your crown benefits for tooth #'s 10, 11, and 12 has been exhausted. Therefore, we decided that the Plan 
does not have to pre-approve crowns (D2750) for tooth #'s 10, 11, and 12.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the auricular PNS device (CPT code(s): 64555 and 
L8679). 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says medical studies have not proven this service/item is helpful for the 
treatment of the enrollee's health problem. 
 
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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the review has determined that the items/services at issue in this case are not medically 
reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the auricular PNS device (CPT code(s): 64555 and L8679).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150) and surgical 
extraction (D7210) to be provided by an oral surgeon. 
 
You asked the Plan to pre-approve the dental services. You say that you were referred to an oral surgeon. You 
say that you have an abscess and are on antibiotics. You also say that you need the tooth extracted. The Plan 
denied your request. The Plan says coverage is only provided for dental services performed by a participating 
general dentist. The Plan also says that dental services performed by an oral surgeon 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 services to be performed 
by an oral surgeon are not among those covered under this benefit. Therefore, we decided that the Plan does not 
have to pre-approve a comprehensive oral evaluation (D0150) and surgical extraction (D7210) to be provided 
by an oral surgeon.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve four gingival irrigations (D4921 x4). 
 
You asked the Plan to pre-approve the gingival irrigations. You say that the Plan has helped you confirm an 
appointment with a provider, and you hope it will be accepted so these services can be provided. 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 four 
gingival irrigations (D4921 x4).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom abutment (D6057) and endosteal implant 
(D6061). 
 
You asked the Plan to pre-approve the custom abutment and endosteal implant. You say that you assumed 
these services were covered. The Plan denied your request. The Plan says these services are not covered under 
your benefit package. 
 
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 a custom abutment (D6057) and endosteal 
implant (D6061).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the molecular pathology procedure (CPT code 81401), for the enrollee.

You asked the Plan to pre-approve the testing. You say that the enrollee continues to have the constellation of symptoms of Huntington's Disease, and is looking to obtain genetic testing for this disease that will give a better understanding of the enrollee's disease process through a CAG repeat analysis. The Plan denied your request. The Plan says the enrollee has all of the clinical findings of Huntington's disease and they have a positive family history in their mother and in a sister. The Plan states the diagnosis was made on the basis of clinical findings in the past and the enrollee reportedly had a previous test for genetic testing that was positive. The Plan states while this was done anonymously, there should still be a way to decode the anonymity of the enrollee to obtain the result. The Plan states genetic test in Huntington's disease has no impact on treatment, management or survival of the enrollee. The Plan states Medicare does not provide coverage in its genetic policy LCD for Molecular Pathology Procedures (L35000) for testing CGA repeats in Huntington's Disease. The Plan states before genetic testing became available, the diagnosis was based on clinical findings and on a positive family history.

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 testing. Our physician reviewer found the documentation does not support that the results of the requested testing would directly impact the treatment or management of this enrollee. It has not been shown that the testing is necessary for medical decision-making. 

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 testing have not been met. Therefore, we decided that the Plan does not have to pre-approve the molecular pathology procedure (CPT code 81401), for the enrollee.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve allergy injections. 
 
You asked the Plan to pre-approve allergy injections. You say that allergy injections are medically necessary. 
The Plan denied your request. The Plan says that the enrollee does not meet the Plan's Medical Policy criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 allergy injections. Our reviewer says 
that the requested allergy injections are considered medically reasonable and necessary in this case. Our 
physician reviewer found that you were initially tested on December 30, 2019. You have been receiving 
injections since 2020. There has been noticeable improvement in your symptoms since staring immunotherapy. 
You also have intermittent asthma and reports not needing albuterol in a long time and you deny any nocturnal 
symptoms taking oral steroids or needing to be seen in the emergency room over the last year. The review has 
determined that the allergy injections at issue in this case are medically reasonable and 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 allergy injections have been met. Therefore, we decided that the Plan has to pre-
approve allergy injections.  
 
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: 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 the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 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 daily 
skilled services are not necessary. Our physician reviewer found the enrollee did not have any parental 
medications, complex wound care or nutrition given via a feeding tube. She was medically stable without any 
acute exacerbations of chronic medical problems. Her physical function was at or near her baseline. The 
enrollee did not require skilled therapy to establish a safe and effective maintenance program. As a practical 
matter, the member did not require any skilled services on an inpatient basis, at a SNF level of care at the time 
of discharge from the hospital. 
 
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 represented by code E2377, a 
harness represented by code E2313, and an electronic connection between wheelchair controller and 2 or more 
power seating system motors represented by code E2311. 
 
You asked the Plan to pre-approve codes E2377, E2313 and E2311. You say that the records provided support 
the need for the items which remain in dispute. The Plan denied your request. The Plan says the enrollee's 
upper limb strength is adequate for the enrollee to be able to control the power options using their own 
switches, which are included in the allowance. 
 
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 codes E2377, E2313 and E2311. Our 
reviewer says that the items which remain in dispute are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the enrollee does have use of his hands and can operate and control the 
power options using the switches that are included in the basic wheelchair. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of codes E2377, E2313 and E2311 have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an expandable controller represented by code E2377, a harness 
represented by code E2313, and an electronic connection between wheelchair controller and 2 or more power 
seating system motors represented by code E2311.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the tendon or muscle forearm repair (25270) provided on 
November 9, 2021. 
  You asked the Plan to pay for the tendon or muscle forearm repair (25270). You say that the entire claim was 
billed with the appropriate modifiers per NCCI edits, and the denials are an error. You say that the codes 
should be reprocessed. The Plan denied your request. The Plan says "procedure code 25515 has been 
overturned. The Plan also says that CPT code 25270 is considered inclusive 
to CPT code 25515." 
 
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 25270 is a column II code to column I code 25515; however, 25270 
was billed with a modifier.  
 
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 tendon or muscle forearm repair (25270). Our reviewer 
says that the documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer 
found that the operative report does not include enough documentation to confirm this procedure is distinct 
separate procedure from the radial shaft fracture treatment. 
 
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 tendon or muscle forearm repair (25270) have not been met. Therefore, we 
decided that the Plan does not have to pay for the tendon or muscle forearm repair (25270) provided on 
November 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the epidural injections (64483,64484). 
 
You asked the Plan to pre-approve the epidural injections. You say that the service is medically necessary. The 
Plan denied your request. The Plan says the service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that pidural steroid injection (ESI) will be considered 
medically reasonable and necessary when the requirements listed in the Medicare Rules section 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 the epidural injections. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found the records submitted do not 
have documentation as to the degree of pain relief. 
 
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 epidural injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the epidural injections (64483,64484).