Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transport chair, adult size, patient weight capacity up to and including 300 pounds (E1038).

You asked the Plan to pre-approve a transport chair. You say that the enrollee was previously independent but now wheelchair bound without ability to transfer. The enrollee's wife is unable to get the wheelchair in her car and the transfer chair is medically necessary. The Plan denied your request. The Plan says the transport chair is being requested for ease of transport in a vehicle not for use inside the home to perform mobility-related activities of daily living. In addition, since the enrollee has been provided with a wheelchair that can meet his needs for MRADLS in your home, the transport chair would be a duplicate item and not covered.

The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. 

The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. The records also show that the enrollee currently has a wheelchair that can meet his needs for MRADLs in the home. A new chair would result in a duplicate item and that is not covered by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve a transport chair, adult size, patient weight capacity up to and including 300 pounds (E1038).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bitewings - four radiographic images (D0274), limited oral 
evaluation - problem focused (D0140), and prophylaxis - adult (D1110) provided on November 22, 2021. 
 
You asked the Plan to pay for the dental services. You say that you were informed by the Plan that you could 
see any dentist regardless of in or out-of-network status. The Plan denied your request. The Plan says the dental 
services were received from an out-of-network provider and are not covered by your supplemental 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 record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for bitewings - four radiographic images (D0274), limited oral evaluation - problem focused (D0140), 
and prophylaxis - adult (D1110) provided on November 22, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of lumbar spine without contrast (72158).

You asked the Plan to pre-approve MRI of lumbar spine. You say that the enrollee needs an MRI with and without contrast. You also say that the enrollee has tried and failed physical therapy. The Plan denied your request. The Plan says the requested service is not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 MRI of lumbar spine. Our reviewer says that the requested MRI of lumbar spine is not medically necessary. Our physician reviewer found the provided documentation indicates the enrollee has previously had lumbar imaging. The reviewer found that there is no clinical justification in the records for repeat imaging of the lumbar spine. Therefore, the reviewer found the requested MRI 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 MRI of lumbar spine have not been met. Therefore, we decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of lumbar spine without contrast (72158).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for panoramic radiographic image (D0330), an adult 
prophylaxis (D1110), bitewings (D0274), and a comprehensive oral evaluation (D0150) provided on July 11, 
2022. 
 
You asked the Plan to pay more for the dental services. You say that you were unaware that this provider is 
out-of-network. The Plan denied your request. The Plan says you are responsible for any charged amount 
above the Plans cost-sharing amount when your services are received from an out-of-network provider. 
 
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. 
 
 
  You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for panoramic radiographic image (D0330), an 
adult prophylaxis (D1110), bitewings (D0274), and a comprehensive oral evaluation (D0150) provided on July 
11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone grafts while placing implants (D6104) for tooth 
#13 and #20. 
 
You asked the Plan to pre-approve the dental services. You say that it is medically necessary for you to get the 
dental procedures done. The Plan denied your request. The Plan says the radiographs and treatment plan show 
no tooth being extracted in this area. There is no documentation to necessitate a bone graft when the radiograph 
shows ample bone for implant placement. 
 
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 
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 dental services. Our reviewer says 
that the documentation does not support the need for a bone graft in the areas of tooth #13 and #20 from the 
records provided. Our physician reviewer found that where a tooth is to be replaced with an endosteal implant, 
the bone to support it needs to be of sufficient quality and quantity. Often at tooth removal a bone graft is 
placed to attempt to preserve as much bone as possible, but where the tooth had previously been removed it is 
possible there is adequate remaining bone such that a graft is not necessary. In this instance there is no showing 
of inadequate bone volume or quality to place an implant. Bone levels look to be adequate on the provided x-
rays. Without support for the need for additional bone support, there would be no necessity for the requested 
bone grafts. 
 
The Plan requires that need for a bone graft procedure be shown to find that the criteria have been met. In this 
instance there is no showing of need for the additional bone to support the implants, and therefore the criteria 
for the requested procedures have not been met. 
 
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 dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve bone grafts while placing implants (D6104) for tooth #13 and #20.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service August 26, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. 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 August 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87150, 87324, 87801) provided on April 25, 
2022. 
 You asked the Plan to pay for the lab services. You say that this should be covered. The Plan denied your 
request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services (87150, 87324, 87801) provided on April 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a second stage implant surgery (D6011) and general 
anesthesia (D9222 and D9223) provided by a participating provider. 
 
You asked the Plan to pre-approve a second stage implant surgery and general anesthesia. You say that these 
services are medically necessary. The Plan denied your request. The Plan says medical criteria for the 
requested dental work have not been met. 
 
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 a second 
stage implant surgery and general anesthesia 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 a second stage implant surgery and 
general anesthesia. Our physician reviewer found the documentation provided does not meet the criteria for 
coverage of medically reasonable and necessary for D6011, second stage implant surgery for area #21 and 26 
and deep sedation/general anesthesia (D9222, D9223). 
  
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 a second stage implant surgery and general anesthesia have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a second stage implant surgery (D6011) and 
general anesthesia (D9222 and D9223) provided by a participating provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99152 provided on March 27, 2022. 
 
You asked the Plan to pay for procedure code 99152. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not supported as billed. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99152 is Moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older. 
 
We find that CPT code 99152 is not supported in the medical record. Specifically, the medical record does not 
contain evidence that moderate sedation was performed with the presence of an independent trained observer. 
Based on this information, we decided that Medicare rules for coverage of procedure code 99152 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 99152 provided on March 27, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the medicaments dispensed in the office for home 
use (D9630) provided on May 6, 2022. 
 
You asked the Plan to reimburse you for the dental service. You say that you thought the Plan covered cleaning 
and the denied dental service should be covered. The Plan denied your request. The Plan says the denial of 
reimbursement for this service is correct, because the medicaments dispensed in the office for home use is not 
covered by the 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse you for 
the medicaments dispensed in the office for home use (D9630) provided on May 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gingival irrigation (D4921). 
 
You asked the Plan to pre-approve gingival irrigation. You say that you disagree with the denial of dental 
services. The Plan denied your request. The Plan says that gingival irrigation (D4921) is not covered by the 
enrollee's 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 
gingival irrigation (D4921).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a PushTracker E3, black preconfigured (K0108). 
 
You asked the Plan to pre-approve a PushTracker. You say that you disagree with the denial and have attached 
the repair history. The Plan denied your request. The Plan says the requested item does not meet the Medicare 
NCD criteria for durable medical equipment. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a PushTracker E3, black preconfigured (K0108).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shower chair (E0240) provided on March 19, 2022. 
 
You asked the Plan to pay for this item. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate for you in this case, neither the Plan nor Medicare offers coverage of 
this item. Therefore, we decided that the Plan does not have to pay for the shower chair (E0240) provided on  
March 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on August 16, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the services requested 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 pay for the dental 
services on August 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on June 20, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on June 20, 
2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergency ambulance transportation (A0426) and 
ground mileage (A0425) provided on July 12, 2022. 
 
You asked the Plan to pay for the non-emergency ambulance transportation and ground mileage. You say that 
the enrollee was transferred for a higher level of care. The Plan denied your request. The Plan says this would 
be an uphold, as the enrollee was an inpatient at this time, and the services are covered under the Part A 
services that are in place at the time for the enrollee. 
 
The Plan must follow Medicare rules. Medicare rules say the movement of the patient after they have been 
admitted to a hospital but need to be transported to another hospital temporarily is considered "patient 
transportation" and is covered as an inpatient hospital service and payment is made under Part A for that 
service.  
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the non-emergency ambulance transportation and ground mileage have not been met. Therefore, 
we decided that the Plan does not have to pay for the non-emergency ambulance transportation (A0426) and 
ground mileage (A0425) provided on July 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the frames and the lenses provided by an out-of-network 
provider on July 26, 2022. 
 You asked the Plan to pay for the frames and the lenses. You say that you do not want to change providers and 
the service should be covered. The Plan denied your request. The Plan says the provider was out-of-network. 
 
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 provided by a network provider. 
 
We looked at the file and the Plan's rules. Specifically, the rendering provider was out-of-network. Based on 
this information, we decided that the Plan's rules for coverage of the frames and the lenses have not been met. 
Therefore, we decided that the Plan does not have to pay for the frames and the lenses provided by an out-of-
network provider on July 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) and a resin-based 
composite of four or more surfaces (D2335) for tooth #24 provided on August 26, 2022. 
 
You asked the Plan to pay for the dental services. You say that the Plan should cover some of the dental 
procedure. The Plan denied your request. The Plan says the denial of payment for these services is correct, 
because the limited oral evaluation and a resin-based composite of four or more surfaces are not covered by the 
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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a limited 
oral evaluation (D0140) and a resin-based composite of four or more surfaces (D2335) for tooth #24 provided 
on August 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2740) and a core build-up (D2950) provided by a 
participating provider on June 8, 2022. 
 
You asked the Plan to pay for a crown and a core build-up. You say that you would like the Plan to pay for this. 
The Plan denied your request. The Plan says the rendered dental services are not 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) and a core build-up (D2950) provided by a participating provider on June 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided by an 
out-of-network provider on June 9, 2022. 
 
You asked the Plan to pay for the dental services. You say that you confirmed this doctor was in-network. 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 January 15, 2020. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) 
provided by an out-of-network provider on June 9, 2022.