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

 
We decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950) 
provided on May 13, 2022. 
 
You asked the Plan to pay for this dental 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 under your 
contractual policy. 
 
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 item provided is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the core buildup, 
including any pins when required (D2950) provided on May 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve connective tissue grafts on tooth #14, 24, and 25 
(D4273) and debridement on tooth #14 (D6102). 
 
You asked the Plan to pre-approve the dental services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that connective tissue grafts (D4273) and debridement (D6102) are not 
covered by your routine 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 
connective tissue grafts on tooth #14, 24, and 25 (D4273) and debridement on tooth #14 (D6102).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reconsider the overpayment recovery for a limited oral evaluation 
(D0140) and periapical x-rays (D0220, D0230) provided on January 15, 2021, and endodontic therapy (D3330) 
provided on February 19, 2021. 
 You asked the Plan to reconsider the overpayment recovery for the dental services. You say that you sent the 
second check back to the Plan. The Plan denied your request. The Plan says the provider has opted out of 
Medicare and is not eligible for payment. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to reconsider the 
overpayment recovery for a limited oral evaluation (D0140) and periapical x-rays (D0220, D0230) provided on 
January 15, 2021, and endodontic therapy (D3330) provided on February 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for temporomandibular joint dysfunction dental service (D9130) 
provided on January 14, 2022 
 
You asked the Plan to pay for the dental services. 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 do not fall 
within 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 pay for 
temporomandibular joint dysfunction dental service (D9130) provided on January 14, 2022
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 83789 billed for date of service March 3, 
2022. 
 
You asked the Plan to pay for procedure code 83789. You say that please review the attached documents and 
reprocess the claim per the benefits of the Plan. The Plan denied your request. The Plan says payment for code 
83789 is bundled into payment for code 80307 and G0481. 
 
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 83789 
is a column II code to column I code 80307 and G0481. 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 83789 billed for date of service 
March 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone replacement graft for ridge preservation - per site 
(D7953). 
 
You asked the Plan to pre-approve a bone replacement graft for ridge preservation - per site (D7953). You say 
that you are requesting reconsideration of the denial of authorization for dental service. The Plan denied your 
request. The Plan says this service is not covered under the benefit package. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
bone replacement graft for ridge preservation - per site (D7953).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the maxillary partial denture  resin base (including, 
retentive/clasping materials, rests, and teeth) (D5211) and mandibular partial denture  resin base (including, 
retentive/clasping materials, rests, and teeth) (D5212) provided January 21, 2022. 
 
You asked the Plan to pay for the upper and lower partial dentures. You say that you feel the provider 
misinformed you about 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 pay for the maxillary partial denture  resin base (including, retentive/clasping materials, rests, and teeth) (D5211) and 
mandibular partial denture  resin base (including, retentive/clasping materials, rests, and teeth) (D5212) 
provided January 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental periodontal scaling and root planing for the upper 
right and lower right quadrants (codes D4341-UR and D43410-LR) provided on May 5, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were told that the Plan would take care of 
this and the dental office did not wait for authorization. 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 March 3, 2021. 
Therefore, we decided that the Plan does not have to pay for dental periodontal scaling and root planing for the 
upper right and lower right quadrants (codes D4341-UR and D43410-LR) provided on May 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an immediate mandibular denture (D5140), panoramic 
radiographic imaging (D0330), a limited oral evaluation (D0140), and extractions (D7210), provided by a 
participating provider on April 27, 2022. 
 
You asked the Plan to pay for an immediate mandibular denture, panoramic radiographic imaging, a limited 
oral evaluation, and extractions. 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 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 an immediate mandibular denture (D5140), panoramic radiographic imaging (D0330), a limited oral evaluation 
(D0140), and extractions (D7210), provided by a participating provider on April 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the application of fluoride (D1206), the oral hygiene 
instructions (D1330), the periodontal scaling (D4341), the periodontal irrigation (D4921), and the periodontal 
procedure (D4999) provided on November 3, 2021. 
 
You asked the Plan to pay for the dental services. You say that you were told that these dental procedures 
would be covered. The Plan denied your request. The Plan says the denial of payment for these services is 
correct, because none of these services are covered by the Plan. The Plan also says that the provider never 
contacted the Plan regarding 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 pay for the 
application of fluoride (D1206), the oral hygiene instructions (D1330), the periodontal scaling (D4341), the 
periodontal irrigation (D4921), and the periodontal procedure (D4999) provided on November 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair (K0899, E2359). 
 
You asked the Plan to pre-approve a power wheelchair. You say that you are immobile and cannot access care 
without this, because one of your feet are deteriorating. You need dental work; you have lost a lot of weight 
and need to access care. The Plan denied your request. The Plan says there has been no POV evaluation done 
from a qualified mobility professionals/physical therapist for this requested power wheelchair (K0899). It is 
hard to determine if you actually need a power wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a power wheelchair. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found you appear to be having difficulty 
with the seating of a manual wheelchair and different cushions have been trialed. It does appear that you are 
having difficulty with ADLs and require a wheelchair but there is no documentation to show that you would be 
able to safely operate a power mobility device in the home thus at this time 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 a power wheelchair have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power wheelchair (K0899, E2359).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve complete maxillary dentures (D5110) and complete 
mandibular dentures (D5210). 
 
You asked the Plan to pre-approve dentures. You say that you are unable to eat without the dentures. The Plan 
denied your request. The Plan says complete maxillary dentures (D5110) and complete mandibular dentures 
(D5210) are not covered by your routine 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 
complete maxillary dentures (D5110) and complete mandibular dentures (D5210).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Volara system, a high frequency chest wall oscillation 
device (E1399). 
 
You asked the Plan to pre-approve a Volara system. You say that the device is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not have a qualifying diagnosis of bronchiectasis, cystic 
fibrosis or neuromuscular disease. The requested device is not reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are 
medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases.  
 
 
 
 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 Volara system. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found the enrollee has severe COPD with 
frequent exacerbations. There is insufficient evidence that the Volara System is effective in the treatment of 
COPD as an outpatient or offers advantages over traditional treatments. The system includes airflow 
oscillation, positive end-expiratory pressure, and nebulization. The first two have not been shown to be 
effective in COPD, and the third is available with a traditional nebulizer. 
 
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 Volara system have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Volara system, a high frequency chest wall oscillation device (E1399).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mass spectrometry and tandem mass spectrometry (83789) 
billed for date of service December 1, 2021. 
 
You asked the Plan to pay for mass spectrometry services. You say that these services were necessary and are 
supported in the medical record. The Plan denied your request. The Plan says they have agreed to pay for the 
drug testing services; however, code 83789 is specimen validity testing which is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of mass spectrometry services have not been met. Specifically, we find that the testing described by 
the billed code is considered specimen validity testing which is not separately payable. Therefore, we decided 
that the Plan does not have to pay for mass spectrometry and tandem mass spectrometry (83789) billed for date 
of service December 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) and intraoral x-rays 
(D0210) provided on April 1, 2022. 
 
You asked the Plan to pay for an evaluation and an x-ray. You say that these services should be covered in full. 
The Plan denied your request. The Plan says a limited oral evaluation (D0140) and intraoral x-rays (D0210) are 
not covered by your supplemental 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 pay for a limited 
oral evaluation (D0140) and intraoral x-rays (D0210) provided on April 1, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Aranesp. 
 
You asked the Plan to pre-approve Aranesp. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the Plan requires a trial of Retacrit or Procrit before it will approve Aranesp. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
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 Aranesp. Our reviewer says that the 
enrollee does not meet the Medicare criteria for a step therapy exception for Aranesp. Our physician reviewer 
found the enrollee has not tried and failed the Plan's preferred drugs of Retacrit or Procrit. The record does not 
show that these drugs would be less effective and/or have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Aranesp have not been met. Therefore, we decided that the Plan does not have 
to pre-approve use of Aranesp.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mandibular partial denture (D5214). 
 
You asked the Plan to pre-approve a mandibular partial denture. You say that you have no teeth, and it hurts 
when you eat so having dentures would help you. The Plan denied your request. The Plan says this is 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
mandibular partial denture (D5214).
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for ultrasound, breast, unilateral, real time with image documentation, 
including axilla when performed; complete (CPT code 76641-50). 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says that the service is 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 service. Our reviewer found the Plan has denied payment 
for unilateral breast ultrasound on June 9, 2022. The records show evidence of a bilateral breast ultrasound on 
June 9, 2022. CPT code 76641 should be paid. 
 
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 service have been met. Therefore, we decided that the Plan has to pay for 
ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; complete 
(CPT code 76641-50).  
 
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: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Epifix. 
 
You asked the Plan to pre-approve Epifix. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that covers application of skin substitutes to Ulcers or 
Wounds under certain circumstances. 
 
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 Epifix. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found based on the provided documentation the 
enrollee appears to be improving with current treatments. Also, it was not clear if the enrollee's diabetes was 
well under control with lifestyle or medical management as required by the LCD criteria. No antidiabetic 
medications were listed as being taken regularly. Therefore, the criteria appear to not be met by this enrollee 
for the Epifix at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Epifix have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Epifix.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided from May 11, 2022, 
through May 12, 2022. 
 
You asked the Plan to pay for the self-administered drugs. You say that you would like the claim for self-
administered medications reprocessed and approved for payment. The Plan denied your request. The Plan says 
these drugs are not covered under your 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 pay for the self-administered drugs 
provided from May 11, 2022, through May 12, 2022.  
 Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.