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

 
We decided that the Plan does not have to pay for oral hygiene instructions (D1330) provided on June 24, 
2022. 
 
You asked the Plan to pay for hygiene instructions. You say that you disagree with the denial of dental 
services. The Plan denied your request. The Plan says oral hygiene instructions (D1330) 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 pay for oral 
hygiene instructions (D1330) provided on June 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded as 87640, 87581, 87486, 
87498, 87541, 87502, 87634 and 87798 provided April 25,2022. 
 
You asked the Plan to pay for the laboratory services. You say that you greatly appreciate review of this claim 
for medical necessity. The Plan denied your request. The Plan says the request does not meet the Medicare 
criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The testing was not ordered by a clinician specializing in Infectious 
Disease or Pulmonology nor does the enrollee have an established underlying respiratory pathology as outlined 
by the policy. the testing is not FDA approved nor has the testing undergone registration with Molecular 
Diagnostic Services Program (MolDX). Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay 
for the laboratory services coded as 87640, 87581, 87486, 87498, 87541, 87502, 87634 and 87798 provided 
April 25,2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mandibular partial denture (D5214) and unspecified 
removable prosthodontic procedure (D5899) provided on June 28, 2022. 
 
You asked the Plan to pay for dental services. You say that you received a bridge, not partial dentures so you 
should not have to pay for this. The Plan denied your request. The Plan says this service is not covered under 
your 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. Mandibular partial denture and 
unspecified removable prosthodontic procedure are not covered under the Plans dental benefits. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested mandibular partial 
denture (D5214) and unspecified removable prosthodontic procedure (D5899) are not among those covered 
under this benefit. Therefore, we decided that the Plan does not have to pay for mandibular partial denture 
(D5214) and unspecified removable prosthodontic procedure (D5899) provided on June 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulation provided by a chiropractor on May 
6, 2022, July 1, 2022, and July 15, 2022, described by code G0283. 
 
You asked the Plan to pay for the electrical stimulation services. You say that you were told that these codes 
would be covered with copayments when you called prior to receiving this care. You would not have had these 
services if you were not told they would be covered. The Plan denied your request. The Plan says it was 
confirmed that you were given misinformation by the Plan, and as such, the codes you were told were covered 
have been approved for payment under your contractual cost sharing. However, no information was given 
regarding code G0283 which is not covered when provided by a chiropractor. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the electrical stimulation provided by a chiropractor on May 6, 2022, July 1, 
2022, and July 15, 2022, described by code G0283.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve partial reconstruction of the lower jawbone with 
implants (21248). 
 
You asked the Plan to pre-approve the dental services. You say that you need the requested services. The Plan 
denied your request. The Plan says the services you requested are not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
partial reconstruction of the lower jawbone with implants (21248).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4341). 
 
You asked the Plan to pre-approve the dental services. You say that the services should be reconsidered for pre-
approval because they are medically necessary. The Plan denied your request. The Plan says the enrollees 
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 the enrollees benefit for the requested item or service was exhausted on date of service December 10, 
2020, for the upper and lower left quadrants; and December 16, 2020, for the upper and lower right quadrants. 
This means you would not be eligible for the requested service on the left quadrants until December 10, 2023. 
Likewise, you would not be eligible for the requested service on the right quadrants until December 16, 2023. 
Therefore, we decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4341).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical placement of an endosteal implant on tooth #30 
(D6010), an abutment-supported porcelain/ceramic crown of tooth #30 (D6058), and a custom-made abutment 
for tooth #30 (D6057). 
 
You asked the Plan to pre-approve the dental services. You say that the enrollee needs this service due to the 
severity of the enrollee's condition. The services would have a positive impact and would facilitate tooth 
preservation. The Plan denied your request. The Plan says the requested services are not covered by the 
enrollees dental benefit under any circumstances. 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 
surgical placement of an endosteal implant on tooth #30 (D6010), an abutment-supported porcelain/ceramic 
crown of tooth #30 (D6058), and a custom-made abutment for tooth #30 (D6057).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a crown on tooth #8 (D2740) provided on May 26, 
2022. 
 
You asked the Plan to pay more for a crown. You say that you cannot afford this payment. The Plan denied 
your request. The Plan says your annual dental allowance has been met. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that the supplemental 
dental benefit includes coverage up to a $2,000 allowance for preventive and comprehensive dental services. The record shows your dental allowance has been met during the processing of this claim. You have been 
asked to pay $915 for a crown. This item/service falls within the dental service benefit category. This means 
that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to pay more for a crown on tooth #8 (D2740) provided on May 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial mandibular denture (D5226). 
 
You asked the Plan to pre-approve the dental services. You say that you disagree with the denial of dental 
services. The Plan denied your request. The Plan says your benefit for the requested item or service has already 
been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service December 31, 2019. 
Therefore, we decided that the Plan does not have to pre-approve a partial mandibular denture (D5226).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for codes 93770 and 94761 
 
You asked the Plan to pay for codes 93770 and 94761. You say that this claim was denied incorrectly. The Plan 
denied your request. The Plan says that per the National Correct Coding Initiative (NCCI), "many procedures 
require cardiopulmonary monitoring, either by the physician performing the procedure or an anesthesia 
provider.  Since these services are integral to the procedure, they are not separately reportable.  Examples of 
these services include cardiac monitoring, pulse oximetry, and ventilation management (e.g. 93000-93010, 
94760, 94761).  The Plan states that based on this rule, codes 93770 and 94761 are not payable. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, we agree with the Plan that the NCCI manual does say that codes 
93770 and 94761 are not separately payable when billed with certain procedures.  However, the Plan has failed 
to identify which specific billed procedure is the 'primary' procedure that these codes would be integral to.  
These codes are not considered integral to every single procedure, so it is crucial that the Plan identify the 
primary procedure.  They have failed to do so in this case. Therefore, we decided that the Plan has to pay for 
codes 93770 and 94761  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the maintenance and cleaning of a maxillofacial 
prosthesis (D6011) 
 
You asked the Plan to pre-approve the maintenance and cleaning of a maxillofacial prosthesis. 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 pre-approve the 
maintenance and cleaning of a maxillofacial prosthesis (D6011)
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an endoskeleton knee-shin hydraulic swing mech lock 
(L5814), an endoskeleton knee-shin system fluid stance extension (L5848), a lower limb prosthesis mx-axial 
ankle with swing phase (L5968), and a lower extremity prosthesis flex-walk system (L5891). 
 
You asked the Plan to pre-approve codes L5814, L5848, L5968, and L5981. You say that this specific 
prosthesis is necessary. The Plan denied your request. The Plan says while the patient meets criteria for a lower 
limb prosthesis, the patient does not meet criteria for a prosthetic leg with an advanced knee and foot with 
ankle. 
 
The Plan follows Medicare rules. Medicare rules say that in order for certain knee and foot systems that are 
part of a prosthesis to be covered, the patient must be at a level 3 functional level or higher. 
 
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 L5814, L5848, L5968, and 
L5981. Our reviewer says that the requested items are not medically necessary. Our physician reviewer found 
additional features or components to a prosthesis may be necessary depending on the patients potential 
functional abilities. Potential functional ability is based on the reasonable expectations of the prosthetist, and 
treating practitioner, considering multiple factors. These factors include the patients past history, current 
condition including the status of the residual limb and the nature of the other medical problems and the 
patients desire to ambulate. A level 3 ambulator has the ability or potential for ambulation with variable 
cadence. This is typical of the community ambulator who has the ability to traverse most environmental 
barriers and may have vocational, therapeutic or exercise activity that demands prosthetic utilization beyond 
simple locomotion. In this case, the member requires a replacement prosthesis. The documentation indicates 
that even with a new prosthesis the member is expected to use an assistive device.  The documentation does not 
support the need for an advanced knee, foot and ankle system. 
 
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 L5814, L5848, L5968, and L5981 have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an endoskeleton knee-shin hydraulic swing mech lock 
(L5814), an endoskeleton knee-shin system fluid stance extension (L5848), a lower limb prosthesis mx-axial 
ankle with swing phase (L5968), and a lower extremity prosthesis flex-walk system (L5891).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) and 
intraoral - periapical first radiographic image (D0220) provided May 20, 2022. 
 
You asked the Plan to pay for the dental services. You say that this was an emergency visit. The Plan denied 
your request. The Plan says your benefit for the requested services has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the limited oral exam was exhausted on date of service February 16, 2022, and the 
periapical x-ray was exhausted on January 19, 2021. Therefore, we decided that the Plan does not have to pay 
for the limited oral evaluation - problem focused (D0140) and intraoral - periapical first radiographic image 
(D0220) provided May 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custom molded shoes (A5501 x2), an ankle foot orthosis 
(L1990), an addition to lower extremity, long tongue stirrup (L2265), a varus/valgus correction (T) strap, 
padded/lined or malleolus pad (L2270), an addition to lower extremity orthosis, noncorrosive finish, per bar 
(L2780 x2), foot inserts (L3020 x2), an out flare wedge (L3390), and an addition to lower extremity, 
dorsiflexion assist (L2210 x2) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve procedure codes A5501 x2, L1990, L2265, L2270, L2780 x2, L3020 x2, 
L3390, and L2210 x2. You say that you would like the Plan to reconsider their denial. The Plan denied your 
request. The Plan says the items you are requesting are approved through an in-network supplier.  
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
custom molded shoes (A5501 x2), an ankle foot orthosis (L1990), an addition to lower extremity, long tongue 
stirrup (L2265), a varus/valgus correction (T) strap, padded/lined or malleolus pad (L2270), an addition to 
lower extremity orthosis, noncorrosive finish, per bar (L2780 x2), foot inserts (L3020 x2), an out flare wedge 
(L3390), and an addition to lower extremity, dorsiflexion assist (L2210 x2) to be provided by an out-of-
network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for periodic oral evaluation (D0120), intraoral 
- periapical first radiographic image (D0220), intraoral - periapical each additional radiographic image (D0230) 
x3 prophylaxis - adult (D1110) provided on May 12, 2022. 
 
You asked the Plan to waive the copayment for dental services. You say that you are disputing the cost share 
copayment applied to the dental services received. The Plan denied your request. The Plan says the coinsurance 
has been applied correctly. 
  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 says you must pay 
$10 copayment per service during the visit for covered routine dental services when provided by an in-network 
and out-of-network provider. 
 
You have been asked to pay $60 for dental services ($10/per service x 6 = $60). Therefore, we decided that the 
Plan does not have to waive the copayment for periodic oral evaluation (D0120), intraoral - periapical first 
radiographic image (D0220), intraoral - periapical each additional radiographic image (D0230) x3 
prophylaxis - adult (D1110) provided on May 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve to replace all teeth and acrylic on cast metal framework 
(D5671). 
 
You asked the Plan to pre-approve the dental services. You say that this service is medically necessary. The 
Plan denied your request. The Plan says the requested service 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 to 
replace all teeth and acrylic on cast metal framework (D5671).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral imaging (D0220) and amalgam (D2160) provided 
by a participating provider on July 8, 2022. 
 
You asked the Plan to pay for intraoral imaging and amalgam. You say that you believe the Plan should be 
reimbursed for this. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 50% 
coinsurance for Dental Services/Class 2 Basic Services.  
 
You have been asked to pay a 50% coinsurance of the allowed amount for intraoral imaging and amalgam. The 
total allowed amount is $185. The total amount you are being asked to pay is $92.50 ($185 x 50% = 
$92.50)This item/service falls within the Dental Services/Class 2 Basic Services benefit category. This means 
that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to pay for intraoral imaging (D0220) and amalgam (D2160) provided by a participating provider 
on July 8, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 97112 and 97530 provided on May 12, 
2022. 
 
You asked the Plan to pay for procedure codes 97112 and 97530. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the medical records do not 
support the billing of codes 97112 and 97530 provided on May 12, 2022. 
 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 97112 is Therapeutic procedure, 1 or more areas, each 15 
minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or 
proprioception for sitting and/or standing activities. The definition of code 97530 is Therapeutic activities, 
direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 
minutes. 
 
We find that CPT codes 97112 and 97530 are not supported in the medical record. Specifically, the medical 
record for the May 12, 2022, date of service does not include a description of codes 97112 and 97530 being 
performed. Based on this information, we decided that Medicare rules for coverage of procedure codes 97112 
and 97530 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 
97112 and 97530 provided on May 12, 2022.