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

 
We decided that the Plan does not have to pre-approve a comprehensive oral exam and tooth extraction by an 
oral surgeon. 
 
You asked the Plan to pre-approve these services. You say that you are in pain and need the tooth extraction. 
The Plan denied your request. The Plan says an oral surgeon 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. The Plan covers supplemental 
dental benefits from a participating general dentist only. 
 
We looked at the file and the Plans rules. The requested services are from an oral surgeon and not a general 
dentist. Based on this information, we decided that the Plan's rules for coverage of these services have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a comprehensive oral exam and tooth 
extraction by an oral surgeon.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the flexible protective outer surface covering for 
prosthetic leg (L5962). 
 
You asked the Plan to pre-approve the flexible protective outer surface covering. You say that this is necessary 
for the enrollee's condition. The Plan denied your request. The Plan says there is no need for the requested extra 
covering. 
 
The Plan must follow Medicare rules. Medicare rules say that that protective outer surface covering systems 
(L5962, L5964, and L5966) are specialized covers intended to be worn over an existing prosthesis. They are 
used by a beneficiary who has special needs for protection against unusually harsh environmental situations 
where it is necessary to protect the lower limb prosthesis beyond the level of protection. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the flexible protective outer surface covering have not been met. Specifically, there is no indication that the enrollee will be in an unusually harsh environmental situation. Therefore, we decided that the Plan does 
not have to pre-approve the flexible protective outer surface covering for prosthetic leg (L5962).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740) provided by an out-of-network 
provider. 
 
You asked the Plan to pre-approve the dental services. You say that you would like the Plan to approve these 
services. The Plan denied your request. The Plan says dental services from an out-of-network provider 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. 
 
You are requesting 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 pre-approve a crown 
(D2740) provided by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an endosteal implant (D6010) provided by a 
participating provider. 
 
You asked the Plan to pre-approve an endosteal implant. You say that these services are medically necessary. 
The Plan denied your request. The Plan says the requested dental service is 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 an 
endosteal implant (D6010) provided by a participating provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes billed with modifier -26 for date of service 
July 11, 2022. 
 
You asked the Plan to pay for procedure codes billed with modifier -26. You say that these services were 
necessary and are supported as billed. The Plan denied your request. The Plan says modifier -26 is not 
supported or appropriate for these services. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
 We looked at the file and Medicare rules. The codes at issue are not supported with modifier -26 as this 
modifier is not billable for codes paid on the Clinical Lab Fee Schedule. Based on this information, we decided 
that Medicare rules for coverage of procedure codes billed with modifier -26 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes billed with modifier -26 for date of service July 
11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture (D5213) provided by a 
participating provider. 
 
You asked the Plan to pre-approve the dental services. You say that you broke your old denture, and you need a 
new one. 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 June 28, 2021. Therefore, 
we decided that the Plan does not have to pre-approve a maxillary partial denture (D5213) provided by a 
participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740) and core buildup (D2950) for tooth 
#13. 
 
You asked the Plan to pre-approve the dental services. You say that the tooth has extensive restorations with 
recurrent decay and fracture lines. The Plan denied your request. The Plan says the tooth does not show large 
decay requiring replacing a significant amount of the tooth. The decay does not involve a cusp of the tooth. A 
buildup is necessary if there is not enough tooth structure remaining after decay is removed to provide retention 
of a crown not to fill in missing tooth structure. 
 
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 the requested dental services. Our physician reviewer 
found that the x-rays and photos do not indicate that tooth #13 has sufficient damage to the tooth structure as to 
require a full coverage crown. In general, if a tooth has about 50% or more of the structure missing or damaged 
a crown restoration can be considered. With a lesser amount of damage, a conventional restoration is usually 
considered appropriate to restore the tooth and preserve more of the intact structure. In this instance there does 
not appear to be sufficient missing structure as to require a full coverage crown to restore the tooth and 
maintain it in function. Therefore, there is no necessity for the requested crown on tooth #13. Core buildups are 
only necessary when a crown is needed and there is insufficient retention to hold the crown. As no crown is 
needed there is no need to consider the service in this case. 
 
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 a crown (D2740) and core buildup (D2950) for tooth #13.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve comprehensive oral evaluation - new or established 
patient (D0150) and extraction, erupted tooth requiring removal of bone and/or sectioning of tooth and 
including elevation of mucoperiosteal flap if indicated (D7210) x2. 
 
You asked the Plan to pre-approve dental services. You say that you have an infection in your mouth, and you 
have teeth that need to be removed as soon as possible. The Plan denied your request. The Plan says this 
service is not covered under your Plan when performed by an oral surgeon. Services must be performed by a 
general dentist. 
 
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. Comprehensive oral 
evaluation - new or established patient and extraction, erupted tooth requiring removal of bone and/or 
sectioning of tooth and including elevation of mucoperiosteal flap if indicated are not covered under the Plans 
dental benefits if not performed by a participating general dentist. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested comprehensive oral 
evaluation - new or established patient and extraction, erupted tooth requiring removal of bone and/or 
sectioning of tooth and including elevation of mucoperiosteal flap if indicated are not covered under the Plans 
dental benefits if not performed by a participating general dentist. The request is for an oral surgeon to perform 
services. Therefore, we decided that the Plan does not have to pre-approve comprehensive oral evaluation - 
new or established patient (D0150) and extraction, erupted tooth requiring removal of bone and/or sectioning 
of tooth and including elevation of mucoperiosteal flap if indicated (D7210) x2.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a mandibular partial denture (D5214) provided by a 
participating provider. 
 
You asked the Plan to pay for the dental services. You say that your other denture does not fit properly. 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 November 12, 2019. 
Therefore, we decided that the Plan does not have to pay for a mandibular partial denture (D5214) provided by 
a participating provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on September 9, 2021, billed 
with codes 0031U, 0078U, 81225, 81226, 81227, 81230, 81231, 81240, 81241, 81328, 81355 and 81401. 
 
You asked the Plan to pay for the genetic testing billed. You say that this test was medically necessary and is 
covered by Medicare. The Plan denied your request. The Plan says panel testing should be billed using one 
CPT code on the claim. 
 The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
September 9, 2021, billed with codes 0031U, 0078U, 81225, 81226, 81227, 81230, 81231, 81240, 81241, 
81328, 81355 and 81401.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary and mandibular denture (D5110 
and D5120). 
 
You asked the Plan to pre-approve the dental services. You say that you cannot eat with your current dentures. 
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 September 16, 2019. 
Therefore, we decided that the Plan does not have to pre-approve a complete maxillary and mandibular denture 
(D5110 and D5120).
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a resin base maxillary partial denture (D5211). 
 
You asked the Plan to pre-approve the dental services. You say that your provider advised you to appeal the 
denial. The Plan denied your request. The Plan says that your benefit for the requested item or service has 
already been exhausted. 
 
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. The Plan did not submit documentation showing that a maxillary partial denture 
was paid for within the last 5 years. This means that the Plan did not support their denial that your benefit has 
been exhausted. Therefore, we decided that the Plan has to pre-approve a resin base maxillary partial denture 
(D5211). 
 
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 gingival irrigation (D4921). 
 
You asked the Plan to pre-approve the dental service. You say that you are appealing the denied dental service. 
The Plan denied your request. The Plan says the denial of authorization for this service is correct, because 
gingival irrigation 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 pre-approve 
gingival irrigation (D4921).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the surgical bone reshaping (D4260) on all 4 quadrants. 
 
You asked the Plan to pre-approve the dental services. You say that the surgery is necessary in order to prevent 
increase in probing depths and potentially loosing teeth. The Plan denied your request. The Plan says the teeth 
in the upper right, upper left and lower right have a poor prognosis. There is not enough bone to hold the teeth 
in place. The teeth in the lower left do not show bone loss or root surface calculus. Before surgery can be done 
on this area, a deep cleaning should be done. 
 
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 osseous surgery in the area of these hopeless teeth is not medically necessary nor reasonable. Our 
physician reviewer found that a review of the submitted documentation indicates multiple hopeless teeth due to 
extreme bone loss, non-restorable caries and broken-down teeth. It is my opinion that the hopeless teeth should 
be removed after which a treatment plan formulated to treat the periodontal issues of the remaining teeth. 
 
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 the surgical bone reshaping (D4260) on all 4 quadrants.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a core build-up (D2950) provided by a participating 
provider. 
 
You asked the Plan to pay for a core build-up. You say that this is medically necessary. The Plan denied your 
request. The Plan says the rendered dental service is 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 pay for a core 
build-up (D2950) provided by a participating provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87634 billed for date of service February 7, 
2022. 
 
You asked the Plan to pay for procedure code 87634. You say that this claim should be paid. The Plan denied 
your request. The Plan says payment for code 87634 is bundled into payment for code 87632.  
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 87634 
is a column II code to column I code 87632. 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 87634 billed for date of service February 7, 
2022.
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 July 5, 2022. 
 
You asked the Plan to pay for the dental services. You say that you believed that your provider 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 Plan 
provided documentation showing that your $1,00 dental allowance was exhausted prior to the requested 
service. Therefore, we decided that the Plan does not have to pay for the core buildup, including any pins when 
required (D2950) provided on July 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a medical eye examination (92014) and the 
scanning of computerized ophthalmic diagnostic imaging of the retina (92134) provided on July 26, 2022. 
 
You asked the Plan to waive the copayment for a medical eye examination (92014) and the scanning of 
computerized ophthalmic diagnostic imaging of the retina (92134). You say that you are appealing with 
supporting records. 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 $25 
copayment for physician services to diagnose and treat diseases and conditions of the eye.   
You have been asked to pay a $25 copayment for a medical eye examination (92014) and the scanning of 
computerized ophthalmic diagnostic imaging of the retina (92134). These services falls within the physician 
services to diagnose and treat diseases and conditions of the eye 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 waive the copayment for a medical eye examination (92014) and the scanning of computerized ophthalmic 
diagnostic imaging of the retina (92134) provided on July 26, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that after a prolonged hospitalization the enrollee has severe functional decline. The Plan denied your request. The Plan says the request is not medically necessary.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.


 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the enrollee's medical problems are stable and there are no complex nursing or rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve IRF admission and services.