Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intracept procedure (64628). 
 
You asked the Plan to pre-approve the intracept procedure. You say that the service is medically necessary. The 
Plan denied your request. The Plan says this service is experimental. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the intracept procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this procedure is experimental and more research is needed to show its safety and 
efficacy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the intracept procedure (64628).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an apicoectomy (D3410) and a retrograde filling 
(D3430) provided by a participating provider. 
 
You asked the Plan to pre-approve an apicoectomy and a retrograde filling. You say that your mouth is in pain. 
The Plan denied your request. The Plan says the enrollee has no dental rider. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement 
of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or 
paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve an apicoectomy 
(D3410) and a retrograde filling (D3430) provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services received on June 28, 2022. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the provider is on the opt out list. 
 
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 pre-approve 
dental services received on June 28, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acute inpatient hospital care. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the enrollee was approved for a right 
shoulder joint arthroplasty and will need inpatient admission after surgery. The Plan denied your request. The 
Plan says there is no documentation provided to support the expectation the enrollee will require a greater than 
2 midnight stay. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.   
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 pay for acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient admission are met in this case. Our 
physician reviewer found the enrollee is approved for a right shoulder joint arthroplasty. The record does not 
document that the treating physician has a reasonable expectation of a length of stay spanning 2 or more 
midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for acute inpatient hospital care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the removal of impacted tooth (D7220 x2), the removal 
of partially bony impacted tooth (D7230 x2), and the bone replacement graft for ridge preservation (D7953. 
 
You asked the Plan to pre-approve the removal of impacted tooth (D7220 x2), the removal of partially bony 
impacted tooth (D7230 x2), and the bone replacement graft for ridge preservation (D7953). You say that you 
are unable to sleep, have headaches, and your jaw hurts. You say you only had one cracked tooth, went to the 
dentist in August to get the issue fixed. You say you now have two cracked teeth. The Plan denied your 
request. The Plan says the 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 removal of impacted tooth (D7220 
x2), the removal of partially bony impacted tooth (D7230 x2), and the bone replacement graft for ridge 
preservation (D7953) are not among those covered under this benefit. Therefore, we decided that the Plan does 
not have to pre-approve the removal of impacted tooth (D7220 x2), the removal of partially bony impacted 
tooth (D7230 x2), and the bone replacement graft for ridge preservation (D7953).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electric breast pump rendered on February 2, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that items that do not contribute meaningfully to the 
treatment of an illness or injury or the functioning of a malformed body member are not covered. 
 
We looked at the file and Medicare rules. The item at issue is an electric breast pump. This item does not 
contribute meaningfully to the treatment of an illness or injury or the functioning of a malformed body member and is not covered. Therefore, we decided that the Plan does not have to pay for the electric breast pump 
rendered on February 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit, (code 99202) and manual therapy techniques 
(code 97140) provided on August 26, 2022. 
 
You asked the Plan to pay for the office visit and manual therapy techniques. You say that the services were 
medically necessary. The Plan denied your request. The Plan says the office visit and manual therapy 
techniques are not a covered acupuncture benefit. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plans rules apply in this case.  
 
We looked at the file, the Plans rules and Medicare rules. The file shows that an office visit and manual 
therapy techniques are not a covered acupuncture benefit. Therefore, we decided that the Plan does not have to 
pay for an office visit, (code 99202) and manual therapy techniques (code 97140) provided on  
August 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral - periapical first radiographic image (D0220) 
provided on July 26, 2022. 
 
You asked the Plan to pay for the dental services. You say that this service was necessary. 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 February 22, 2022. 
Therefore, we decided that the Plan does not have to pay for the intraoral - periapical first radiographic image 
(D0220) provided on July 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cone beam computed tomography (CT) capture and 
interpretation (D0364) provided on June 29, 2022. 
 
You asked the Plan to pay for the cone beam computed tomography (CT) capture and interpretation (D0364). 
You say that you were not informed that the service was not covered. You say the oral examination should not 
have counted towards the benefit limitation. The Plan denied your request. The Plan says the 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 cone beam computed tomography 
(CT) capture and interpretation (D0364) is not among those covered under this benefit. Therefore, we decided 
that the Plan does not have to pay for the cone beam computed tomography (CT) capture and interpretation 
(D0364) provided on June 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A4550 billed for date of service July 19, 
2022. You asked the Plan to pay for procedure code A4550. The Plan denied your request. The Plan says procedure 
code A4550 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code A4550 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code A4550 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
A4550 billed for date of service July 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lower partial denture (D5214) for tooth #24 and #30. 
 
You asked the Plan to pre-approve the dental service. You say that you need the partial dentures to help with 
the health of the bone and integrity of the teeth. The Plan denied your request. The Plan says the denial of 
authorization for this service is correct, because partial dentures 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 pre-approve a 
lower partial denture (D5214) for tooth #24 and #30.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone graft while placing implant (D0364), a computed 
tomography (CT) scan (D6104), and an abutment for implant for teeth 5, 7, and 10 (D6057). 
 
  You asked the Plan to pre-approve a bone graft while placing implant (D0364), a computed tomography (CT) 
scan (D6104), and an abutment for implant for teeth 5, 7, and 10 (D6057). You say that you are appealing with 
supporting records. The Plan denied your request. The Plan says they denied the bone graft while placing 
implant (D0364) and the computed tomography (CT) scan (D6104). The Plan also says that these services are 
not covered by the Plan. The Plan also says that this condition does not meet required clinical criteria to 
establish medical necessity. The Plan also says that they denied an abutment for implant for teeth 5, 7, and 101 
(D6057). The Plan also says that they only cover single tooth abutments and crown. 
 
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 bone graft 
while placing implant (D0364), and a computed tomography (CT) scan (D6104) when the services are 
medically necessary and reasonable.  The Plan excludes an abutment for implant for teeth 5, 7, and 10 (D6057). 
 
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 bone graft while placing implant 
(D0364), and a computed tomography (CT) scan (D6104. Our reviewer says that the service requested for the 
bone graft while placing implant (D0364) and the computed tomography (CT) scan (D6104) is not medically 
necessary. Our physician reviewer found the Plan allows for single tooth implants and not for implant 
supported fixed bridges or overdentures. Our physician reviewer also found that the requested treatment would 
be requesting a fixed bridge from numbers five to ten, which is not a covered service under the Plan. 
 
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 bone graft while placing implant (D0364), a computed tomography (CT) scan 
(D6104), and an abutment for implant for teeth 5, 7, and 10 (D6057) have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a bone graft while placing implant (D0364), a computed tomography 
(CT) scan (D6104), and an abutment for implant for teeth 5, 7, and 10 (D6057).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the placement of intra-socket biological dressing 
(D7922) provided by a participating provider. 
 
You asked the Plan to pre-approve the placement of intra-socket biological dressing. You say that you would 
like the Plan to approve this. 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 the 
placement of intra-socket biological dressing (D7922) provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the interim partial denture (including retentive/clasping 
materials, rests, and teeth), maxillary (D5820) provided on July 28, 2022. 
 
You asked the Plan to pay for the interim partial denture. You say that this service is necessary. The Plan 
denied your request. The Plan says this service is 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 
interim partial denture (including retentive/clasping materials, rests, and teeth), maxillary (D5820) provided on 
July 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection between wheelchair controller 
and two or more power seating system motors. 
 
You asked the Plan to pre-approve an electronic connection between wheelchair controller and 2 or more 
power seating system motors. You say that you disagree with the Plan's denial. The Plan denied your request. 
The Plan says you do not meet criteria for the requested item. 
 
The Plan must follow Medicare rules. Medicare rules say that power wheelchair accessories are only covered 
for certain indications.  
 
We looked at the file and Medicare rules. Review of the file shows that the approved power tilt and recline and 
the leg elevation feature includes switch controls. The documentation supports that you can operate the switch 
controller that is already included. This means the requested upgraded electronic is not necessary. Based on this 
information, we decided that Medicare rules for coverage of an electronic connection between wheelchair 
controller and two or more power seating system motors have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an electronic connection between wheelchair controller and two or more 
power seating system motors.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services coded 83789 and 80299 for date of service April 
18, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Medicare rules say that providers performing validity testing on urine specimens utilized for drug testing should not separately bill the validity testing. 
 
In this case, the CPT Code Manual definition of code 80299 is quantitation of therapeutic drug, not elsewhere 
specified. 
 
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 for the services coded 80299. Our reviewer says that the documentation 
does not support payment for the services coded 80299. Our reviewer found that per CPT guidelines for 
Therapeutic drug assays Therapeutic drug assays are performed to monitor levels of a known, prescribed, or 
over-the-counter medication.  The material for examination is whole blood, serum, plasma, or cerebrospinal 
fluid. In this case, medical record includes a urine drug screen, and therefore this procedure code cannot be 
verified. In addition, we find that the testing described by code 83789 is not separately payable according to 
Medicare rules. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of codes 83789 and 80299 have not been met.  Therefore, we decided that the Plan 
does not have to pay for the services coded 83789 and 80299 for date of service April 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation - established patient (D0120) 
provided on August 1, 2022. 
 
You asked the Plan to pay for the dental services. You say that you schedule your examinations six months 
apart. 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 dates of service January 3, 2022, and 
March 7, 2022. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation - 
established patient (D0120) provided on August 1, 2022.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve deep sedation/general anesthesia. We decided that the Plan does 
not have to pre-approve dental extractions.  
 
You asked the Plan to pre-approve deep sedation/general anesthesia (D9222, D9223 provided by a participating 
provider. You say that these services are medically necessary. The Plan says that dental x-rays do not show 
medical necessity. 
 
 
 
 We decided that the Plan has to pre-approve deep sedation/general anesthesia.  
 
Therefore, we decided that the Plan has to pre-approve deep sedation/general anesthesia. Our doctor found that 
the documentation meets the criteria for deep sedation/general anesthesia (D9222, D9223) for the multiple 
extractions. 
 
We also decided that the Plan does not have to pre-approve dental extractions. 
 
A less severe extraction code would be considered. Therefore, we decided that the Plan does not have to pre-
approve dental extractions. 
 
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 pay for the dental services (D0140 and D0330) on July 12, 2022. 
 
You asked the Plan to pay for the dental services (D0140 and D0330). You say that you would like to request 
reconsideration of the denied claim. 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 service (D0140) was exhausted on date of service February 08, 2022, and 
the requested service  (D0330) was exhausted on date of service June 10, 2022. Therefore, we decided that the 
Plan does not have to pay for the dental services (D0140 and D0330) on July 12, 2022.