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

 
We decided that the Plan does not have to pre-approve intra-operative epicardial and endocardial pacing and 
mapping to localize the site of tachycardia or zone of slow conduction for surgical correction (CPT code(s): 
93631 and 93662). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the enrollee's request is not medically necessary because their records show they do not 
have any heart rhythm problems. 
 
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 services. Our physician reviewer 
found there is insufficient documentation to support the medical necessity for the requested patent foramen 
ovale (PFO) closure in this enrollees clinical management.  
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve intra-operative epicardial and endocardial pacing and mapping to localize the site of 
tachycardia or zone of slow conduction for surgical correction (CPT code(s): 93631 and 93662).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve denture repair and replacement. 
 
You asked the Plan to pre-approve denture repair and replacement. You say that you are without a lower 
denture which affects your smile, eating, and confidence. You say that you cannot afford to fix the problem. 
The Plan denied your request. The Plan says the requested services are not included in the Plans dental 
coverage. 
 
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 
denture repair and replacement.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Mass spectrometry and tandem mass spectrometry 
(83789) provided on March 23, 2022. 
 
You asked the Plan to pay for procedure code 83789. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
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 procedure code 83789 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 the Mass spectrometry and tandem mass spectrometry (83789) provided on 
March 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive oral evaluation and extraction services 
(D0150, D7210) to be provided by an oral surgeon. 
 
You asked the Plan to pre-approve comprehensive oral evaluation and extraction 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, extractions can only be covered if 
performed by a general dentist and not a surgeon, they are also only covered once per calendar year. 
 
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 
comprehensive oral evaluation and extraction services (D0150, D7210) to be provided by an oral surgeon.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dental crown (D2751) 
 
You asked the Plan to pre-approve the dental crown. 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 you do 
not qualify for them, the record indicates that you do not have enough tooth to support the 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. 
 
 
  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 
dental crown (D2751)
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for extractions (D7210), guided tissue regeneration (D4266), 
bone replacement grafts (D7953), biologic materials (D4265), and alveoloplasty (D7310) provided on March 
14, 2022. 
 
You asked the Plan to pay for the dental services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says the requested dental services are not covered. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for 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 pay for extractions (D7210), guided 
tissue regeneration (D4266), bone replacement grafts (D7953), biologic materials (D4265), and alveoloplasty 
(D7310) provided on March 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a dental comprehensive oral evaluation, panoramic images, 
and periapical images provided on June 21, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would appreciate it if the Plan made an 
exception. The Plan denied your request. The Plan says your benefit for the requested items or 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 requested comprehensive oral evaluation and panoramic imaging was exhausted on 
date of service May 19, 2021. The benefit for the requested periapical imaging was exhausted on June 21, 
2022, because you received 2 sets of periapical images so the first set exhausted this benefit, resulting in a 
denial of the second set of images. Therefore, we decided that the Plan does not have to pay for a dental 
comprehensive oral evaluation, panoramic images, and periapical images provided on June 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the gingival irrigation (D4921x4) to be provided by an 
out-of-network provider. 
 
You asked the Plan to pre-approve the gingival irrigation (D4921x4). You say that you have not had a cleaning 
in 20 years and this service should be covered. 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 gingival irrigation (D4921x4) is 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
the gingival irrigation (D4921x4) to be provided by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for unlisted chemistry procedure (84999) provided on February
3, 2022, by an out-of-network (OON) provider.

You asked the Plan to pay for out-of-network services. You say that these services were performed by an
accredited laboratory and referred by a physician. The Plan denied your request. The Plan says out-of-network
care is covered only in certain limited circumstances. The services at issue were not provided or referred by one
of the available network providers, and they were not urgent or emergent.

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 pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan had network providers
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for unlisted chemistry procedure (84999) provided on
February 3, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nerve conduction studies (95910), and needle 
electromyography (95886) provided on March 10, 2022. 
 
You asked the Plan to pay for codes 95910 and 95886. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not supported. 
 
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 95910 is Nerve conduction studies; 7-8 studies. We find that CPT code 95910 is not supported in the 
medical record. Specifically, the record does not show that nerve conduction studies were performed on 7-8 to 
nerves.  
 
Additionally, we have confirmed that codes 95886-26 and 95886-26-XU are add-on codes and as the primary 
procedure code, 95910, is not covered, the add-on codes cannot be separately reimbursed. 
 
Based on this information, we decided that Medicare rules for coverage of codes 95910 and 95886 have not 
been met. Therefore, we decided that the Plan does not have to pay for the nerve conduction studies (95910), 
and needle electromyography (95886) provided on March 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone replacement grafts on tooth #4, 5, 6, and 7 
(D7953), facial surgery on tooth #4, 5, 6, and 7 (D7950), and the collection and application of blood on tooth # 
4, 5, 6, and 7 (D7921). 
 
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 bone replacement grafts (D7953), facial surgery 
(D7950), and the collection and application of blood (D7921) are not covered by 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 bone 
replacement grafts on tooth #4, 5, 6, and 7 (D7953), facial surgery on tooth #4, 5, 6, and 7 (D7950), and the 
collection and application of blood on tooth # 4, 5, 6, and 7 (D7921).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99072 billed for date of service January 27, 
2022. 
 
You asked the Plan to pay for procedure code 99072. You say that these charges are appropriate for the level of 
service provided to the patient. The Plan denied your request. The Plan says procedure code 99072 is 
considered bundled and 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 99072 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99072 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99072 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99072 billed for date of service January 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for incontinence supplies provided on June 3, 2022. 
 
You asked the Plan to pay for incontinence supplies. You say that the items at issue were a medical necessity 
for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pay for incontinence supplies provided on 
June 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a dental consultation for diagnostic services on June 9, 2022. 
 
You asked the Plan to pay for a dental consultation for diagnostic services. You say that you would like to 
request reconsideration of the denied claim. 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 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 dental 
consultation for diagnostic services on June 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a prosthetic tray for fluoride treatments (21089) provided on 
April 20, 2022. 
 
You asked the Plan to pay for the prosthetic tray for fluoride treatments. You say that the services should be 
covered as you disagree with the denial. The Plan denied your request. The Plan says the dental services denied 
correctly as they do not fall within your dental benefits. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
 
  The services you are asking the Plan to pay for 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 pay for a prosthetic tray for fluoride 
treatments (21089) provided on April 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a removal of torus mandibularis (D7473). 
 
You asked the Plan to pre-approve the removal of torus mandibularis. You say that you believe this service 
should be covered under your plan. The Plan denied your request. The Plan says this service is not covered 
under your 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 
removal of torus mandibularis (D7473).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service March 18, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says procedure code 99100 is considered bundled 
and 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 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service March 18, 2022.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve the removal of residual tooth roots on tooth #17 (D7250). We also 
decided that the Plan does not have to pre-approve the removal of residual tooth roots on tooth #7 (D7250).  
 
You asked the Plan to pre-approve the removal of residual tooth roots. You say that you disagree with the 
denial of dental services. The Plan denied your request. The Plan says that the clinical criteria has not been met. 
 
 
 Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the removal 
of residual tooth roots when the services are medically necessary and reasonable. 
 
We decided that the Plan has to pre-approve the removal of residual tooth roots on tooth #17 (D7250). 
 
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 removal of tooth roots. Our 
reviewer says that the coverage criteria has been met for the removal of residual tooth roots on tooth #17. Our 
physician reviewer found that tooth #17 appears to have had the remainder of the tooth removed at an earlier 
time leaving a root tip in the bone. Under the Plan criteria tooth #17 would qualify for the requested procedure 
code as a residual root with proper documentation at the time of the procedure. 
 
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 removal of tooth roots have been met. Therefore, we decided that the Plan 
has to pre-approve the removal of residual tooth roots on tooth #17 (D7250).  
 
We also decided that the Plan does not have to pre-approve the removal of residual tooth roots on tooth 
#7 (D7250). 
 
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 removal of tooth roots. Our 
reviewer says that the coverage criteria has not been met for the removal of residual tooth roots on tooth #7. 
Our physician reviewer found that tooth #7 has had no prior attempted removal and would not qualify as a 
residual root. 
 
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 removal of tooth roots have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the removal of residual tooth roots on tooth # 7 (D7250).  
 
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 a periodic oral evaluation - established patient (D0120), 
bitewings - four radiographic images (D0274), and prophylaxis - adult (D1110) provided on September 8, 
2021. 
 
You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says the dental 
services were received from an out-of-network provider and are not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider.  Therefore, we decided that the Plan does not have to pay for a periodic oral evaluation - established patient 
(D0120), bitewings - four radiographic images (D0274), and prophylaxis - adult (D1110) provided on 
September 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bitewings (D0274) provided by a participating provider on 
June 8, 2022. 
 
You asked the Plan to pay for the dental services. You say that the Plan should pay for this. 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 8, 2022, with codes 
D0220 and D0230. Therefore, we decided that the Plan does not have to pay for bitewings (D0274) provided 
by a participating provider on June 8, 2022.