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

 
We decided that the Plan does not have to pay for a complete denture - maxillary (D5110) and an unspecified 
removable prosthodontic procedure (D5899) provided on April 7, 2022. 
 
You asked the Plan to pay for the denture and removable prosthodontic procedure. You say that you thought 
the dentist office was responsible for checking to see if you had denture coverage. The Plan denied your 
request. The Plan says the services provided are not a covered benefit under your dental 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 pay for a 
complete denture - maxillary (D5110) and an unspecified removable prosthodontic procedure (D5899) 
provided on April 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pulp vitality (D0460), a core build-up (D2950), and 
endodontic therapy (D3330), provided by an out-of-network provider on February 7, 2022. 
 
You asked the Plan to pay for a pulp vitality, a core build-up, and endodontic therapy. You say that these 
services were medically necessary. You say that the Plan should pay for this. The Plan denied your request. 
The Plan says the dental work provided are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a pulp 
vitality (D0460), a core build-up (D2950), and endodontic therapy (D3330), provided by an out-of-network 
provider on February 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on April 7, 
2022. 
 
You asked the Plan to pay for this dental service. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says your benefit for the service provided 
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 service provided in this case was exhausted on date of service January 6, 2022. 
Specifically, the Plan contract states that one limited oral evaluation is covered per year. You previously 
received this service on January 6, 2022, which was paid for by the Plan. Therefore, the allowable benefit for 
this service has been exhausted. Therefore, we decided that the Plan does not have to pay for the limited oral 
evaluation (D0140) provided on April 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on May 
17, 2022. 
 
You asked the Plan to pay for the dental services. You say that you had a dental emergency and had to go to a 
different dentist. 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 August 16, 2021. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) 
provided on May 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a consultation and extractions to be performed by an 
oral surgeon. 
 
You asked the Plan to pre-approve the dental services. You say that you were told by a previous agent that this 
will be worked in a way that it would be covered. You say that you received a denial instead. The Plan denied 
your request. The Plan says consultation and extractions provided by a provider other than a general dentist are 
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 consultation and 
extractions are not among those covered under this benefit when performed by an oral surgeon. Therefore, we 
decided that the Plan does not have to pre-approve a consultation and extractions to be performed by an oral 
surgeon.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the microprocessor knee and advanced foot (CPT 
code(s): L5845, L5848, L5856, L5981, L5828 and L5986). 
 
You asked the Plan to pre-approve the items. You say that the items are necessary. The Plan denied your 
request. The Plan says request for microprocessor knee and advanced foot does not meet Medicare criteria as 
reasonable and necessary. 
 
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 items. Our physician reviewer 
found the provided statement from the prescribing physician indicates that the enrollee intends to use the 
prosthesis to hunt, hike, and other outdoor activities; however, the advanced prosthetic device would not be 
appropriate for the outdoor environment on a regular basis, and there was no explanation as to why a 
mechanical prosthesis would not be more appropriate for the activities intended. The provided records do not 
meet the requirements listed in the LCD for Medicare coverage for the microprocessor knee and advanced foot. 
 
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 items have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the microprocessor knee and advanced foot (CPT code(s): L5845, L5848, L5856, L5981, L5828 
and L5986).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the knee-shin system (L5845). 
 
You asked the Plan to pre-approve the item. You say that the item is necessary. The Plan denied your request. 
The Plan says the requested prosthetic part exceeds the enrollee's need. The Plan states stance control is already 
included with the approved knee. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the item have not been met. The prosthetic part requested is already 
included with the approved knee. This cannot be requested separately. That is why this requested prosthetic 
part is still denied. Therefore, we decided that the Plan does not have to pre-approve the knee-shin system 
(L5845).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone density testing.
You asked the Plan to pre-approve the requested bone density testing. You say that the enrollee has been in a great deal of pain and needs this imaging to determine the cause. The Plan denied your request. The Plan says there is no evidence that this testing has been ordered by your primary care provider.
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a physician who has furnished a consultation or treats an enrollee for a specific medical problem. We looked at the file and Medicare rules. In this case, the Plan has requested an order and medical records from your primary care provider, and these have not been received. Without an order from the provider indicating that the tests are necessary, they cannot be approved. Based on this information, we decided that Medicare rules for coverage of the requested bone density testing have not been met. Therefore, we decided that the Plan does not have to pre-approve bone density testing.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve one facet joint injection. 
 
You asked the Plan to pre-approve the injection. You say that you would like to treat the facet-based 
component of pain at this time. The Plan denied your request. The Plan says per Medicare rules only two joints 
are allowed to be injected per session. The Plan states they will partially approve two (2) facet joints to be 
injected instead of the three (3) requested. 
 
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 injection. Our physician reviewer 
found the first two level meet the LCD utilization criteria and the third level exceeds it. The request is deemed 
medically reasonable and necessary for only the first two levels. 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 injection 
have not been met. Therefore, we decided that the Plan does not have to pre-approve one facet joint injection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller with related electronic 
connections and harness for use with an approved power wheelchair. 
 
You asked the Plan to pre-approve the expandable controller. You say that it is felt that the wheelchair should 
be approved as requested. The Plan denied your request. The Plan says the expandable controller exceeds the 
enrollee's need. 
 
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 expandable controller. Our reviewer 
says that the requested items are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the provided records document that the enrollee has 3+/5 bilateral upper extremity strength and 
is independent with eating with set-up assistance. This indicates she has adequate upper extremity strength and function to operate the wheelchair's power options with their own switches.  
 
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 expandable controller have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an expandable controller with related electronic connections and harness for 
use with an approved power wheelchair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), intraoral x-rays 
(D0210), and prophylaxis (D1110) provided on May 19, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were told that the office accepted your 
insurance. 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 comprehensive oral evaluation (D0150), intraoral x-rays (D0210), and prophylaxis (D1110) 
provided on May 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99140 billed for date of service November 
11, 2021. 
 
You asked the Plan to pay for procedure code 99140. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says procedure code 99140 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 99140 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99140 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99140 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99140 billed for date of service November 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prophylaxis (D1110) and fluoride treatment (D1206) 
provided on June 1, 2022. 
 
You asked the Plan to pay for the dental services. You say that you spoke to a representative and were told this 
provider was in-network. 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 prophylaxis (D1110) and fluoride treatment (D1206) provided on June 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mass spectrometry and tandem mass spectrometry specimen 
testing (83789) provided on May 10, 2021. 
 
You asked the Plan to pay for specimen testing. You say that these services are supported in the medical 
records and were medically necessary. The Plan denied your request. The Plan says they have agreed to pay for 
the drug testing services; however, specimen validity testing is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of specimen testing have not been met. Specifically, we find that the testing described by the billed 
code is considered specimen validity testing which is not separately payable. Therefore, we decided that the 
Plan does not have to pay for mass spectrometry and tandem mass spectrometry specimen testing (83789) 
provided on May 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an out-of-network provider on 
February 1, 2022, to February 3, 2022 
 
You asked the Plan to pay for the dental services. You say that you have gone to this dentist for a long time. 
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 dental services provided by an out-of-network provider on February 1, 2022, to February 3, 2022
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a mandibular immediate denture (D5140) provided on 
February 7, 2022, and extractions of tooth# 19, 20, 22, 23, 25, 26, 27, 28, and 29 (D7140) provided on 
February 23, 2022. 
 
You asked the Plan to pay for a denture and extractions. You say that you disagree with the denial of dental 
services. The Plan denied your request. The Plan says a mandibular immediate denture (D5140) and extractions 
(D7140) are not covered by the enrollees supplemental dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a 
mandibular immediate denture (D5140) provided on February 7, 2022, and extractions of tooth# 19, 20, 22, 23, 
25, 26, 27, 28, and 29 (D7140) provided on February 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for consultation - Diagnostic service provided by dentist or 
physician other than requesting dentist or physician (D9310) and cone beam computed tomography (CT) scan 
capture and interpretation with limited field of view - less than one whole jaw (D0364) provided on April 13, 2022. 
 
You asked the Plan to pay for consultation (D9310) and cone beam CT scan (D0364). You say that you were 
advised by the Plan that the services would be covered. The Plan denied your request. The Plan says these 
services are 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 Plan's 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 
consultation - Diagnostic service provided by dentist or physician other than requesting dentist or physician 
(D9310) and cone beam computed tomography (CT) scan capture and interpretation with limited field of view - 
less than one whole jaw (D0364) provided on April 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on April 21, 2022. 
 
You asked the Plan to pay for the periodontal maintenance. You say that you have seen this provider before, 
and the claim was paid. The Plan denied your request. The Plan says the denial for this service is correct, 
because periodontal maintenance is not covered by the Plan when the rendering provider is OON. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's 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 when the provider is an OON provider. Therefore, we decided that the 
Plan does not have to pay for the periodontal maintenance (D4910) provided on April 21, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the use of Infuse BMP allograft during an approved 
spinal fusion surgery. 
 
You asked the Plan to pre-approve the Infuse BMP allograft. You say that it is felt that this surgery is 
necessary, and that the BMP allograft would be beneficial. The Plan denied your request. The Plan says the 
surgery has been approved; however, use of the requested allograft is not supported. 
 
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 Infuse BMP allograft. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found BMP allograft remains experimental for use in the posterior lumbar spine. It is not 
approved by the Food and Drug Administration for use in the posterior lumbar spine.  
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 Infuse BMP allograft have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the use of Infuse BMP allograft during an approved spinal fusion surgery.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 25295 billed for date of service December 
16, 2021. 
 You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says payment for 
code 25295 is bundled into payment for code 25320. 
 
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 25295 is a column II code to column I code 25320. 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 25295 
billed for date of service December 16, 2021.