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

 
We decided that the Plan does not have to pre-approve percutaneous vertebral augmentation, including cavity 
creation (fracture reduction and bone biopsy included when performed) using mechanical device (eg, 
kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance; lumbar 
(CPT code 22514). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the service is not medically 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 service. Our physician reviewer 
found the magnetic resonance imaging (MRI) shows fracture retropulsion in spinal canal which is a 
contraindication to kyphoplasty. 
 
 
 
 
 
 
 
 
 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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve percutaneous vertebral augmentation, including cavity creation (fracture reduction and 
bone biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 vertebral body, unilateral 
or bilateral cannulation, inclusive of all imaging guidance; lumbar (CPT code 22514).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99100) provided on December 8, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 
service. 
 
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 find that CPT code 99100 has a status indicator of B on the Physician Fee Schedule. This means that CPT code 99100 is not separately payable. 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 pay for the services 
(99100) provided on December 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the comprehensive oral evaluation (D0150) 
provided on December 7, 2021. 
 
You asked the Plan to reimburse you for the dental service. You say that you had to change dentists because 
your regular dentist was no longer in network. You also say that it is not your fault that you had to change 
dentists. The Plan denied your request. The Plan says a comprehensive oral evaluation is covered once every 3 
plan years. The Plan also says that the frequency limit has been exceeded. 
 
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 and comprehensive oral evaluation is 
covered once every 3 plan years, the frequency limit has been exceeded. The record shows that the Plan paid for a comprehensive oral evaluation that you received on June 11, 2021. Therefore, we decided that the Plan does 
not have to reimburse you for the comprehensive oral evaluation (D0150) provided on December 7, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT) scan of the abdomen and 
pelvis for the enrollee. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is not enough information to show that this is reasonable and necessary for this 
condition. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically 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 scan. Our reviewer says that the 
requested scan is not medically reasonable or necessary. Our physician reviewer found the enrollee had a recent 
medical visit on 2/6/22. There is no abdominal physical exam in the records for this visit. There is a report of a 
right upper quadrant ultrasound showing an absent gallbladder and a fatty liver. The pancreas was not seen. 
There is no lab work available. The medical necessity for the requested CT has not yet been explained by the 
requesting clinician. 
 
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 scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve computed tomography (CT) scan of the abdomen and pelvis for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee requires ongoing acute care services. The enrollee continues to receive 
acute care services, and these have not been denied.  The medical record does not indicate that the enrollee 
requires services that he is not currently receiving but that would be available at the LTACH facility. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (88305) provided on December 3, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment is included in 
the payment to the facility. 
 
The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other 
than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all 
necessary covered services to the beneficiary either directly or under arrangements made with outside 
providers. Payment for all fees related to this service would have been included under the facility claim. 
Therefore, we decided that the Plan does not have to pay for the services (88305) provided on December 3, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150) to be rendered 
by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the comprehensive oral evaluation. You say that when you got the offer for 
the Plan you were told they would honor the work you were having done. You also say that now you were told 
your dentist could send in a referral letter to the Plan so you could continue to see them. The Plan denied your 
request. The Plan says unless your plan approves it, only services done by your assigned dentist are covered. 
 
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 
covered when they are received OON. Therefore, we decided that the Plan does not have to pre-approve a 
comprehensive oral evaluation (D0150) to be rendered by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve three bone grafts at time of implant placements (D6104 x3). 
 
You asked the Plan to pre-approve the bone grafts. You say that implants were approved, and you need bone 
grafts to complete the procedure. The Plan denied your request. The Plan says this service is not covered under 
your benefit 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 pre-approve three 
bone grafts at time of implant placements (D6104 x3).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a consult with a periodontist. 
 
You asked the Plan to pre-approve the dental service. You say that you were previously approved to see a 
different periodontist that was too far from your home. The Plan denied your request. The Plan says dental 
services must be performed by a participating general dentist. The Plan says that there is no record of you being 
approved to see a periodontist. The Plan also says 
 
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, dental services must be performed by a 
participating general dentist. Therefore, we decided that the Plan does not have to pre-approve a consult with a 
periodontist.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the special anesthesia service (99100) provided on 
November 23, 2020. 
 
You asked the Plan to pay for the special anesthesia service (99100). You say that the records submitted are 
clear, concise and follow guidelines. You say that this line item should be reprocessed for payment. The Plan 
denied your request. The Plan says procedure code 01920 has been overturned. The Plan also says that CPT 
code 99100 remains denied as bundled services are not eligible for separate payment.  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 find that CPT code 99100 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99100 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of the special anesthesia service (99100) have not been met. Therefore, we decided that the Plan does not have 
to pay for the special anesthesia service (99100) provided on November 23, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services (G0483) provided on June 30, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is 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 G0483 is "Drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or 
more drug class(es), including metabolite(s) if performed". 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, the records do not show that 
22 or more drug classes were tested on the date of service in question. 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 pay for the drug testing services (G0483) provided on June 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the facial bone graft (21210) unlisted dental surgery 
procedure (41899), surgical placement of implant body (D6010) and deep sedation/general anesthesia (D9222, 
D9223) provided on November 17, 2021. 
 
You asked the Plan to pay for the dental services. You say that these services were necessary following an 
accident. The Plan denied your request. The Plan says these services are dental in nature and are not covered by 
Medicare or 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 the facial 
bone graft (21210) unlisted dental surgery procedure (41899), surgical placement of implant body (D6010) and 
deep sedation/general anesthesia (D9222, D9223) provided on November 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve six (6) implant supported porcelain/ceramic crowns (D6065). 
 
You asked the Plan to pre-approve implant supported crowns. You say that these services are necessary. The 
Plan denied your request. The Plan says these services are not covered by your dental benefit. 
 
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 pre-approve six 
(6) implant supported porcelain/ceramic crowns (D6065).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical implant placements (D6010), prefabricated 
abutments (D6056) and implant supported porcelain/ceramic crowns (D6065). 
 
You asked the Plan to pre-approve the dental services. You say that these services are necessary. The Plan 
denied your request. The Plan says these services are not covered by your dental 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 
surgical implant placements (D6010), prefabricated abutments (D6056) and implant supported 
porcelain/ceramic crowns (D6065).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete mandibular denture (D5120). 
 
You asked the Plan to pre-approve the complete mandibular denture. You say that you lost your partial denture 
and would like to know if the Plan can help you replace it. The Plan denied your request. The Plan says the 
records indicate that you received dentures on December 6th, 2018, and your denture benefit has been 
exhausted until 2023. 
 
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, partial or full dentures are limited to 1 
per 5 years. The record shows that you received dentures on December 6th, 2018 and your denture benefit has 
been exhausted. Therefore, we decided that the Plan does not have to pre-approve a complete mandibular 
denture (D5120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prefabricated stainless-steel crown (D2931) for tooth # 18. 
 
You asked the Plan to pre-approve the dental service. You say that a stainless-steel crown is necessary to 
stabilize the tooth. The Plan denied your request. The Plan says prefabricated stainless-steel crown is not listed 
as a covered service. 
 
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 prefabricated stainless-steel crown is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a prefabricated stainless-steel crown (D2931) for tooth # 18.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a surgical extraction (D7210) to be performed by an oral 
surgeon. 
 
You asked the Plan to pre-approve the dental service. You say that you cannot afford to pay for this out of 
pocket. The Plan denied your request. The Plan says dental services benefit states that services must be 
performed by a participating general dentist. The Plan also says that dental services performed by an oral 
surgeon 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, dental services benefit states that 
services must be performed by a participating general dentist. Dental services performed by an oral surgeon are 
not covered. Therefore, we decided that the Plan does not have to pre-approve a surgical extraction (D7210) to 
be performed by an oral surgeon.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home health physical therapist (PT) visits (CPT 
code G0151 X 4). 
 
You asked the Plan to pre-approve the home health physical therapist visits. You say that the services are 
medically necessary. The Plan denied your request. The Plan says they approved visits to teach the enrollee and 
their caregiver a home exercise program. The Plan states the enrollee's records suggest that continuing this 
exercise program should help the enrollee maintain their level of function or improve further. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health physical therapist 
visits. Our physician reviewer found the documentation does not support that the enrollee requires additional 
skilled rehabilitation services to provide treatment that is medically necessary. The enrollee does not require 
additional skilled rehabilitation services to effectively provide treatment, care, and/or services in order to 
improve the enrollee's condition, perform a maintenance program to maintain the enrollee's condition and/or 
prevent deterioration. The enrollee has been medically stable without any recent exacerbations of chronic 
medical problems or hospitalizations. The requested home health services are not medically necessary. 
 
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 home health physical therapist visits have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the home health physical therapist (PT) visits (CPT code 
G0151 X 4).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a root canal (D3320) to be performed by an out-of-network provider.
You asked the Plan to pre-approve out-of-network dental care. You say that this service is necessary, and you are in a lot of pain. The Plan denied your request. The Plan says the requested provider is not part of the Plan's dental network. Out-of-network dental care is not covered by your benefit.
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. The Plan covers eligible dental services when they are performed by a participating (in-network) provider. We looked at the file and the Plan's rules. The requested provider is out-of-network. Based on this information, we decided that the Plan's rules for coverage of dental services have not been met. Therefore, we decided that the Plan does not have to pre-approve a root canal (D3320) to be performed by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 6 implant supported crowns (D6065). 
 
You asked the Plan to pre-approve the dental services. You say that the dental office started the implant 
process. You say that they did part of teeth, but the other part has been denied. You say that you cannot eat and 
are experiencing pain. You also say that you are not able to pay to complete the dental work. The Plan denied 
your request. The Plan says dental implants and all associated services are excluded from 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 implant supported 
crowns are not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pre-approve 6 implant supported crowns (D6065).