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

 
We decided that the Plan does not have to pay more for the resin-based composite (D2391) provided on 
February 23, 2022. 
 
You asked the Plan to pay more for the resin-based composite. You say that at this appointment, you were not 
advised that the provider was out-of-network, or that there would be a partial payment. The Plan denied your 
request. The Plan says the treating provider is listed as an out-of-network provider, but the Plan has processed 
this claim in accordance with your in-network plan benefit. The Plan also says that you are responsible for a 
50% coinsurance for the service, and no further reimbursement is due to you from 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, though this service was rendered by an 
out-of-network provider, the Plan is only holding you responsible for the in-network benefit rate of a 50% 
coinsurance. Therefore, we decided that the Plan does not have to pay more for the resin-based composite 
(D2391) provided on February 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on April 21, 2022, to July 20, 2022. 
 
You asked the Plan to pay for the dental 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 the dental 
services on April 21, 2022, to July 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the oral evaluation (D0120) and the prophylaxis 
(D1110) provided on June 16, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you were told that dental services from an 
out-of-network provider would be covered. The Plan denied your request. The Plan says you are responsible 
for any charged amount above the Plans cost-sharing amount when your services are received from an out-of-
network provider. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to pay more for the oral evaluation (D0120) and the 
prophylaxis (D1110) provided on June 16, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to waive the cost share for recementing a crown on tooth #31 (D2920) provided 
on June 16, 2021, and a crown on tooth #31 (D2792) provided on August 26, 2021. 
 
You asked the Plan to waive the cost share for the dental services. You say that the services you received were 
on the wrong tooth. The Plan denied your request. The Plan says that the pre-authorization and provider's office 
notes state that the services would be on tooth #31. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not provide the correct Evidence of Coverage (EOC) for the dates 
of services requested. Without the correct EOC we are unable to determine if the claim was processed 
correctly. Therefore, we decided that the Plan has to waive the cost share for recementing a crown on tooth #31 
(D2920) provided on June 16, 2021, and a crown on tooth #31 (D2792) provided on August 26, 2021.  
 
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 comprehensive periodontal evaluation (D0180) provided 
on July 19, 2022. 
 
You asked the Plan to pay for the dental services. You say that your primary dentist referred you to a 
periodontist. 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 July 11, 2022. Therefore, 
we decided that the Plan does not have to pay for a comprehensive periodontal evaluation (D0180) provided on 
July 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on April 7, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. 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 the dental services on April 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 83789 billed for date of service August 25, 
2021. 
 
You asked the Plan to pay for procedure code 83789. You say that please see medical records attached with 
waiver of liability. The Plan denied your request. The Plan says payment for code 83789 is bundled into 
payment for code CPT code 80307 and HCPCS code G0480. 
 
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 83789 
is a column II code to column I codes 80307 G0480. This code is not separately reimbursed when billed for 
specimen validity testing on urine specimens utilized for drug testing. 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 
83789 billed for date of service August 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for bone replacement graft for ridge preservation - per site 
tooth #21 (D7953) provided on April 23, 2022. 
 
You asked the Plan to reimburse for dental services. You say that you are not sure the procedure was a success; 
therefore, you would like the Plan to reimburse you for the cost of the procedure. The Plan denied your request. 
The Plan says this service is 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested bone replacement graft 
for ridge preservation - per site (D7953) is not among those covered under this benefit. Therefore, we decided 
that the Plan does not have to reimburse for bone replacement graft for ridge preservation - per site tooth #21 
(D7953) provided on April 23, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for core build up on tooth #5 (D2950) provided on April 29, 2022. 
 
You asked the Plan to pay for core build up. You say that you fell and damaged your mouth. The Plan denied 
your request. The Plan says that core build up is only necessary for the retention of the final restoration and 
preservation of the tooth. 
 
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 core build up 
when the services are medically necessary and reasonable. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for core build up. Our reviewer says that the 
coverage criteria has been met. Our physician reviewer found that a review of the documentation indicates that 
tooth #5 has significant coronal breakdown due to caries or fracture to warrant a core buildup and crown 
restoration. 
 
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 core build up have been met. Therefore, we decided that the Plan has to pay for 
core build up on tooth #5 (D2950) provided on April 29, 2022.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve tension socket system (BOA) (CPT code L5999). 
 
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 records show that a replacement artificial leg socket has already been approved for you. The 
Plan states there is a request for a BOA click socket and this socket does not have Food and Drug 
Administration (FDA) approval. 
 
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 item. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found you have been authorized to have a replacement socket. The requested device has not been 
shown to be superior to other standard treatments for the medical condition. The requested device is 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 item have not been met. Therefore, we decided that the Plan does not have 
to pre-approve tension socket system (BOA) (CPT code L5999).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the maxillary partial denture (D5213) and mandibular partial 
denture (D5214) provided on June 28, 2022. 
 
You asked the Plan to pay for the partial dentures. You say that these services were properly pre-authorized. 
The Plan denied your request. The Plan says your benefits for the requested items have 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 benefits for the requested items were exhausted on date of service October 21, 2021. Therefore, we 
decided that the Plan does not have to pay for the maxillary partial denture (D5213) and mandibular partial 
denture (D5214) provided on June 28, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for corneal hysteresis determination, by air impulse stimulation, 
unilateral or bilateral, with interpretation and report (92145) provided June 29, 2022. 
 
You asked the Plan to pay for the vision services. You say that this was medically necessary due to the 
seriousness of your glaucoma. The provider felt the test was needed to test the instability of your cornea. The 
Plan denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the vision services have not been met. Therefore, we decided that the Plan does not have to pay for 
corneal hysteresis determination, by air impulse stimulation, unilateral or bilateral, with interpretation and 
report (92145) provided June 29, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve two (2) fractions of IGRT (CPT code 77387). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says that the requested service is not covered by Medicare or the Health Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 services. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found IGRT could be considered medically necessary, particularly when delivering such low doses as 
2 Gy x 1. However, for cases with difficult set up, IGRT is an accepted standard. This enrollee had what is 
described as a mobile target, exacerbated by obesity. While the dose is low, it would be ineffective if unable to 
target accurately (which is not an issue with most palliative cases). This case appears to be exceptional as by 
virtue of difficult set-up for which IGRT is an accepted standard of care. Our physician reviewer's decision is 
favorable. 
 
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 been met. Therefore, we decided that the Plan has to pre-
approve two (2) fractions of IGRT (CPT code 77387).  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prosthesis with an advanced knee and foot. 
 
You asked the Plan to pre-approve a prosthesis with an advanced knee and foot. You say that the prosthesis 
with an advanced knee and foot is necessary. The Plan denied your request. The Plan says the request for K3 
knee and 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 a prosthesis with an advanced knee and 
foot. Our physician reviewer found a microprocessor foot or ankle system (flex-walk system or equal) and a 
fluid, pneumatic, or electronic/microprocessor knee are covered only when the enrollee is at K3 functional 
level. The documentation does not support that the enrollee is at K3 functional level. The documentation does 
not support that the enrollee has the ability to traverse most environmental barriers and has vocational, 
therapeutic, or exercise activity that demands prosthetic utilization beyond simple locomotion. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a prosthesis with an advanced knee and foot have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a prosthesis with an advanced knee and foot.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 88342 and 88341 billed for date of service 
August 9, 2021. 
 You asked the Plan to pay for procedure codes 88342 and 88341. You say that these services should be paid. 
The Plan denied your request. The Plan says payment for code 88342 and 88341 is bundled into payment for 
code 88360. 
 
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 codes 
88342 and 88341 are column II codes in relation to column I code 88360. 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 codes 88342 and 88341 billed 
for date of service August 9, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the hospital is ready to release you, but you are in no 
shape or physical condition to go home. The Plan denied your request. The Plan says the enrollee does not meet 
all the required Medicare criteria for admission to an IRF. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require the intensity of services provided at an IRF. 
Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular 
physician evaluation. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you want to go to a facility for short term 
rehabilitation. The Plan denied your request. The Plan says based on Medicare guidelines the inpatient 
rehabilitation facility services you are requesting do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you were admitted for sepsis, urinary tract infection, and obstructive uropathy. 
Medical problems are stable.  There are no complex nursing or rehabilitation needs. While you have a need for physical or occupational 
therapy, there is no documentation of a need for an intensive rehabilitation program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the thrombolysis, cerebral, by intravenous infusion (CPT 
code 37195) provided from November 6, 2021, through November 7, 2021. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the service is not covered as billed. 
 
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 services have not been met. Review of the file shows that CPT 
code 37195 has a PC/TC indicator of five (5) which payment may not be made by carriers for these services 
when they are provided to hospital inpatients or patients in a hospital outpatient department. The enrollee was 
in an inpatient hospital setting for dates of service November 05, 2021, to November 10, 2021. Therefore, we decided that the Plan does not have to pay for the thrombolysis, cerebral, by intravenous infusion (CPT code 
37195) provided from November 6, 2021, through November 7, 2021.