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

 
We decided that the Plan does not have to pay for the oral evaluation (D0140), the apicoectomy (D3410), and 
the retrograde filling (D3430) for tooth #8 and #9 provided on June 2, 2022, and June 15, 2022. 
 
You asked the Plan to pay for the dental services. You say that the dental services were an emergency. The 
Plan denied your request. The Plan says your benefit for the requested item or service has already been 
exhausted. Also, the denial of payment for the apicoectomy and the retrograde filling is correct, because they 
are not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the oral evaluation was exhausted on the date of service of April 13, 2022. The 
apicoectomy and the retrograde filling are not covered under the dental benefit. Therefore, we decided that the 
Plan does not have to pay for the oral evaluation (D0140), the apicoectomy (D3410), and the retrograde filling 
(D3430) for tooth #8 and #9 provided on June 2, 2022, and June 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for panoramic radiographic image (D0330) provided on August 
31, 2022. 
 
You asked the Plan to pay for dental services. You say that you did not know the service provided was not a 
covered benefit. 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. Panoramic radiographic image 
(D0330) is not covered under the Plans dental benefits. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested Panoramic radiographic 
image (D0330) is not among those covered under this benefit. Therefore, we decided that the Plan does not 
have to pay for panoramic radiographic image (D0330) provided on August 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a diagnostic consultation (D9310) provided on August 9, 
2022. 
 
You asked the Plan to pay for a diagnostic consultation (D9310). You say that your dentist referred you to the 
only endodontist service in town. The Plan denied your request. The Plan says this general service is not 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 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 
diagnostic consultation (D9310) provided on August 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88341 billed for date of service October 5, 
2021. 
 
You asked the Plan to pay for procedure code 88341. The Plan denied your request. The Plan says payment for 
code 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 code 88341 is a column II code 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 code 88341 
billed for date of service October 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for limited oral evaluation - problem focused (D0140) provided 
on September 12, 2022. 
 
You asked the Plan to pay for dental services. You say that you should not have to pay anything for this visit. 
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. Limited oral evaluation - 
problem focused (D0140) is not covered under the Plans dental benefits. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested limited oral evaluation - 
problem focused (D0140) is not among those covered under this benefit. Therefore, we decided that the Plan 
does not have to pay for limited oral evaluation - problem focused (D0140) provided on September 12, 2022.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve core buildup, including any pins when required (D2950) Tooth 
#10 and 11 and retainer crown - porcelain/ceramic (D6740) Tooth #10 and 11. We decided that the Plan 
does not have to pre-approve core buildup, including any pins when required (D2950) Tooth # 5, 6, 7, 8, 9 and 
13, pontic - porcelain/ceramic  (D6245) Tooth #12 and retainer crown - porcelain/ceramic (D6740) Tooth #5, 
6, 7, 8, 9 and 13.  
 
You asked the Plan to pre-approve core buildup, including any pins when required (D2950) Tooth # 5, 6, 7, 8, 
9, 10, 11 and 13, pontic - porcelain/ceramic (D6245) Tooth #12 and retainer crown - porcelain/ceramic 
(D6740) Tooth # 5, 6, 7, 8, 9, 10, 11 and 13. You say that the services are medically necessary. The Plan says 
that based on this information, the request is not medically necessary. Per guidelines the teeth you are 
requesting a crown on have enough support remaining to support a crown and do not require build up. 
 
We decided that the Plan has to pre-approve core buildup, including any pins when required (D2950) 
Tooth #10 and 11 and retainer crown - porcelain/ceramic (D6740) Tooth #10 and 11.  
 
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. 
 
Our doctor found that a review of the documentation indicates that core buildup for teeth #'s 10 and 11 is 
medically reasonable and necessary and crowns on teeth #'s 10 and 11 are medically reasonable and necessary. 
 
We also decided that the Plan does not have to pre-approve core buildup, including any pins when 
required (D2950) Tooth # 5, 6, 7, 8, 9 and 13, pontic - porcelain/ceramic  (D6245) Tooth #12 and retainer 
crown - porcelain/ceramic (D6740) Tooth #5, 6, 7, 8, 9 and 13. 
 
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. 
 
Our doctor found that a review of the documentation indicates that teeth #'s 2, 5-12 are present in the maxilla. 
Teeth #'s 5-9 and 12 have crowns in place. The crown on tooth #10 is defective. There was no indication as to 
why the crowns on teeth #'s 5-9 need to be replaced. There is no need for a pontic since tooth #12 is present. 
Therefore, these services are not medically necessary. 
 
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 removal of torus mandibularis (D7473), and intravenous 
moderate (conscious) sedation/analgesia  each subsequent 15 (D9243). 
 
You asked the Plan to pay for the dental services. You say that you are appealing the over max amount of $944. 
The Plan denied your request. The Plan says your benefit for the requested item or service $3,000 dollar limit 
was 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. 
 
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 April 7, 2022. The Plan 
paid $59.00 towards the combined allowance on date of service March 1, 2022, and $2,941 towards the 
combined allowance on date of service April 7, 2022 ($59.00 + $2,941.00 = $3,000.00). Therefore, we decided that the Plan does not have to pay for removal of torus mandibularis (D7473), and 
intravenous moderate (conscious) sedation/analgesia  each subsequent 15 (D9243).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for FreeStyle Libre 2 sensor kit. 
 
You asked the Plan to pay for FreeStyle Libre 2 sensor kit. You say that you are appealing the denial of the 
FreeStyle Libre to monitor your diabetes. The Plan denied your request. The Plan says the enrollee does not 
meet all of the criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of FreeStyle Libre 2 sensor kit have not been met. 
Therefore, we decided that the Plan does not have to pay for FreeStyle Libre 2 sensor kit.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an immediate mandibular denture (D5140) and the 
realignment of a complete maxillary denture (D5750) provided by an out-of-network provider on August 16, 
2022, to August 17, 2022. 
 
You asked the Plan to pay for an immediate mandibular denture and the realignment of a complete maxillary 
denture. You say that you would like the Plan to pay for this. The Plan denied your request. The Plan says the 
rendered dental services are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an immediate mandibular denture (D5140) and the realignment of a complete maxillary denture (D5750) provided 
by an out-of-network provider on August 16, 2022, to August 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral periapical first x-ray images (D0220) for teeth 
numbers 1 and 32, and resin-based composites - two surfaces (D2392) for tooth number 4 provided on August 
2, 2022. 
 
You asked the Plan to pay for the dental services. You say that this work was necessary due to a broken tooth. 
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 April 14, 2022. 
Therefore, we decided that the Plan does not have to pay for intraoral periapical first x-ray images (D0220) for 
teeth numbers 1 and 32, and resin-based composites - two surfaces (D2392) for tooth number 4 provided on 
August 2, 2022.  
 
Your complaint about the potentially poor quality of your Plan is not a valid appeal for medical coverage. This 
part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for limited oral evaluation - problem focused (D0140) and 
panoramic radiographic image (D0330) provided on July 12, 2022. 
 
You asked the Plan to pay for the dental services. You say that the x-ray was needed and should be covered. 
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. This benefit includes the 
requested limited oral evaluation - problem focused but is limited to one procedure code per calendar year and 
panoramic radiographic image but is limited to one procedure code every five calendar years. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested limited oral evaluation - problem focused (D0140) was exhausted on date 
of service August 7, 2022, and panoramic radiographic image (D0330) was exhausted on date of service March 
23, 2022. Therefore, we decided that the Plan does not have to pay for limited oral evaluation - problem 
focused (D0140) and panoramic radiographic image (D0330) provided on July 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for polycarbonate lenses (V2784) provided on June 15, 2022. 
 
You asked the Plan to pay for polycarbonate lenses (V2784). You say that you have not used the benefit for 
any other vision services during 2022, so the lenses and frames should be covered. The Plan denied your 
request. The Plan says the requested service is non-coverable. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers one set of lenses per calendar year. The Plan contract also says that lenses include 
basic single vision, lined bifocal, lined trifocal and lenticular lenses only. Polycarbonate lenses (V2784) are 
excluded from this benefit. 
 
We looked at the file and the Plan's rules. The Plan rules say that the Plan covers one set of frames every 
calendar year. The Plan contract also says that they cover one set of lenses per calendar year. The Plan contract 
also says that lenses include basic single vision, lined bifocal, lined trifocal and lenticular lenses only. 
Polycarbonate lenses (V2784) are excluded from this benefit. Based on this information, we decided that the 
Plan's rules for coverage of polycarbonate lenses (V2784) have not been met. Therefore, we decided that the 
Plan does not have to pay for polycarbonate lenses (V2784) provided on June 15, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the endoscopic services billed for date of service June 23, 
2022. 
 
You asked the Plan to pay for the billed services. You say that medical records were provided for processing. 
The Plan denied your request. The Plan says the payment was included in another procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
 The file shows that endoscopic procedures 45380 and 45385 were billed for the same date of service. We find 
that code 45380 has a multiple procedure indicator of 3. The records show that $271.74 was paid for code 
45385, which is the highest valued endoscopy. The records also show that $16, 65 was paid, which is the 
difference between the next highest value and the base endoscopy value. We found no exception which would 
require the Plan to further pay for the billed services. Therefore, we decided that the Plan does not have to 
further pay for the endoscopic services billed for date of service June 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (95861) provided on March 15, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed service 
cannot be verified. 
 
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 95861 is "Needle electromyography; 2 extremities with 
or without related paraspinal areas". 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the use of code 95861 is 
not supported by the records provided. Our reviewer found that the procedure report does not include sufficient 
documentation to confirm this procedure has been performed. Per NCCI Policy, "In this procedure, the 
provider uses an electromyograph to record electrical activity that skeletal muscle cells produce while the 
provider inserts needles into the muscle during rest and while contracted. The provider can hear the recordings 
on a loudspeaker". The procedure report documents "Somatosensory evoked potentials were obtained of the upper and lower extremities ilaterally. Bilateral needle EMG was monitored throughout the procedure, 
including the anal sphincter." The procedure report does not describe needle electromyography, 2 extremities 
with or without paraspinal areas, and therefore this code cannot be verified. 
 
We looked at this coder'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 pay for the services (95861) provided on March 15, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary visit (99326) provided on May 13, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the evaluation and management service. You say that this should be covered. The 
Plan denied your request. The Plan says prior authorization was not obtained. 
 
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 provider in this case is not a network provider with the Plan. 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 the domiciliary visit (99326) provided on May 13, 2022, by an 
out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional third level of medial branch block (MBB) 
injection services. 
 
You asked the Plan to pre-approve third level of injection services. You say that this procedure is medically 
reasonable and necessary. The Plan denied your request. The Plan says the requested third level of injections is 
not medically reasonable and necessary as there is no unique circumstance as required by the relevant Medicare 
LCD. 
 
The Plan follows Medicare rules. Medicare rules say that the need for a three or four-level procedure bilaterally 
may be considered under unique circumstances and with sufficient documentation of medical necessity on 
appeal. 
 
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 third level of injection services. Our 
reviewer says that the requested third level of injections are not medically reasonable and necessary. Our 
physician reviewer found the request is for 3 levels which exceeds utilization criteria. There is no exceptional 
circumstance documented here as is required by the Medicare LCD. Therefore, the request for a third level is 
deemed not medically reasonable and 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 third level of injection services have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an additional third level of medial branch block (MBB) injection 
services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment billed for date of service July 
4, 2022. 
 
You asked the Plan to pay for the billed services. You say that this is an accepted procedure code. The Plan 
denied your request. The Plan says the billed code cannot be verified. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 The record does not contain a valid physician order, proof of delivery, or relevant medical records which 
support medical necessity for the supplies provided in this case. The record shows that the Plan made several 
attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not 
have to pay for the durable medical equipment billed for date of service July 4, 2022.