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

 
We decided that the Plan has to pre-approve a crown (D2740) for tooth #18. 
 
You asked the Plan to pre-approve a crown (D2740) for tooth #18. The Plan denied your request. The Plan says 
that the x-rays provided show a crown is not needed to fix tooth #18. 
 
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 Independent Review Entity (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. Specifically, digital quality x-rays were provided with this case. We requested 
these x-rays, but they were not received. Without digital quality x-rays we cannot determine if a crown for 
tooth #18 is not medically necessary. Therefore, we decided that the Plan has to pre-approve a crown (D2740) 
for tooth #18.  
 
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 the comprehensive oral evaluation (D0150), bitewing x-rays (D0274), panoramic x-ray (D0330), prophylaxis (D1110), partial upper denture with flexible base (D5225), nitrous oxide (D9230), and extraction (D7210) provided from February 8, 2022, to February 15, 2022, by an opt-out provider.
You asked the Plan to pay for the dental services. You say that the dental office staff advised that you could submit the claim as out of network. You say that you feel you were misinformed by the office staff. You also say that you relied on them for information. The Plan denied your request. The Plan says the claim processed correctly.
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 dental services are not among those covered under this benefit when provided by an opt-out provider. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), bitewing x-rays (D0274), panoramic x-ray (D0330), prophylaxis (D1110), partial upper denture with flexible base (D5225), nitrous oxide (D9230), and extraction (D7210) provided from February 8, 2022, to February 15, 2022, by an opt-out provider.
Your complaint about being misinformed by the dental office 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 pre-approve a consultation and 14 extractions with an oral surgeon. 
 
You asked the Plan to pre-approve a consultation and 14 extractions with an oral surgeon. You say that the 
services are necessary. The Plan denied your request. The Plan says based on the documentation provided, 
coverage criteria has not been met. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers one extraction 
per year and that covered services must be performed by a participating general dentist. 
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of a consultation and 14 extractions with an oral surgeon have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a consultation and 14 extractions with an oral surgeon.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene panel testing provided on August 17, 2021. 
 
You asked the Plan to pay for the testing services. You say that you enable physicians to deliver personalized 
cancer care. The Plan denied your request. The Plan says one code must be submitted for the panel. 
 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 looked at the file and the rules. The claim information shows that multiple codes were billed for the gene 
panel. If a single procedure is performed, only one code with one unit of service may be reported for the 
procedure. Based on this information, we decided that Medicare rules for coverage of the testing services have 
not been met. Therefore, we decided that the Plan does not have to pay for the gene panel testing provided on 
August 17, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the periodontal maintenance (D4910) provided on March 3, 2022. 
 
You asked the Plan to pay for the periodontal maintenance. You say that you have had a deep cleaning before, 
on August 14, 2012. The Plan denied your request. The Plan says that periodontal maintenance is only allowed 
when you have had a deep cleaning done in the past. The Plan also says that your dental records do not show 
that you have had a deep cleaning. 
 
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. 
 
We looked at the file and Medicare rules. The 2022 Evidence of Coverage (EOC) states periodontics are 
covered every 6 to 36 months, and the ranges relate to the frequency of the procedures performed. The contract 
does not clearly state any benefit limitations for periodontal maintenance specifically, nor does the EOC refer 
you to any other documents to check for criteria prior to receiving the service. You reasonably believed this 
service would be covered because periodontics in general is listed as a covered service. Based on this 
information, we decided that the Plan's rules for coverage of the periodontal maintenance have been met. 
Therefore, we decided that the Plan has to pay for the periodontal maintenance (D4910) provided on March 3, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88112 billed for date of service November 5, 2021. 
 You asked the Plan to pay for procedure code 88112. You say that these were separate specimens and should 
be paid. The Plan denied your request. The Plan says an appropriate modifier was not billed. 
 
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 88112 is a column II code to column I code 88173. 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 88112 
billed for date of service November 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scaling and root planing - four or more teeth 
per quadrant (D4341) for the upper right and left quadrants. 
 
You asked the Plan to pre-approve periodontal scaling and root planing for the upper quadrants. You say that 
this service is necessary. The Plan denied your request. The Plan says the code your dentist sent must have at 
least four teeth in the same part of the mouth that need treatment. The x-rays your dentist sent do not show you 
have four teeth that need treatment. 
 
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 periodontal 
scaling and root planing for the upper quadrants when there are at least 4 teeth affected in the quadrant.  
 
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 periodontal scaling and root planing for 
the upper quadrants. Our reviewer says that this service is not medically necessary. Our physician reviewer 
found the documentation provided does not indicate the presence of 4 or more teeth in the maxillary right and 
left quadrants to meet the criteria for scaling and root planing (D4341). A lesser code would be appropriate.  
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 periodontal scaling and root planing for the upper quadrants have not been met. 
Therefore, we decided that the Plan does not have to pre-approve periodontal scaling and root planing - four or 
more teeth per quadrant (D4341) for the upper right and left quadrants.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electric stimulation therapy provided on February 8, 2022. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says this code is 
not valid for Medicare purposes. 
 
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 97014 has a Status Indicator of I on the Physician Fee Schedule. This means that CPT 
code 97014 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for 
coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay 
for the electric stimulation therapy provided on February 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cardiac risk assessment genetic screening testing (CPT 
code(s): 81238, 81286, 81410, 81411) provided on May 13, 2021. 
 
You asked the Plan to pay for the laboratory testing. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The documentation submitted on appeal indicates the cardiovascular genetic screening panel was initiated by 
the laboratory and not by the enrollee's treating physician nor following a consultation or evaluation by the 
enrollee's treating physician. Therefore, we decided that the Plan does not have to pay for cardiac risk 
assessment genetic screening testing (CPT code(s): 81238, 81286, 81410, 81411) provided on May 13, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a 2-day inpatient hospital stay. 
 
You asked the Plan to pre-approve a 2-day inpatient hospital stay. You say that the clinical information 
provided supports the need for a 2-day inpatient hospital stay. The Plan denied your request. The Plan says the 
medical necessity for 2 bed days has not been established after clinical review and per the peer-reviewed 
medical literature. 
 
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 a 2-day inpatient hospital stay. Our 
reviewer says that a 2-day inpatient hospital stay not considered medically reasonable and necessary in this 
case. Our physician reviewer found the lumbar laminectomy surgery may be safely performed with a 1-day 
inpatient stay.  
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 2-day inpatient hospital stay have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a 2-day inpatient hospital stay.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 1, 2021, billed with 
codes 81404, 81405, 81406, and 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that this was medically necessary testing as 
ordered by the enrollee's treating physician. The Plan denied your request. The Plan says this testing cannot be 
covered as Medicare does not cover cardiovascular screening under the billed codes. However, the Plan elected 
to pay three of the codes. 
 The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
June 1, 2021, billed with codes 81404, 81405, 81406, and 81479.
Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve controller, harness, and electronic connection. We decided that 
the Plan does not have to pre-approve power seat elevation feature.  
 
You asked the Plan to pre-approve controller, harness, electronic connection, and power seat elevation feature. 
You say that you are appealing this denial. The Plan says that the denial of authorization for these components 
is correct, because your upper limb strength and function are adequate to control the wheelchair's power 
options using their own switches, and a power seat elevation feature is not covered by Medicare. 
 
We decided that the Plan has to pre-approve expandable controller (code E2377), controller harness 
(E2313), and electronic connection device (E2311).  
 
 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 controller, harness, electronic 
connection, and power seat elevation feature. Our reviewer says that you meet the Medicare criteria for the 
requested controller, harness, and electronic connection. Our physician reviewer found the documentation 
shows that your power wheelchair has 3 power functions, and you have impaired range of motion and upper 
limb weakness.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of controller, harness, and electronic connection have been met. Therefore, we 
decided that the Plan has to pre-approve controller, harness, and electronic connection.  
 
We also decided that the Plan does not have to pre-approve power seat elevation feature (code E2300). 
 
The Plan follows Medicare rules. Medicare rules state that a power seat elevation feature is not covered by 
Medicare because it is not primarily medical in nature.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of power seat elevation feature have not been met. Therefore, we decided that the Plan does not have 
to pre-approve power seat elevation feature. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the general health panel provided on December 17, 2021. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says this code is not 
payable under Medicare. 
 
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 80050 is not covered by Medicare. Based on this information, we decided that 
Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for 
the general health panel provided on December 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete maxillary denture (D5110) provided on January 
25, 2022. 
 
You asked the Plan to pay for a denture. You say that you disagree with the denial of dental services. The Plan 
denied your request. The Plan says a complete maxillary denture (D5110) is not covered by your dental 
benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a 
complete maxillary denture (D5110) provided on January 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral exam (D0120), prophylaxis (D1110), and panoramic 
x-ray (D0330) provided on March 14, 2022, by the out-of-network provider. 
 
You asked the Plan to pay for the dental services. You say that you switched plans. You say that you were not 
aware that your provider was no longer in-network. You also say that you want this to be covered as you have 
been seeing this provider for several years. 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 Plan's 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 oral exam, prophylaxis, and x-ray 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 oral exam (D0120), prophylaxis (D1110), and panoramic x-ray (D0330) provided on March 
14, 2022, by the out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81404 and 81479) provided on 
March 29, 2021. 
 
You asked the Plan to pay for codes 81404 and 81479. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 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.  
 
The file does not contain documentation of an established relationship between the enrollee and the ordering 
provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this 
testing have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services 
(81404 and 81479) provided on March 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical removal of a tooth (code D7210) provided from 
March 3, 2022, to March 16, 2022. 
 
You asked the Plan to pay for the surgical removal of a tooth. You say that you had a tooth bothering you and 
needed to see a dentist right away. The Plan denied your request. The Plan says the surgical removal of a tooth 
is not covered by the supplemental 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 
surgical removal of an erupted tooth requiring removal of bone and/or sectioning of tooth (code D7210) 
provided from March 3, 2022, to March 16, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve fourteen (14) physical therapy (PT) visits (97110). 
 
You asked the Plan to pre-approve 14 PT visits. You say that the requested PT visits are medically necessary. 
The Plan denied your request. The Plan says the requested PT visits do not meet criteria. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 14 PT visits. Our reviewer says that 
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found there is no documentation that the unique skills of a professional 
therapist are required to safely and effectively provide treatment, that the services can be safely and effectively 
performed only by a therapist or under the supervision of a therapist. You appear to have "relatively plateaued" 
with therapy as stated in a medical note of 07/26/2022. Given this assessment and the therapy you have already 
received as well as the ten additional treatments just approved, further improvement in your functional status 
does not appear to be predictable in a reasonable time frame to necessitate the additional 14 therapy visits at 
this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 14 PT visits have not been met. Therefore, we decided that the Plan does not 
have to pre-approve fourteen (14) physical therapy (PT) visits (97110).