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

 
We decided that the Plan has to pre-approve a crown on tooth #30 (D2740). 
 
You asked the Plan to pre-approve a crown. Your provider says that a crown is necessary due to the amount of 
tooth structure that has been compromised. The Plan denied your request. The Plan says that the documentation 
does not demonstrate significant breakdown due to decay or trauma. 
 
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 a crown 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 a crown. Our reviewer says that the coverage 
criteria has been met. Our physician reviewer found the documentation indicates a large restoration in tooth 
#30 with areas of recurrent decay. Our physician reviewer also found that a crown restoration is medically 
reasonable and necessary to restore tooth #30 to adequate masticatory function. 
 
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 a crown have been met. Therefore, we decided that the Plan has to pre-approve 
a crown on tooth #30 (D2740).  
 
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 an electronic connection between a wheelchair 
controller and two or more power seating system motors (E2311), a harness for an upgrade to an expandable 
controller (E2313), an expandable controller (E2377), a USB charger, a Braze Sentina Plus kit, a controller 
mount option and a Braze Echo Head kit (K0108). 
 
You asked the Plan to pre-approve power wheelchair accessories. You say that the enrollee can operate and 
would benefit from having an electronic wheelchair. She had a stroke that affected the right side of her body. 
Her left side of her body is unaffected and can operate an electronic wheelchair. The Plan denied your request. 
The Plan says a USB charger, a Braze Sentina Plus kit, a controller mount option and a Braze Echo Head kit do 
not service a medical purpose. The Plan also says although there are three requested power options, there is not 
a medical need to control these power options through the joystick. The enrollee's upper limb strength and 
function are adequate for the enrollee to be able to control the power options using their own switches which 
are included in the allowance of these power options. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve an electronic connection between a wheelchair controller 
and two or more power seating system motors (E2311), a harness for an upgrade to an expandable controller 
(E2313), an expandable controller (E2377), a USB charger, a Braze Sentina Plus kit, a controller mount option 
and a Braze Echo Head kit (K0108).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for custom abutment on tooth #3 (D6057) and abutment 
supported crown on tooth #3 (D6058). 
 
You asked the Plan to pay for the dental services. You say that you already had the implant placement and need 
the second part to complete the process. The Plan denied your request. The Plan says custom abutment (D6057) 
and abutment supported crown (D6058) are 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 custom 
abutment on tooth #3 (D6057) and abutment supported crown on tooth #3 (D6058).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97010 billed for date of service January 24, 2022. 
 
You asked the Plan to pay for procedure code 97010. You say that these services were authorized and should 
be paid. The Plan denied your request. The Plan says separate payment is never made for this code. 
 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 97010 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 97010 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of procedure code 97010 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 97010 billed for date of service January 24, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sclerosant injection procedure (36471) and a stab 
phlebectomy of varicose veins (37765). 
 
You asked the Plan to pre-approve a sclerosant injection procedure and a stab phlebectomy of varicose veins. 
You say that the requested services are a medical necessity for the enrollee. The Plan denied your request. The 
Plan says medical necessity rules for coverage of the requested services have not been met. 
 
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 sclerosant injection procedure and a 
stab phlebectomy of varicose veins. Our reviewer says that the requested services are not medically reasonable 
and necessary in this case. Our physician reviewer found that the enrollee has chronic lower extremity 
lymphedema with prior radiofrequency ablation of the right greater saphenous vein. There is no documentation 
of the location and number of varicosities nor that for tributary veins. The documentation does not meet 
guideline criteria for use of the requested therapy. 
 
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 sclerosant injection procedure and a stab phlebectomy of varicose veins have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a sclerosant injection procedure 
(36471) and a stab phlebectomy of varicose veins (37765).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient hospital services for the enrollee. 
 
You asked the Plan to pre-approve inpatient hospital services. You say that these services are medically 
necessary. The Plan denied your request. The Plan says that there is no documentation provided to support the 
expectation the enrollee will require a greater than 2 midnight stay. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 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 inpatient hospital services. Our 
reviewer says that inpatient hospital services are not medically reasonable and necessary. The enrollee is 
medically stable and has been provided medical clearance to undergo the total shoulder arthroplasty. The 
planned procedure is not listed on the CMS Inpatient Only List. The procedure is currently approved as an 
ambulatory procedure. There is no documentation provided to support the expectation the enrollee will require 
a greater than 2 midnight stay. Our physician reviewer found that the enrollee's condition does not meet criteria 
for coverage of inpatient hospital services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient hospital services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve inpatient hospital services for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient hospital services for the enrollee. 
 
You asked the Plan to pre-approve inpatient hospital services. You say that these services are medically 
necessary. The Plan denied your request. The Plan says that medical records do not show the necessity of these 
services. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 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 inpatient hospital services. Our 
reviewer says that inpatient hospital services are not medically reasonable and necessary. The enrollee is 
medically stable and there is no documentation provided indicating medical necessity for inpatient admission 
services for this elective outpatient procedure. The review indicates that the record did not show that at the time 
of inpatient admission the admitting physician reasonably expects that the patient's necessary hospital care 
would span two midnights. Our physician reviewer found that the enrollee's condition does not meet criteria for 
coverage of inpatient hospital services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient hospital services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve inpatient hospital services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mounting block permobil B. 
 
You asked the Plan to pre-approve a mounting block permobil B. You say that you would like the Plan to 
reconsider their denial. The Plan denied your request. The Plan says the requested mounting hardware is 
included in the approved item under code E0955. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have been approved for a headrest, that includes fixed mounting hardware (E0955). 
The fixed mounting hardware (E0955) serves the same purpose as a mounting block permobil B. Therefore, we 
decided that the Plan does not have to pre-approve a mounting block permobil B.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mandibular partial denture (D5214). 
 
You asked the Plan to pre-approve the dental services. You say that you had upper dentures made on October 
2, 2017, but you had lost them. 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 October 2, 2017. 
Therefore, we decided that the Plan does not have to pre-approve a mandibular partial denture (D5214).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator (CPT code E1392). 
 
You asked the Plan to pre-approve a portable oxygen concentrator. You say that a portable oxygen concentrator 
is necessary. The Plan denied your request. The Plan says this is not covered. 
 
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 a portable oxygen concentrator have not been met. Review of the 
file shows that you have already been approved for an oxygen concentrator at home which serves the same 
purpose as a portable oxygen concentrator. Therefore, we decided that the Plan does not have to pre-approve a 
portable oxygen concentrator (CPT code E1392).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the core buildup, including any pins when 
required (D2950) provided on March 2, 2022. 
 
You asked the Plan to issue reimbursement for this item. You say that you are requesting a reconsideration of 
the Plan's denial for payment. The Plan denied your request. The Plan says this item is not a covered benefit 
under your contractual policy. 
 
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 item provided in this case is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to issue 
reimbursement for the core buildup, including any pins when required (D2950) provided on March 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental implants on tooth #4, 7, 13, and 19 (D6010), 
bone graft on tooth #7, 10, and 13 (D6104), and prefabricated abutment on tooth #7, 10, and 13 (D6056). 
 
You asked the Plan to pre-approve the dental services. You say that you disagree with the denial of dental 
services. The Plan denied your request. The Plan says dental implants (D6010), bone graft (D6104), and 
prefabricated abutment (D6056) are not covered by your routine 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 pre-approve 
dental implants on tooth #4, 7, 13, and 19 (D6010), bone graft on tooth #7, 10, and 13 (D6104), and 
prefabricated abutment on tooth #7, 10, and 13 (D6056).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture (D5213) and a mandibular 
partial denture (D5214). 
 
You asked the Plan to pre-approve the partial dentures. You say that you were told these services were covered 
under your dental plan. The Plan denied your request. The Plan says these services are not covered under your 
plan. The Plan also says that you are not enrolled in a 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 a 
maxillary partial denture (D5213) and a mandibular partial denture (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950) 
provided on April 22, 2022. 
 
You asked the Plan to pay for the core buildup. You say that you would like to appeal this service. The Plan 
denied your request. The Plan says this service is not a covered expense under your dental plan. The Plan also 
says that you did not contact the Plan prior to the date of service to verify benefits and provider eligibility. 
 
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 core 
buildup, including any pins when required (D2950) provided on April 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve partial upper and lower dentures (D5212, D5211). 
 
You asked the Plan to pre-approve partial dentures. You say that your current dentures are broken and 
unusable. 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 May 10, 2018. Therefore, 
we decided that the Plan does not have to pre-approve partial upper and lower dentures (D5212, D5211).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit coded 99204 provided on January 11, 2022. 
 
You asked the Plan to pay for the office visit. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the services are not payable as 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. 
 
We find that CPT code 99204 is not supported in the medical record. Specifically, this code has a status code of 
"B". A status code of B means that this code is bundled. No separately additional reimbursement can be made. 
Based on this information, we decided that Medicare rules for coverage of the office visit have not been met. 
Therefore, we decided that the Plan does not have to pay for the office visit coded 99204 provided on January 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the molecular pharmacogenetic testing coded with 81230, 
81240, 81240, 81241, 81249, 81291, 81408 and 81335 provided August 27, 2021. 
 You asked the Plan to pay for the laboratory service. You say that kindly review the document attached and 
reprocess the claim for payment. The Plan denied your request. The Plan says the medical records do not 
support the service 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 find that CPT code 81230, 81240, 81240, 81241, 81249, 81291, 81408 and 81335. is not 
supported in the medical record. Specifically, Medicare denies coverage when a laboratory assays two or more 
genes in a patient in parallel. Those two or more genes will be considered part of the same panel. A panel 
constitutes a single procedural service, so one CPT code must be submitted for the panel. Based on this 
information, we decided that Medicare rules for coverage of the laboratory service have not been met. 
Therefore, we decided that the Plan does not have to pay for the molecular pharmacogenetic testing coded with 
81230, 81240, 81240, 81241, 81249, 81291, 81408 and 81335 provided August 27, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 81238, 81225, 81230, 81241, 
81291, and 81240 provided on July 13, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services are not payable as 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. 
 We find that CPT codes 81238, 81225, 81230, 81241, 81291, and 81240 are not supported in the medical 
record. Specifically, when a laboratory assays two or more genes in an enrollee in parallel, those two or more 
genes will be considered part of the same panel. A panel constitutes a single procedural service, so one code 
must be submitted for the panel. Review of the file does not support that only one code was submitted for the 
panel provided. Based on this information, we decided that Medicare rules for coverage of the laboratory 
services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services 
coded 81238, 81225, 81230, 81241, 81291, and 81240 provided on July 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown on tooth #7 (D2750), prefabricated post on 
tooth #7 (D2954), endodontic therapy on tooth #7 (D3310), resin-based composite filling on tooth #11 
(D2332), and resin-based composite filling on tooth # 13, 14, 15, and 16 (D2391). 
 
You asked the Plan to pre-approve the dental services. You say that you disagree with the denial of dental 
services. The Plan denied your request. The Plan says your dental allowance for the year has been exhausted. 
 
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 record shows the annual dental 
allowance for the year has been exhausted. 
 
Therefore, we decided that the Plan does not have to pre-approve a crown on tooth #7 (D2750), prefabricated 
post on tooth #7 (D2954), endodontic therapy on tooth #7 (D3310), resin-based composite filling on tooth #11 
(D2332), and resin-based composite filling on tooth # 13, 14, 15, and 16 (D2391).