Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for continued inpatient behavioral health services. 
 
You asked the Plan to pay for the inpatient services. You say that the medical records support the necessity of 
the services in dispute. The Plan denied your request. The Plan says the enrollee does not meet the criteria for 
Inpatient behavioral health services 
 The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 the inpatient services. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee was admitted to the acute inpatient psychiatric hospitalization on September 10, 
2022 with Cocaine Use Disorder, Schizoaffective Disorder and Borderline Personality Disorder. Based upon 
review the records provided it was not expected this enrollee would improve in a reasonable period of time for 
the dates in question as the enrollee did not have suicidal or homicidal ideation, auditory or visual 
hallucinations. The enrollee was compliant with treatment while not showing any acute threats to safety. It did 
not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of 
care rather than a lower level of care beyond the dates in question as the enrollee did not have dangerousness to 
self or others and was compliant with the treatment. I am unable to find an individualized treatment plan 
however the entire record is not present. It did appear that the records were supervised and evaluated by a 
physician. Based upon review the records provided for the admission of this enrollee does not meet the criteria 
for September 30, 2022 forward as this enrollee was not shown to be a danger to themself or others, delusions, 
auditory or visual hallucinations noted.  
 
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 inpatient services have not been met. Therefore, we decided that the Plan 
does not have to pay for continued inpatient behavioral health services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on June 
28, 2022. 
 
You asked the Plan to pay for the dental services. You say that you have never received any information 
informing you what procedures are allowed and how many times. 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 dates of service January 18, 2022, and 
February 3, 2022. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation 
(D0150) provided on June 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mass spectrometry and tandem mass spectrometry (83789) 
billed for date of service January 3, 2022. 
 
You asked the Plan to pay for mass spectrometry services. You say that these services are supported as billed. 
The Plan denied your request. The Plan says they have agreed to pay for code G0481; however, the payment 
for 83789 is included in this service and is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of mass spectrometry services have not been met. Specifically, we find that the testing described by 
the billed code is considered specimen validity testing which is not separately payable. Therefore, we decided 
that the Plan does not have to pay for mass spectrometry and tandem mass spectrometry (83789) billed for date 
of service January 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a false tooth for bridge (D6242) and abutment (D6059) 
 
You asked the Plan to pre-approve D6242 and D6059. You say that you are appealing the denial. The Plan 
denied your request. The Plan says this service is not covered by the Plan's 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 a 
false tooth for bridge (D6242) and abutment (D6059)
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an endosteal implant (D6010). 
 
You asked the Plan to pre-approve an implant. You say that an implant is medically necessary. The Plan denied 
your request. The Plan says an endosteal implant (D6010) 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 pre-approve an 
endosteal implant (D6010).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing provided on March 16, 2021, billed with codes 
87481, 87640, 87641, 87651, 87653, and 87798. 
 
You asked the Plan to pay for the lab testing as billed. You say that this testing should be paid. The Plan denied 
your request. The Plan says the Column 1 code was paid on appeal; however, the rest of the codes are not 
separately payable. 
 
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 87481, 87640, 87641, 87651, 87653, and 87798 are column II codes 
to column I code 87801; however, 87481, 87640, 87641, 87651, 87653, and 87798 were billed with a modifier.  
 
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 lab testing as billed. Our reviewer says that the 
documentation does not support the use of modifier -59 to bypass the edits for these codes. Our reviewer found 
the laboratory report describes one specimen from one wound. The use of modifier -59 is not appropriate in this 
case. 
 
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 lab testing as billed have not been met. Therefore, we decided that the Plan 
does not have to pay for the lab testing provided on March 16, 2021, billed with codes 87481, 87640, 87641, 
87651, 87653, and 87798.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve second stage implant surgery on tooth #30 and 31 
(D6011). 
 
You asked the Plan to pre-approve implant surgery. You say that you disagree with the denial of dental 
services. The Plan denied your request. The Plan says second stage implant surgery (D6011) is not covered by 
the enrollees 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 
second stage implant surgery on tooth #30 and 31 (D6011).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a prefabricated supported porcelain crown (D6061) and a 
prefabricated abutment (D6056) provided by a participating provider on May 24, 2022. 
 
You asked the Plan to pay for a prefabricated supported porcelain crown and a prefabricated abutment. You say 
that you did not know implant services were not part of the crown benefit. The Plan denied your request. The 
Plan says the rendered dental work 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 a 
prefabricated supported porcelain crown (D6061) and a prefabricated abutment (D6056) provided by a 
participating provider on May 24, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 70450 and 70030 billed for date of service 
February 27, 2022. 
 
You asked the Plan to pay for procedure codes 70450 and 70030. You say that the patient had multiple exams 
on this date of service The Plan denied your request. The Plan says payment for code 70450 is bundled into 
payment for code 70496. The Plan also says that the medical records do not support payment for code 70030. 
 
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 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. In addition, you billed code 70030 which is defined as an x-ray of the eye for the detection of a 
foreign body. The medical records you provided do not document this procedure.  In fact, there is no reference 
to an x-ray at all.  The only records you provided show evidence of a computed tomography (CT) angiography 
of the head and a CT of the head/brain.  There is nothing in the records to support the billing of the x-ray of the 
eye. 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 70450 and 70030 billed for date of service February 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an interim partial denture (including retentive/clasping 
materials, rests, and teeth), maxillary (D5820). 
 
You asked the Plan to pre-approve interim partial denture (including retentive/clasping materials, rests, and 
teeth), maxillary (D5820). You say that you are appealing the denial of D5820 due to it was denied because the 
service is not covered under the benefit package. The Plan denied your request. The Plan says this service is not 
covered by the Plan's 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 an 
interim partial denture (including retentive/clasping materials, rests, and teeth), maxillary (D5820).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for prophylaxis (D1110), bitewings (D0274), a periodic 
oral evaluation (D0120), intraoral imaging (D0220), and a crown (D2740), provided by an out-of-network 
provider on March 31, 2022, to May 19, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you believe that the Plan should pay for 
this. 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 prophylaxis (D1110), bitewings (D0274), a 
periodic oral evaluation (D0120), intraoral imaging (D0220), and a crown (D2740), provided by an out-of-
network provider on March 31, 2022, to May 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a surgical placement of an implant body (D6010x14), a 
custom fabricated abutment, includes placement (D6057x14), a complete upper overdenture (D5863) and a 
complete lower overdenture (D5865). 
 
You asked the Plan to pre-approve dental services. You say that you have a history of high blood pressure and 
asthma. The requested procedures are necessary. The Plan denied your request. The Plan says the dental codes 
submitted are benefit exclusions, therefore, the 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
surgical placement of an implant body (D6010x14), a custom fabricated abutment, includes placement 
(D6057x14), a complete upper overdenture (D5863) and a complete lower overdenture (D5865).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lower extremity prosthetic components (codes L5611, 
L5810, L5828, L5845, L5850, L5981). 
 
You asked the Plan to pre-approve lower extremity prosthetic components. You say that you are appealing this 
denial. The Plan denied your request. The Plan says you do not meet the Medicare criteria for the requested 
components. 
 
The Plan follows Medicare rules. Medicare rules state that lower limb prosthetic components may be covered 
under certain conditions when they are considered medically reasonable and necessary, taking into 
consideration the functional level of the beneficiary. 
 
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 lower extremity prosthetic components. 
Our reviewer says that you do not meet the Medicare criteria for the requested components. Our physician 
reviewer found the records provided do not contain any support that you are a K3 level ambulator. The records 
document that you are chair-bound and you are receiving home health services due to your inability to leave 
home as the effort is too taxing. These factors do not support that you are a K3 level ambulator to justify the 
need for the requested advanced K3 knee and foot. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of lower extremity prosthetic components have not been met. Therefore, we 
decided that the Plan does not have to pre-approve lower extremity prosthetic components (codes L5611, 
L5810, L5828, L5845, L5850, L5981).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the removal of residual tooth roots (D7250) provided by a 
participating provider on April 26, 2022. 
 
You asked the Plan to pay for extractions and the removal of residual tooth roots. You say that you cannot 
afford this bill. The Plan denied your request. The Plan says the rendered dental 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 
removal of residual tooth roots (D7250) provided by a participating provider on April 26, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fluoroscopy services coded 76000 provided on 
November 10, 2021. 
 
You asked the Plan to pay for the fluoroscopy services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are not separately payable. 
 
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 76000 is not supported in the medical record. Specifically, the operative report provided 
states that fluoroscopy was used intraoperatively, therefore, rendering it is bundled into the primary surgical 
procedure CPT code (28485). This means separate payment for this code cannot be made. Based on this 
information, we decided that Medicare rules for coverage of the fluoroscopy services have not been met. Therefore, we decided that the Plan does not have to pay for the fluoroscopy services coded 76000 provided on 
November 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve mandibular partial denture - flexible base (D5226). 
 
You asked the Plan to pre-approve dental services. You say that you without the partial denture, you only have 
two teeth you can chew on. 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 mandibular partial 
denture - flexible base (D5226) is not among those covered under this benefit. Therefore, we decided that the 
Plan does not have to pre-approve mandibular partial denture - flexible base (D5226).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gum medication (D4381), gingival irrigation (D4921), 
and periodontal scaling and root planing (D4342). 
 
You asked the Plan to pre-approve the dental services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says gum medication (D4381), gingival irrigation (D4921), and periodontal 
scaling and root planing (D4342) are not covered by the enrollee's 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 gum 
medication (D4381), gingival irrigation (D4921), and periodontal scaling and root planing (D4342).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crowns (D2751) for teeth # 27 and 28. 
 
You asked the Plan to pre-approve the crowns for teeth # 27 and 28. You say that the crowns for teeth # 27 and 
28 have been removed. You say that the enrollee complains of not being able to chew on these teeth. You also 
say that the enrollee needs new crowns. The Plan denied your request. The Plan says the crowns for teeth # 27 
and 28 are not medically necessary. 
 
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 the crowns 
for teeth # 27 and 28 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 pre-approve the crowns for teeth # 27 and 28. Our reviewer says that the crowns for teeth # 27 and 28 are not medically necessary. Our physician reviewer found 
the provided documentation indicates there are inadequate root canal fillings on teeth # 27 and 28. Therefore, 
the reviewer found that the criteria for coverage of the crowns have not been met. 
 
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 the crowns for teeth # 27 and 28 have not been met. Therefore, we decided that 
the Plan does not have to pre-approve crowns (D2751) for teeth # 27 and 28.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the general anesthesia (D9222, D9223 x 6), and therapeutic 
parenteral drug (D9610) provided on January 24, 2022. 
 
You asked the Plan to pay for the dental services. You say that the dental office only does extractions with 
anesthesia. You also say that you would like these services to be covered. The Plan denied your request. The 
Plan says general anesthesia is not listed as a covered service. The Plan says therapeutic parenteral drug is not 
listed as a covered service either. 
 
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 dental services are not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the general anesthesia 
(D9222, D9223 x 6), and therapeutic parenteral drug (D9610) provided on January 24, 2022.