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

 
We decided that the Plan does not have to pre-approve a pontic (D6210) and abutment supported crowns 
(D6060 x 2). 
 
You asked the Plan to pre-approve the dental services. You say that you have problems eating. You also say 
that you do not feel comfortable. The Plan denied your request. The Plan says dental implants and all 
associated services are not covered. 
 
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 pontic and abutment 
supported crowns are not among those covered under this benefit. Therefore, we decided that the Plan does not 
have to pre-approve a pontic (D6210) and abutment supported crowns (D6060 x 2).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 4 additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve 4 additional PT visits. You say that you are still having uncomfortable pain 
in the right side of your neck, shoulder and arm. You say that you need additional visits to get more release 
from the pain. You also say that you feel additional sessions will make pain less. The Plan denied your request. 
The Plan says the additional PT visits are not medically necessary.  
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 4 additional 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 you have had prior therapy and the documentation does not 
reveal that you require the unique skills of a professional therapist   to safely and effectively provide treatment, 
or that the services can be safely and effectively performed only by a therapist, or by or under the supervision 
of a therapist. The reviewer found that your deficits are not so significant that you require ongoing formal 
therapy. The reviewer found that you have been trained in a home exercise program. The requested services are 
not part of a maintenance program, and the specialized skill, knowledge and judgment of a qualified therapist is 
not required to establish, design and/or deliver a program to maintain your current condition or to prevent or 
slow further deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 4 additional PT visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 4 additional physical therapy (PT) visits.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intravenous (IV) tubing extension set (S1015) provided 
on October 6, 2021. 
 
You asked the Plan to pay for the IV tubing extension set. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says this code is not payable by 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. 
In this case, the CPT Code Manual definition of code S1015 is Iv tubing extension set. 
 
We find that CPT code S1015 is not supported in the medical record. Specifically, this code is not eligible for 
payment by Medicare. Based on this information, we decided that Medicare rules for coverage of the IV tubing 
extension set have not been met. Therefore, we decided that the Plan does not have to pay for the intravenous 
(IV) tubing extension set (S1015) provided on October 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit (99202) mechanical traction 
(97012) therapeutic exercise (97110) provided May 11, 2021 to June 11, 2021. 
 
You asked the Plan to pay for the chiropractic services. You say that you were told by a Plan representative that 
you have chiropractic coverage. However, after 6 visits and having paid $20 copays for each visit, you are now 
told none of your visits are covered by Medicare. The Plan denied your request. The Plan says these services 
are not covered when rendered by a chiropractor. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the outpatient office visit (99202) mechanical traction (97012) therapeutic 
exercise (97110) provided May 11, 2021 to June 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone replacement graft (D4263), guided tissue 
regeneration (D4267), three custom fabricated abutments (D6057 x3), three implant supported crowns (D6066 
x3), and a pontic (D6242) for tooth #4. 
 
You asked the Plan to pre-approve the bone replacement graft, guided tissue regeneration, custom fabricated 
abutments, implant supported crowns, and pontic. You say that you would like these services to be approved 
for coverage because you cannot stand the discomfort you are in. The Plan denied your request. The Plan says 
the bone replacement graft, guided tissue regeneration, custom fabricated abutment, and implant supported 
crown are not covered under your benefit plan. The Plan also says that the pontic is not medically necessary 
because you are missing more than one tooth in the arch. 
 
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 Plan covers pontics when 
the service is 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 pontic. Our reviewer says that the 
documentation does not meet the criteria for coverage for a pontic replacing missing tooth #4. Our physician 
reviewer found coverage for implants for tooth #'s 3 and 5 were denied since these are not covered services, 
therefore, a pontic cannot be used in the area to replace the missing tooth #4. Our reviewer found that in order 
for a pontic to be used, abutment retainers must be present. In this case this would not be possible. Our 
physician reviewer also found that replacing any missing teeth would require the use of a removable prosthesis. 
 
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 bone replacement graft, guided tissue regeneration, custom fabricated 
abutments, implant supported crowns, and pontic have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a bone replacement graft (D4263), guided tissue regeneration (D4267), three custom 
fabricated abutments (D6057 x3), three implant supported crowns (D6066 x3), and a pontic (D6242) for tooth 
#4.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services coded 99053 provided on September 2, 2021. 
 
You asked the Plan to pay for the medical services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says this claim has not been billed as required 
by Medicare coding regulations.
 
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 99053 is service(s) provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service. 
 
We looked at the file and Medicare rules. In this case, code 99053 has a status code of "B" under the Physician 
Fee Schedule. This means that payment for covered services are always bundled into payment for other 
services not specified. Based on this information, we decided that Medicare rules for coverage of the medical 
services have not been met. Therefore, we decided that the Plan does not have to pay for the medical services 
coded 99053 provided on September 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a battery charger (E2366) and lead acid battery (E2365). 
 
You asked the Plan to pre-approve the power vehicle equipment. You say that you would like this claim 
reprocessed and approved for separate payment. The Plan denied your request. The Plan says these items are 
not eligible for separate payment. 
 
The Plan must follow Medicare rules. Medicare rules say that that all options and accessories are included in 
the allowance for a Power Operated Vehicle (K0800, K0801, K0802, K0806, K0807, K0808, K0812) when 
provided at the same time. Based on this information, we decided that Medicare rules for coverage of the 
power vehicle equipment have not been met. No separate payment will be made for these items. Therefore, we 
decided that the Plan does not have to pre-approve a battery charger (E2366) and lead acid battery (E2365).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the power wheelchair accessories (CPT code(s): E2377, 
E2311, E2313, E2300, and K0108 x3). 
 
You asked the Plan to pre-approve the items. You say that the items are necessary. The Plan denied your 
request. The Plan says the items are not covered. 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
Upgraded electronics (electronic connection, expandable controller and harness) cannot be covered per 
Medicare rules. They are necessary when there is a medical need to control power options though the joystick. 
The notes do not show a medical need to control the power options through the joystick. The power options can 
be controlled using their own switches. These switches can be made any size without asking for a separate 
request. They can be made from any material without asking for a separate request. All of this can be done 
without the need to use the joystick to control the power features. The joystick controller display is part of the 
upgraded electronics. This cannot be requested separately. The seat lift does not serve a primary medical 
purpose. This cannot be covered. The calf pads, arm rests are already included in the approved wheelchair. 
They cannot be requested separately Therefore, we decided that the Plan does not have to pre-approve the 
power wheelchair accessories (CPT code(s): E2377, E2311, E2313, E2300, and K0108 x3).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care services provide from July 13, 2021, to July 
15, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the billed 
code 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 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. We find that CPT code 99291 is not supported in 
the medical record. Specifically, the records do not indicate how much time was spent for the services at issue. 
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 critical care services provide from July 
13, 2021, to July 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral imaging (D0230 and D0220) provided by a 
participating provider on October 20, 2021. 
 
You asked the Plan to pay for intraoral imaging. You say that you would like the Plan to pay for this. The Plan 
denied your request. The Plan says the benefit limit for intraoral imaging has already 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 intraoral 
image per year. 
 
We looked at the file and Medicare rules. Evidence was provided that show D0220 and D0230 were provided 
on January 14, 2021. Based on this information, we decided that the Plan's rules for coverage of intraoral imaging have not been met. Therefore, we decided that the Plan does not have to pay for intraoral imaging 
(D0230 and D0220) provided by a participating provider on October 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Column chromatography (82542) and the Mass 
spectrometry and tandem mass spectrometry (83789) provided on June 2, 2021. 
 
You asked the Plan to pay for codes 82542 and 83789. 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 providers must report services correctly. 
 
In this case, the CPT Code Manual definition of code 82542 is Column chromatography, includes mass 
spectrometry, if performed (eg, HPLC, LC, LC/MS, LC/MS-MS, GC, GC/MS-MS, GC/MS, HPLC/MS), non-drug analyte(s) not elsewhere specified, qualitative or quantitative, each specimen. The definition of code 
83789 is Mass spectrometry and tandem mass spectrometry (e.g., MS, MS/MS, MALDI, MS-TOF, QTOF), 
non-drug analyte(s) not elsewhere specified, qualitative or quantitative, each specimen. We find that tests to 
confirm that a urine specimen is not adulterated is not separately billable. Therefore, we decided that the Plan 
does not have to pay for the Column chromatography (82542) and the Mass spectrometry and tandem mass 
spectrometry (83789) provided on June 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removal of an impacted tooth (D7240) and an excision 
of a benign lesion greater than 1.25 cm (D7411). 
 
You asked the Plan to pre-approve removal of an impacted tooth and an excision of a benign lesion. You say 
that the appeal is for 2 wisdom teeth and a tooth is a tooth, no matter if its erupted or impacted. You also say 
these teeth are causing you great pain and preventing your ability to eat because your mouth is so sore. The 
Plan denied your request. The Plan says the procedure codes are not listed and therefore 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, 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 
removal of an impacted tooth (D7240) and an excision of a benign lesion greater than 1.25 cm (D7411).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional payment for the intraoral - periapical first 
radiographic image (D0220), intraoral - periapical each additional radiographic image (D0230), and 
periodontal maintenance (D4910) provided November 16, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to provide additional payment for the intraoral x-rays and periodontal maintenance. You 
say that you were not informed that you could not see a provider who has opted out of Medicare. The Plan 
denied your request. The Plan says they have made a one-time exception to provide coverage for this claim for 
service rendered by a provider who has opted out of Medicare. The claims have processed according to your OON benefits. Two of the x-rays are not covered because you have exceeded the frequency limit for this type of x-ray. 
 
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 Plan covers one intraoral 
x-ray and four periodontal maintenance procedures codes per calendar year with 50% coinsurance when the 
services are provided OON.  
 
We looked at the file and Medicare rules. The Plan has provided documentation showing that they have 
covered 50% of the allowed amount for the periodontal maintenance and two intraoral x-rays. You are being 
asked to pay 50% coinsurance plus the difference between the allowed amount and the total cost charged by the 
OON provider for these services. Two intraoral x-rays have not been covered because you have exceeded the 
frequency limit for this service. Therefore, we decided that the Plan does not have to provide additional 
payment for the intraoral - periapical first radiographic image (D0220), intraoral - periapical each additional 
radiographic image (D0230), and periodontal maintenance (D4910) provided November 16, 2021, by an out-
of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom fabricated abutment (D6057), abutment 
supported porcelain/ceramic crown (D6058), and implant supported porcelain/ceramic crown (D6065). 
 
You asked the Plan to pre-approve the custom fabricated abutment, abutment supported porcelain/ceramic 
crown, and implant supported porcelain/ceramic crown. You say that you would like special consideration to 
be made in the coverage to be inclusive to restore tooth #11 with a crown as a covered expense. The Plan 
denied your request. The Plan says these services are not covered. 
 
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 
custom fabricated abutment (D6057), abutment supported porcelain/ceramic crown (D6058), and implant 
supported porcelain/ceramic crown (D6065).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental codes D0120, D0272, D1110, and D2332 provided on 
November 1, 2021, and November 9, 2021. 
 
You asked the Plan to pay for dental codes D0120, D0272, D1110, and D2332. You say that you would like the 
Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the dental maximum 
benefit of $1000 has already been met for the 2021 calendar year as of your March 23, 2021, date of service. 
 
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, the Plan's contract, and Medicare rules. The Plan covers a $1000 annual maximum for 
supplemental dental services. The file shows that the dental maximum benefit of $1000 has already been met 
for the 2021 calendar year as of your March 23, 2021, date of service. Therefore, we decided that the Plan does not have to pay for dental codes D0120, D0272, D1110, and D2332 provided on November 1, 2021, and November 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve scaling and root planing (D4341 x 4), and mouth guard 
(D9944). 
 
You asked the Plan to pre-approve the dental services. You say that the deep cleaning is a critical benefit for 
you. You say that you need coverage for the procedure on a yearly basis. You also say that you were not aware 
of the limitation of every 3 years when you signed up with this plan. The Plan denied your request. The Plan 
says scaling and root planing is covered once per quadrant every 3 years. The Plan says that the frequency limit 
has been reached. The Plan also says that mouth guard is not listed as 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 and scaling and root planing is listed as 
covered, the frequency limit of once per quadrant every 3 years has been reached. The record shows that the 
Plan paid for scaling and root planing for all 4 quadrants that you received on January 11, 2021. Additionally, the requested mouth guard is not among those covered under this benefit. Therefore, we decided that the Plan 
does not have to pre-approve scaling and root planing (D4341 x 4), and mouth guard (D9944).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the IV tubing extension set (S1015) and the infection control 
supplies (S8301) provided on September 10, 2021. 
 
You asked the Plan to pay for codes S1015 and S8301. 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 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 looked at the file and Medicare rules. In this case, CPT codes S1015 and S8301 have a status code of "I" 
under the Medicare Physicians Fee Schedule Database (MPFSDB) and are not valid for Medicare purposes. 
Medicare uses other codes for reporting of, and payment for, these services. Therefore, we decided that the 
Plan does not have to pay for the IV tubing extension set (S1015) and the infection control supplies (S8301) 
provided on September 10, 2021.