Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Laparoscopy (49652) provided on November 24, 2021. 
 
You asked the Plan to pay for the Laparoscopy. You say that the medical records support the use of modifier 59 
with code 49652. The Plan denied your request. The Plan says the medical records do not support the use of 
modifier 59 with code 49652. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
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 Laparoscopy Our reviewer says that the 
medical records do not support the use of modifier 59 with code 49652. Our physician reviewer found the 
record indicates that the enrollee underwent laparoscopic colectomy. The operative note indicates that the 
hernia site was included in the incision for the colectomy procedure.  Per NCCI Policy Manual 2020, VIE (Abdominal Procedures, 4); If a hernia repair is performed at the site of 
an incision for an open or laparoscopic abdominal procedure, the hernia repair (e.g., CPT codes 49560-49566, 
49652-49657) is not separately reportable. The elements of the coverage criteria are not satisfied.  The 
requested service is not recommended. 
 
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 Laparoscopy have not been met. Therefore, we decided that the Plan does 
not have to pay for the Laparoscopy (49652) provided on November 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for am intraoral - periapical each additional radiographic image 
on June 9, 2022. 
 
You asked the Plan to pay for the dental services. You say that you believe you have been double billed. 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 June 9, 2022. Therefore, 
we decided that the Plan does not have to pay for am intraoral - periapical each additional radiographic image 
on June 9, 2022.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to waive the cost share for fluoride varnish. We also decided that the Plan does 
not have to reduce the cost share for a crown, core build up, and prophylaxis.  
 
You asked the Plan to reimburse you for the dental services. You say that you were overcharged and are due a 
refund of $745. The Plan denied your request. The Plan says that you have been charged the correct cost 
sharing amount. 
 
We decided that the Plan has to waive the cost share for fluoride varnish.  
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information.  
 
According to the Explanation of Benefits, you have no copayment for fluoride varnish (D1206). Therefore, we 
decided that the Plan does have to waive the cost share for fluoride varnish provided on March 23, 2022. 
 
We also decided that the Plan does not have to reduce the cost share for a crown, core build up, and 
prophylaxis. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a $425 
copayment for a crown (D2750). The contract also says you have a $50 copayment for core build up (D2950). 
The contract says that you must pay a $15 copayment for prophylaxis (D1110).  
 
You have been asked to pay a $425 copayment for a crown (D2740). You have also been asked to pay a $50 
copayment for core build up (D2950). You have also been asked to pay a $15 copayment for prophylaxis 
(D1110). You have been asked to pay a total of $490 ($425 + $50 + $15 = $490). A crown, core build up, and 
prophylaxis fall within the Dental Services benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. 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 reduce the cost share 
for a crown, core build up, and prophylaxis provided on March 23, 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Prolia.

You asked the Plan to pre-approve Prolia. You say that the requested drug is a medical necessity for the enrollee. The Plan denied your request. The Plan says step-therapy rules for the requested drug have not been met.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.

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 Prolia. Our reviewer says that the requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the Plan requires a trial of oral bisphosphonates and zoledronic acid before they will approve the requested drug. In this case, the enrollee has not tried and failed the required drugs. There is no documentation provided indicating that the Plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve treatment with Prolia.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve eighteen (18) additional units of ultrasonic guidance for 
IGRT (G6002). 
 
You asked the Plan to pre-approve additional units of ultrasonic guidance for IGRT. You say that the requested 
service is medically necessary. The Plan denied your request. The Plan says the additional eighteen (18) units 
of ultrasonic guidance for placement of radiation therapy remains denied due to lack of medical necessity. 
 
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 additional units of ultrasonic guidance 
for IGRT. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the treatment itself is not disputed in this case but rather 
the need for image guidance. Usually, IGRT is used when critical structures are abutting or in close proximity 
to the target that is being treated to high doses. This situation does not apply to enrollee for which the target 
lesion can be seen on the skin to assist in daily set up. The case file describes a paper using daily ultrasound. 
Certainly, using ultrasound on a daily basis is not unreasonable to offer but not necessary. Therefore, to bill for 
daily simple simulations and/or IGRT for a technology for which need has not been established by published 
data or supported by consensus guidelines (many of which recommend against treatment with these devices in 
general) is not necessary. Billing for these services would not be furnished in accordance with accepted 
standards of medical practice. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional units of ultrasonic guidance for IGRT have not been met. Therefore, 
we decided that the Plan does not have to pre-approve eighteen (18) additional units of ultrasonic guidance for 
IGRT (G6002).
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for progressive lenses (V2781), and deluxe frames (V2025) received on 
January 18, 2022. 
 
You asked the Plan to pay for progressive lenses, and deluxe frames. You say that these services should be 
covered. The Plan denied your request. The Plan says that the services are not covered benefits. 
 Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services up to a $200 annual maximum toward the purchase of eyeglass lenses, 
frames, and contact lenses. 
 
We looked at the file and the Plan's rules. The Plan pays up to a $200 annual maximum plan benefit allowance 
toward the purchase of eyeglass lenses, frames, and contact lenses. The annual maximum plan benefit does not 
specify certain frames or lenses as excluded. You used a plan contracted provider and would reasonably have 
expected the Plans $200 annual maximum plan benefit to apply towards these frames and lenses. Based on this 
information, we decided that the Plan's rules for coverage of progressive lenses, and deluxe frames have been 
met. Therefore, we decided that the Plan has to pay for progressive lenses (V2781), and deluxe frames (V2025) 
received on January 18, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic radiographic image (D0330) provided on 
August 26, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says your benefit for the service provided 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 service provided was exhausted on date of service August 25, 2020.  
 Specifically, the Plan provides coverage of one panoramic radiographic image every three years. You 
previously received this service on August 25, 2020, which was paid for by the Plan. Therefore, you have 
exhausted the allowable benefit for this service. Therefore, we decided that the Plan does not have to pay for 
the panoramic radiographic image (D0330) provided on August 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composite-one surface, anterior (D2330), 
resin-based composite-three surfaces, anterior (D2332), resin-based composite- two surfaces, posterior 
(D2392), resin-based composite-three surfaces, posterior (D2393), and the resin-based composite-four or more 
surfaces, posterior (D2394) provided on April 20, 2022. 
 
You asked the Plan to pay for these dental services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says these services are not covered 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 services provided are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the resin-based 
composite-one surface, anterior (D2330), resin-based composite-three surfaces, anterior (D2332), resin-based 
composite- two surfaces, posterior (D2392), resin-based composite-three surfaces, posterior (D2393), and the 
resin-based composite-four or more surfaces, posterior (D2394) provided on April 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for limited oral evaluation (code D0140), biologic materials to 
aid in soft and osseous tissue regeneration (code D4265) and periodontal scaling and root planing one to three 
teeth per quadrant (code D4342) provided from February 23, 2022, through May 11, 2022. 
 
You asked the Plan to pay for limited oral evaluation, biologic materials to aid in soft and osseous tissue 
regeneration and periodontal scaling and root planing one to three teeth per quadrant. You say that these 
services should be paid as you were referred by your regular dentist and these services were not for regular 
cleaning or routine treatment. The Plan denied your request. The Plan says these services are not covered under 
the members contract under 2022 plan year 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 limited 
oral evaluation (code D0140), biologic materials to aid in soft and osseous tissue regeneration (code D4265) 
and periodontal scaling and root planing one to three teeth per quadrant (code D4342) provided from 
February 23, 2022, through May 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for recementing a crown on tooth #12 (D2920) provided on May 
23, 2022. 
 
You asked the Plan to pay for a crown. You say that your crown fell off and you were in a lot of pain. The Plan 
denied your request. The Plan says recementing a crown (D2920) is 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 pay for 
recementing a crown on tooth #12 (D2920) provided on May 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral complete x-ray series (D0210) provided on May 
4, 2022. 
 
You asked the Plan to pay for the dental services. You say that you did not know you could not get the x-ray 
again. 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 20, 2020. 
Therefore, we decided that the Plan does not have to pay for an intraoral complete x-ray series (D0210) 
provided on May 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay in full for the pontic (D6245) and retainer crown (D6740) 
provided on July 22, 2021. 
 
You asked the Plan to pay in full for the pontic and retainer crown. You say that the enrollee received 
verification of a zero-dollar patient responsibility from the Plan prior to the services being rendered. You also 
say that you feel the Plan made a mistake, and should be held responsible for the $2,111.00 due. The Plan 
denied your request. The Plan says the enrollee's annual maximum dental benefit has been exhausted. The Plan 
also says that the pre-authorization the provider received from the Plan is not a guarantee of payment, and the 
total benefits may not exceed the Plan's maximums. 
 
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 the enrollee's annual maximum dental benefit was exhausted on date of service July 22, 2021. The 
record also shows that the enrollee contacted the Plan on May 19, 2021, and again on May 28, 2021, inquiring 
about in-network providers. The enrollee was also advised that they may have to pay out-of-pocket for some 
services, but would depend on the services received. Therefore, we decided that the Plan does not have to pay 
in full for the pontic (D6245) and retainer crown (D6740) provided on July 22, 2021.
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 a colonoscopy. The 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intravenous moderate (conscious) sedation/analgesia-first 
15 minutes (D9239) and the intravenous moderate (conscious) sedation/analgesiaeach subsequent 15 minute 
increment (D9243) provided on March 9, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not covered 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 services provided are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the intravenous 
moderate (conscious) sedation/analgesia-first 15 minutes (D9239) and the intravenous moderate (conscious) 
sedation/analgesiaeach subsequent 15 minute increment (D9243) provided on March 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110), a lower partial 
denture (D5214) and an added metal substructure to acrylic full denture, per arch (D5876). 
 
You asked the Plan to pre-approve the dental services. You say that you need dentures, and you cannot wear 
the ones that you have due to being broken. You cannot eat solid foods and are currently taking potassium pills 
due to not being able to eat properly. Additionally, you say it is embarrassing to see family and go out in public 
without teeth. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. The Plan also says that an added metal substructure is not listed as a covered benefit 
with 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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service December 7, 2020. The 
record also shows that an added metal substructure is not listed as a covered benefit. Therefore, we decided that 
the Plan does not have to pre-approve a complete upper denture (D5110), a lower partial denture (D5214) and 
an added metal substructure to acrylic full denture, per arch (D5876).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bone replacement graft (D7953) provided on April 27, 
2022. 
 
You asked the Plan to pay for a replacement graft. You say that you had an infected abscess. The Plan denied 
your request. The Plan says a bone replacement graft (D7953) 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 bone 
replacement graft (D7953) provided on April 27, 2022.