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

 
We decided that the Plan does not have to pre-approve dental therapeutic parenteral drugs and deep 
sedation/general anesthesia (D9223, D9612) 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says your benefit for the requested item or 
service has already been exhausted with the authorization, additional services cannot be covered after the 
$3,500 maximum is reached. 
 
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 will be exhausted. Therefore, we decided that the Plan 
does not have to pre-approve dental therapeutic parenteral drugs and deep sedation/general anesthesia (D9223, 
D9612).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drug provided in an outpatient setting 
on January 3, 2022. 
 
You asked the Plan to pay for the self-administered drug. You say that these services should be covered. The 
Plan denied your request. The Plan says self-administered drug is not covered under Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drug 
provided in an outpatient setting on January 3, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an inpatient admission. 
 
You asked the Plan to pre-approve the inpatient admission. You say that the admission is medically necessary 
for the enrollee. The Plan denied your request. The Plan says the requested inpatient admission is not medically 
necessary. 
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this 
case. Our physician reviewer found the record did not show that at the it is reasonably expected that the 
enrollee's necessary hospital care would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an inpatient admission.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial maxillary denture (D5213). 
 
You asked the Plan to pre-approve the dental services. You say that your dentures broke. 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 January 27, 2021. 
Therefore, we decided that the Plan does not have to pre-approve a partial maxillary denture (D5213).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gingival irrigation in all four quadrants (D4921). 
 
You asked the Plan to pre-approve gingival irrigation. You say that these services are medically necessary. The 
Plan denied your request. The Plan says gingival irrigation (D4921) 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 
gingival irrigation in all four quadrants (D4921).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cone beam computed tomography (CT) imaging 
services. 
 
You asked the Plan to pre-approve cone beam computed tomography (CT) imaging services. You say that this 
imaging is medically necessary. The Plan denied your request. The Plan says the criteria for coverage have not 
been met. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
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 cone 
beam computed tomography (CT) imaging services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an attendant control represented by code E2331. 
 
You asked the Plan to pre-approve the attendant control. You say that the records provided support the need for 
the item which remains in dispute. The Plan denied your request. The Plan says the criteria for coverage for the 
attendant control have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that if an attendant control (E2331) is provided in addition 
to a beneficiary-operated drive control system, it will be denied as non-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 the attendant control. Our reviewer says 
that the criteria for coverage have not been met. Our physician reviewer found the enrollee was approved for an 
E2377 expandable controller as well as the E2311 electronic connection between the controller and 2 or more 
power seating system motors. The enrollee was also approved for the E2313 harness for upgrade to expandable 
controller. Given the approval of an enrollee operated drive control system the attendant control represented by 
code E2331 is not medically necessary. 
 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 attendant control have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an attendant control represented by code E2331.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure codes 82962 and 82947 billed for date of service
January 27, 2022.

You asked the Plan to pay for procedure code 82947. You say that you disagree with the Plan's denial. The
Plan denied your request. The Plan says payment for code 82947 is bundled into payment for code 82962. The
Plan also says that code 82962 is not medically necessary.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pay for code 82962. Our reviewer says that the
services rendered with code 82962 is not medically necessary. Our physician reviewer found the enrollee has a
history of horseshoe kidney, hypertension, hypersensitivity lung disease, deep vein thrombosis. The enrollee is
on Eliquis. The enrollee has chronic pain and follows multiple specialists including primary care physician,
pain management, and nephrology. The enrollee is not diabetic, and diagnosis code M79.2 - Neuralgia and
neuronitis, unspecified does not support medical necessity for CPT 82962 - Glucose, blood by glucose
monitoring device(s) cleared by the FDA specifically for home use. The review has determined that the
documentation does not support that the enrollee met criteria for the glucose testing based on the NCD rules.

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 82947
is a column II code to column I code 82962. This claim has not been billed with an appropriate modifier to
bypass the edit. We looked at this physician's review, the file, and Medicare rules. 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 82962 and 82947 billed for date of service January 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220), two additional 
intraoral periapical x-rays (D0230), and root canal (D3330) provided on April 28, 2022. 
 
You asked the Plan to pay for the intraoral periapical x-rays and root canal. You say that you were told that 
these services would be covered by your insurance. The Plan denied your request. The Plan says your benefits 
for the requested services have 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 benefits for the requested services were exhausted on dates of service February 21, 2022, and April 
28, 2022. Therefore, we decided that the Plan does not have to pay for the first intraoral periapical x-ray 
(D0220), two additional intraoral periapical x-rays (D0230), and root canal (D3330) provided on April 28, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve abutment supported porcelain fused to metal crowns 
(high noble metal) (D6059). 
 
You asked the Plan to pre-approve abutment supported crowns. You say that you would like this service 
covered. The Plan denied your request. The Plan says this service is not covered under your 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 
abutment supported porcelain fused to metal crowns (high noble metal) (D6059).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve three custom fabricated abutments (D6057 x3) and three 
abutment supported porcelain/ceramic crowns (D6058 x3). 
 
You asked the Plan to pre-approve custom fabricated abutments and abutment supported porcelain/ceramic 
crowns. You say that the dental implant work began last year. You also say that it is medically necessary for 
this work to be completed, as the implants will not hold without the abutments. 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 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 three 
custom fabricated abutments (D6057 x3) and three abutment supported porcelain/ceramic crowns (D6058 x3).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a nasal/sinus endoscopy, surgical; with biopsy, polypectomy, 
or debridement (31237) provided on March 18, 2022. 
 You asked the Plan to pay for a nasal/sinus endoscopy. You say that you are requesting reconsideration for 
services, advising the referral and medical records were included with the appeal, supporting reprocessing of 
the claim for payment. The Plan denied your request. The Plan says code 31237 remains denied because an 
anatomical modifier was not appended. A corrected claim may be submitted and has not been received at this 
time. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code and modifiers. 
 
We find that CPT code 31237 is not supported in the medical record. Specifically, there is no anatomic 
modifier listed with code 31237. This should be billed with the appropriate modifier for the service. Please 
note, the Plan has paid for the office visit and the enrollee has a $15 copayment responsibility. Based on this 
information, we decided that Medicare rules for coverage of a nasal/sinus endoscopy have not been met. 
Therefore, we decided that the Plan does not have to pay for a nasal/sinus endoscopy, surgical; with biopsy, 
polypectomy, or debridement (31237) provided on March 18, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve four further hours of neuropsychological testing 
evaluation services. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that neuropsychological evaluation testing is covered 
when specific criteria are met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has depression, anxiety, and chronic fatigue. There is no documentation of cognitive impairment. Neuropsychological testing is 
intended to diagnose and characterize the neurocognitive effects of medical disorders that impinge directly on 
or indirectly on the brain including detection of neurologic disease based on quantitative assessment of 
neurocognitive abilities, differential diagnosis between psychogenic and neurogenic syndromes, delineation of 
neurocognitive effects of central nervous system disorders, neurocognitive monitoring of recovery or 
progression of central nervous system disorders or assessment of neurocognitive function for the formulation of 
rehabilitation and/or management strategies among individuals with neuropsychiatric disorders, documentation 
does not show the enrollee requires four more units of neuropsychological testing and therefore is not 
medically necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve four further hours of neuropsychological testing evaluation services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thirteen (13) additional home physical therapy visits for 
the enrollee. 
 You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that the approved visits should be enough to complete the enrollee's 
goals, teach the enrollee a home exercise program, and establish a safe discharge plan. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 these services. Our reviewer says that 
thirteen (13) additional home physical therapy visits are not medically reasonable and necessary. 
Documentation doesnt support that the enrollee requires additional skilled rehab services to provide treatment 
that is medically necessary. The enrollee does not require additional skilled rehab services to effectively 
provide treatment, care, and/or services in order to improve the enrollees condition, perform a maintenance 
program to maintain the enrollees condition and/or prevent deterioration. The enrollee has been medically 
stable without any recent exacerbation of chronic medical problems or hospitalizations. Our physician reviewer 
found that the enrollee's condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve thirteen (13) additional home physical therapy visits for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for endodontic therapy (D3320), a crown (D2740), and resin-
based composites (D2331 and D2391), provided by a participating provider on December 1, 2021. 
 
You asked the Plan to pay for endodontic therapy, a crown, and resin-based composites. You say that you 
believe the Plan should pay for this. The Plan denied your request. The Plan says this claim has been processed 
correctly. 
 
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, D2740 or D3320 are not among those 
covered under this benefit. Resin-based composites were exhausted on June 28, 2021. Therefore, we decided 
that the Plan does not have to pay for endodontic therapy (D3320), a crown (D2740), and resin-based 
composites (D2331 and D2391), provided by a participating provider on December 1, 2021.
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 April 11, 2022. 
 
You asked the Plan to pay for mass spectrometry services. You say that these services are supported in the 
medical record. The Plan denied your request. The Plan says they have agreed to pay for code G0480; however, 
the payment for code 83789 is included in this payment and is denied as a separate service. 
 
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 April 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an extraction (D7140) provided by an out-of-network 
provider on June 9, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were unaware that this provider was out-of-
network. The Plan denied your request. The Plan says the dental services were received from an out-of-network 
provider and are not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for an extraction (D7140) provided by an out-of-network provider on June 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740) provided by a participating provider. 
 
You asked the Plan to pre-approve a crown. You say that D2740 is medically necessary. The Plan denied your 
request. The Plan says D2740 is 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 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 pre-approve a crown. Our reviewer says that D2740 
is not medically necessary. Our physician reviewer found the radiograph does not appear to show a significant 
amount of missing structure involving the body or cusps of the tooth that would indicate a need for a full 
coverage crown.  
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 not been met. Therefore, we decided that the Plan does not have 
to pre-approve a crown (D2740) provided by a participating provider.