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

 
We decided that the Plan does not have to pre-approve non-emergency wheelchair van transportation (A0130). 
 
You asked the Plan to pre-approve the non-emergency wheelchair van transportation. You say that you have 
not driven in years because you have Macular Degeneration, which is treated every 4 to 6 weeks and is the 
reason for this request. The Plan denied your request. The Plan says there is no clinical pertaining to your 
current mobility status that was submitted to establish the medical necessity for coverage of the requested 
service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport 
services.  
 
The services you have asked the Plan to pre-approve are wheelchair van transport services. Therefore, we 
decided that the Plan does not have to pre-approve non-emergency wheelchair van transportation (A0130).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a diagnostic colonoscopy (45378). 
 
You asked the Plan to pre-approve a diagnostic colonoscopy. You say that the requested service is medically 
necessary. The Plan denied your request. The Plan says the requested service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a diagnostic colonoscopy. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the provided documentation indicates that the enrollee's last study had no 
abnormalities only 6 years ago, when based on the USMSTF guidelines recommend a 10 year wait. Therefore, 
this request for colonoscopy is premature, not supported in the documentation, and will be considered 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 a diagnostic colonoscopy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a diagnostic colonoscopy (45378).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve microsurgical techniques, requiring use of operating 
microscope (List separately in addition to code for primary procedure) (CPT code 69990). 
 
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says Medicare guidance says an operating microscope cannot be billed for separately during 
this type of surgery. 
 
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 the service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the requested microsurgical techniques, requiring use of operating microscope (CPT 69990), in 
this case, is not medically reasonable and necessary to be billed in conjunction with approved spinal fusion 
(CPT codes: 20936, 20930, 63051, 63040, 22600, 22614, 63020, 63035). 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve microsurgical techniques, requiring use of operating microscope (List separately in 
addition to code for primary procedure) (CPT code 69990).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the records provided support the need for IRF care. The Plan denied your request. The Plan says IRF care is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.
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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee is living at home after recent treatment for urinary tract infection and COVID infection. There is ongoing weakness despite home health services. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and 
first intraoral periapical x-ray (D0220) provided on November 8, 2021. 
 
You asked the Plan to pay for the problem focused limited oral evaluation and first intraoral periapical x-ray. 
You say that you would like these services to be covered. The Plan denied your request. The Plan says these 
services are not covered expenses under your dental plan. The Plan also says that neither you or your provider 
did not contact the Plan prior to the date of service to verify benefits and provider eligibility. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 pay for the 
problem focused limited oral evaluation (D0140) and first intraoral periapical x-ray (D0220) provided on 
November 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone graft in conjunction with periradicular surgery, 
per tooth (D3428) for tooth #18 and tooth #19. 
 
You asked the Plan to pre-approve a bone graft. You say that you disagree with the denial and would like the 
plan to reconsider. The Plan denied your request. The Plan says the requested service is excluded from 
coverage and is not a 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, 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 
bone graft in conjunction with periradicular surgery, per tooth (D3428) for tooth #18 and tooth #19.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical extraction (D7210) and bone replacement graft 
(D7953) provided on October 25, 2021. 
 
You asked the Plan to pay for the dental services. You say that your face was swollen. You say that you needed 
to have an extraction. You say that you were not aware this would not be a normal tooth extraction. You also 
say that the services were urgent and should be covered under your medical benefit. The Plan denied your 
request. The Plan says the services you received are routine dental in nature. The Plan says that the services are 
not covered by your medical plan. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 

The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for the surgical extraction (D7210) 
and bone replacement graft (D7953) provided on October 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the four crowns (D2750 x4) provided on October 11, 2021. 
 
You asked the Plan to pay more for the crowns. You say that you are upset that you paid $4,000 and are not 
being reimbursed for it. The Plan denied your request. The Plan says this claim processed correctly in 
accordance with the Plan's benefit. The Plan also says that you reached the $2,000 individual maximum with 
this claim. 
 
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, you are responsible for a 20% 
coinsurance for restorative services. The Plan also offers a $2,000 allowance every year for restorative dental 
services. The record shows that you met the annual maximum benefit while processing this claim for the 
October 11, 2021 date of service and your annual maximum benefit has been exhausted. Therefore, we decided 
that the Plan does not have to pay more for the four crowns (D2750 x4) provided on October 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), bitewing x-rays 
(D0274), and prophylaxis (D1110) provided on November 8, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the comprehensive oral evaluation, bitewing x-rays, and prophylaxis. You say 
that when you made the appointment you were told that you had OON coverage which takes care of 80% 
which you were satisfied with. You also say that you would like to be reimbursed for what your plan's coverage 
is. The Plan denied your request. The Plan says these services were rendered by a non-participating dental 
provider. The Plan also says that services need to be provided in-network to be eligible for payment. 
 
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 
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the 
comprehensive oral evaluation (D0150), bitewing x-rays (D0274), and prophylaxis (D1110) provided on 
November 8, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the removable prosthodontic procedure (D5899) and 
complete mandibular denture (D5120) provided on July 8, 2021. 
 
You asked the Plan to pay for the removable prosthodontic procedure and complete mandibular denture. The 
enrollee says that they never received the bottom denture that the Plan was charged $971 for. The Plan denied 
your request. The Plan says the removable prosthodontic procedure is not a covered expense under the 
enrollee's benefit plan. The Plan also says that the enrollee's benefits for the complete mandibular denture have 
been satisfied and the frequency limitation has been exceeded. 
 
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, unspecified removable prosthodontic 
procedure (D5899) is not among those covered under this benefit. The contract says that the enrollee is limited 
to one upper complete and/or one lower complete denture every five years. The record shows that the enrollee 
received a complete mandibular denture (D5120) on February 27, 2020 and the enrollee's complete mandibular 
denture benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the removable 
prosthodontic procedure (D5899) and complete mandibular denture (D5120) provided on July 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two additional intraoral periapical x-rays (D0230 x2), 
oral hygiene instructions (D1330), and four gingival irrigations (D4921 x4) provided on October 15, 2021, and 
November 11, 2021.  
You asked the Plan to pay for the additional intraoral periapical x-rays, oral hygiene instructions, and gingival 
irrigations. You say that you would like these services to be covered. The Plan denied your request. The Plan 
says your benefit for the additional intraoral periapical x-rays has been satisfied and the frequency limitation 
has been exceeded. The Plan also says that oral hygiene instructions and gingival irrigation are not covered 
expenses under your dental 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, oral hygiene instructions (D1330) and 
gingival irrigation (D4921) are not among those covered under this benefit. The contract says that intraoral x-
rays are limited to one procedure code per calendar year. The record shows that you received a first intraoral 
periapical x-ray (D0220) on October 15, 2021 and your intraoral x-rays benefit has been exhausted. Therefore, 
we decided that the Plan does not have to pay for the two additional intraoral periapical x-rays (D0230 x2), oral 
hygiene instructions (D1330), and four gingival irrigations (D4921 x4) provided on October 15, 2021, and 
November 11, 2021.  
 
Your complaint about your bad experience with the treating provider and staff is not a valid appeal for medical 
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not 
permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on October 29, 2021. 
 
You asked the Plan to pay for the dental service. You say that over the course of a year you have had 2 teeth 
crack. You also say that these were necessary to avoid infection and preserve teeth. The Plan denied your 
request. The Plan says 1 limited oral evaluation per plan year is covered. The Plan also says that the frequency 
limit has been exceeded. 
 
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 and 1 limited oral evaluation is covered 
per plan year, the frequency limit has been exceeded. The record shows that the Plan paid for a limited oral 
evaluation that you received on June 4, 2021. Therefore, we decided that the Plan does not have to pay for the 
limited oral evaluation (D0140) provided on October 29, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 81206, 81235, 81292, 
81301, and 81321) provided on April 15, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the laboratory services have not been met. As Comprehensive 
Genomic Profile (CGP) testing is not defined as a targeted panel by MolDX; and it is a test not currently 
satisfactorily described by any existing CPT code; to report a CGP, service providers should use 1-unit only 
of CPT code 81479 (used for the entire bundled multi-test panel) at this time, in addition to the approved 
DEX Z-CodeTM entered adjacent in the comment/narrative field for the test; not unbundled to separate codes, 
or other unlisted code. Therefore, we decided that the Plan does not have to pay for the laboratory services 
(CPT code(s): 81206, 81235, 81292, 81301, and 81321) provided on April 15, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for spectrometry testing (83789) provided on March 1, 2021.
You asked the Plan to pay for spectrometry testing. You say that this is supported in the records. The Plan denied your request. The Plan says this testing should not be billed separately.
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine specimens used for drug testing shall not separately bill the validity testing. For example, if a laboratory performs a urinary pH, specific gravity, creatinine, nitrates, oxidants, or other tests to confirm that a urine specimen is not adulterated, this testing is not separately billed. We find that CPT code 83789 is not supported in the medical record. Specifically, the records show that this testing was performed as validity testing for the specimen used for drug testing. Based on this information, we decided that Medicare rules for coverage of spectrometry testing have not been met. Therefore, we decided that the Plan does not have to pay for spectrometry testing (83789) provided on March 1, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the 2 additional lumbar epidural injections. 
 
You asked the Plan to pre-approve the 2 additional lumbar epidural injections. You say that the records 
provided support the need for the requested injection services. The Plan denied your request. The Plan says the 
clinical information provided does not support that the requested procedure is indicated at this time. 
 
The Plan follows Medicare rules. Medicare rules say that repeat ESI injections may be considered medically 
reasonable and necessary when the first injection of the series directly and significantly provides improvement 
and when the medical record documents 50% sustained improvement in pain and/or function for at least three 
months.   
 
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 2 additional lumbar epidural 
injections. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the 
Plan has approved the next epidural steroid injection. There is no role for a series of three injections to be 
approved. Each injection must be assessed for effectiveness and duration of pain relief and therapeutic value. Epidural steroid injections must provide 3 months of pain relief. 
 
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 2 additional lumbar epidural injections have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the 2 additional lumbar epidural injections.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance and pay for a resin-based composite (D2330), 
and an interim partial maxillary denture (D5820) provided by a participating provider on November 2, 2021. 
 
You asked the Plan to waive the coinsurance and pay for a resin-based composite and an interim partial 
maxillary denture. You say that you would like the Plan to reconsider this. You say that you would like this 
claim paid. The Plan denied your request. The Plan says the benefit limit for D2330 has already been 
exhausted. The Plan says that D5820 is not a covered benefit. 
 
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 20% coinsurance for dental services.  
 
You have been asked to pay a 20% coinsurance of the allowed amount for a resin-based composite. The total 
allowed amount is $90. The amount you are being asked to pay for D2330 is $18 ($90 x 20% = $18). An 
interim partial maxillary denture is not a covered benefit. A resin-based composite and an interim partial 
maxillary denture falls 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 waive the 
coinsurance for a resin-based composite (D2330), and an interim partial maxillary denture (D5820) provided 
by a participating provider on November 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Ultrasound guidance (76937) provided on August 23, 2021. 
You asked the Plan to pay for code 76937. 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. In this case, we have confirmed that code 76937 
is an add-on code and has not been billed with an appropriate primary procedure code. Based on the claim 
submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to 
pay for the Ultrasound guidance (76937) provided on August 23, 2021.