Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure code 80307. We decided that the Plan does not have to pay 
for procedure code 83789.  
 
You asked the Plan to pay for presumptive drug testing billed with code 80307 and validity testing billed with 
code 83789 for date of service May 25, 2022. You say that these services were necessary and were reported 
correctly. The Plan says that code 83789 represents validity testing which is not separately payable, and 
presumptive drug testing may only be paid once per day to any provider. The Plan has paid for other 
presumptive drug testing for this enrollee on this date. 
 
We decided that the Plan has to pay for procedure code 80307.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not provided any documentation to show that another 
presumptive drug test (code set 80305-80307) was performed and paid to any provider for this enrollee on the 
date in question. Without evidence that the maximum allowed one presumptive drug testing has been paid for 
the same date and enrollee, the Plans denial is not substantiated. Therefore, we decided that the Plan has to pay 
for procedure code 80307.  
 
We also decided that the Plan does not have to pay for procedure code 83789. 
 
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 code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for procedure code 83789. 
 
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 an oral evaluation (D0140) provided on April 22, 2022. 
 
You asked the Plan to pay for 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 the services denied correctly as they do not fall 
within 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 an oral 
evaluation (D0140) provided on April 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740) for tooth # 18. 
 
You asked the Plan to pre-approve the dental service. You say that the enrollee's tooth is fractured. You also 
say they are in a lot of pain when biting down. The Plan denied your request. The Plan says the requested 
crown 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 the dental 
service when the services are medically necessary and reasonable.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the dental service. Our reviewer says 
that a crown for tooth # 18 is not medically necessary. Our physician reviewer found the provided 
documentation indicates a small restoration on tooth # 18. The reviewer found that there is not sufficient 
missing structure as to require a full coverage crown to restore the tooth and maintain it in function. Therefore, 
the reviewer found that a tooth for tooth # 18 is not medically necessary. 
 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 dental service have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a crown (D2740) for tooth # 18.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service May 23, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says procedure code 99100 is considered bundled and not separately 
payable. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service May 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cone beam computed tomography (CT) capture (D0364) 
and a diagnostic service consultation (D9310) for tooth number 15 provided on February 21, 2022. 
 
You asked the Plan to pay for a cone beam computed tomography (CT) capture (D0364) and a diagnostic 
service consultation (D9310) for tooth number 15. You say that you wish to be reimbursed for the $2,253. You 
also say that without the services performed by this provider, the problem of an infection in your system during 
major back surgery could have been very problematic for both you and the Plan. The Plan denied your request. 
The Plan says according to the EOC, pages 84 to 86, there is no coverage for a cone beam computed 
tomography (CT) capture (D0364) or a diagnostic service consultation (D9310). 
 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 cone 
beam computed tomography (CT) capture (D0364) and a diagnostic service consultation (D9310) for tooth 
number 15 provided on February 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and intraoral 
imaging (D0210) provided by a participating provider on June 29, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for this. 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 6, 2021. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and 
intraoral imaging (D0210) provided by a participating provider on June 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a gingival irrigation (D4921) for the upper right 
quadrant. 
 
You asked the Plan to pre-approve a gingival irrigation. The Plan denied your request. The Plan says this 
service is not covered under the enrollee's benefit 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 
gingival irrigation (D4921) for the upper right quadrant.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an unlisted maxillofacial prosthetic procedure. 
 
You asked the Plan to pre-approve an unlisted maxillofacial prosthetic procedure. You say that the services are 
medically necessary. The Plan denied your request. The Plan says Medicare does not cover primary dental 
services provided for the care, treatment, removal, or replacement of teeth or structures directly supporting 
teeth, regardless of cause or complexity. 
 
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 an unlisted 
maxillofacial prosthetic procedure 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 an unlisted maxillofacial prosthetic 
procedure. Our reviewer says that based on the documentation submitted there would be no necessity for the 
requested service.  Our physician reviewer found the Plan provision follows the Medicare statute allowances, which does not 
provide any coverage for teeth or supporting structures, and not preventive treatment despite the treatment of a 
primary medical condition. The fluoride application appliance is not primarily medical in nature.  It is dental in 
nature and noted as a preventive measure to protect the teeth from lack of salivary flow and subsequent caries. 
 
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 an unlisted maxillofacial prosthetic procedure have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an unlisted maxillofacial prosthetic procedure.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional neuropsychological testing. 
 
You asked the Plan to pre-approve additional neuropsychological testing. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that neuropsychological testing is only covered for certain 
indications. 
 
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 neuropsychological testing. 
Our reviewer says that the documentation does not support that the requested services are medically reasonable 
or necessary. Our physician reviewer found the enrollee has cognitive complaints. The requested 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. The 
documentation does not support that the enrollee is showing severity of symptoms that would warrant this type 
of diagnostic treatment. Therefore, the enrollee does not meet criteria for the requested 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 additional neuropsychological testing have not been met. Therefore, we decided 
that the Plan does not have to pre-approve additional neuropsychological testing.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9501 billed for dates of service June 7, 
2022, to June 13, 2022. 
 
You asked the Plan to pay for procedure code S9501. You say that you called and were told these services were 
covered. The Plan denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code S9501 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9501 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9501 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9501 billed for dates of service June 7, 2022, to June 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the periodic oral evaluation (D0120), intraoral - 
periapical first radiographic image (D0220), intraoral - periapical each additional radiographic image (D0230), 
bitewings - four radiographic images (D0274) and dental cleaning (D1110) provided on June 21, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay more for the dental services. You say that you have been going to this dental office 
for 30 years. The Plan denied your request. The Plan says you are responsible for any charged amount above 
the Plans cost-sharing amount when your services are received from an out-of-network provider. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to pay more for the periodic oral evaluation (D0120), 
intraoral - periapical first radiographic image (D0220), intraoral - periapical each additional radiographic image 
(D0230), bitewings - four radiographic images (D0274) and dental cleaning (D1110) provided on June 21, 
2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an addition to lower limb prosthesis, multiaxial ankle 
with swing phase active dorsiflexion feature (L5968) and an all-lower extremity prosthesis, flex-walk system 
(L5981). 
 
You asked the Plan to pre-approve prostheses. You say that you disagree with the denial. This type of 
componentry is also adjustable so the enrollee can dial back on range of motion when needed. She is a high risk 
for falling with a lesser foot feature. This foot feature will provide the stability and safety that she needs. If she 
were to fall again her rehabilitation will be a set back and hinder her progress to walk independently with her 
prostheses. The Plan denied your request. The Plan says the request was partially approved because the 
provider asked for prosthetic legs with advanced foot and ankle features. The enrollee is missing parts of her 
natural legs and need prosthetics to walk. Unfortunately, the request cannot be approved at this time by 
Medicare or your health plan. You may meet criteria for a simpler foot. 
 
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 prostheses. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found based on the medical records provided, there is no documentation that the K3 level advanced 
foot and ankle system at issue in this case meets all Medicare criteria for medically reasonable and necessary 
for the enrollee. Provided medical records from the enrollee's treating physician do not corroborate the 
prosthetist's assertion that the enrollee is or has the potential to be a K3 level ambulator as required by 
Medicare criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of prostheses have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an addition to lower limb prosthesis, multiaxial ankle with swing phase active dorsiflexion 
feature (L5968) and an all-lower extremity prosthesis, flex-walk system (L5981).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral exam (D0140), panoramic x-rays (D0330), 
and cone beam computed tomography (CT) capture and interpretation with field of view of both jaws (D0367) 
provided on June 28, 2022. 
 
You asked the Plan to pay for the dental services. You say that this service should be considered medical, not 
dental in nature. 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 limited oral exam was exhausted on March 16, 2022, and the panoramic x-ray was 
exhausted on May 24, 2022. The cone beam CT scan of the jaw is not covered under your benefits. Therefore, 
we decided that the Plan does not have to pay for the limited oral exam (D0140), panoramic x-rays (D0330), 
and cone beam computed tomography (CT) capture and interpretation with field of view of both jaws (D0367) 
provided on June 28, 2022.  
 
Your complaint about these services being considered dental in nature 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 a crown (D2740) and core build up (D2950) for tooth #3 
provided on July 20, 2021. 
 
You asked the Plan to pay for the dental services. You say that you were never told these dental services were 
not covered by the Plan. The Plan denied your request. The Plan says the denial of payment for these services 
is correct, because crowns and core build up are 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 pay for a crown 
(D2740) and core build up (D2950) for tooth #3 provided on July 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prefabricated abutment (D6056) and an implant 
supported crown (D6065) provided by a participating provider. 
 
You asked the Plan to pre-approve a prefabricated abutment and an implant supported crown. You say that you 
need this procedure completed because you cannot eat, and this is damaging your health. The Plan denied your 
request. The Plan says the requested dental services are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
prefabricated abutment (D6056) and an implant supported crown (D6065) provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bone replacement graft for ridge preservation-per site 
(D7953) provided on May 5, 2022. 
 
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 this service is not a covered benefit under the 
enrollee's 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 service provided is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the bone 
replacement graft for ridge preservation-per site (D7953) provided on May 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an extraction (D7210) and analgesia/inhalation of nitrous 
oxide (D9230) provided by an out-of-network provider on July 1, 2022. 
 
You asked the Plan to pay for the dental services. You say that you called to verify that these services would be 
covered. 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 (D7210) and analgesia/inhalation of nitrous oxide (D9230) provided by an out-of-
network provider on July 1, 2022.