Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transport brackets (K0108) and a folding stroller handle 
(K0108). 
 
You asked the Plan to pre-approve transport brackets and a folding stroller handle. You say that you would like 
the Plan to reconsider their denial. The Plan denied your request. The Plan says transport brackets and a folding 
stroller handle to be used outside the home are not covered.  
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The items at issue in this appeal are for use outside of the home. Although these items may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve transport brackets (K0108) and a folding stroller handle (K0108).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220) and bitewing x-
rays (D0274) provided on December 29, 2021. 
 
You asked the Plan to pay for the first intraoral periapical x-ray and bitewing x-rays. You say that you would 
like to appeal these services. The Plan denied your request. The Plan says these services exceed the benefit 
allowance. 
 
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, dental x-rays are limited to one (1) 
every 2 years. The record shows that you received dental x-rays on February 25, 2021, and June 8, 2021, and 
your dental x-rays benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the 
first intraoral periapical x-ray (D0220) and bitewing x-rays (D0274) provided on December 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on 
December 6, 2021. 
 
You asked the Plan to pay for the comprehensive oral evaluation. You say that you would like the $22 that you 
are being charged for this service to be dropped. The Plan denied your request. The Plan says your benefits for 
this service 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, periodic oral exam and comprehensive 
oral evaluation share a frequency limitation of two procedure codes per calendar year. The record shows that 
you received a comprehensive oral evaluation (D0150) on May 4, 2021, and a periodic oral evaluation (D0120) 
on August 11, 2021, and your periodic oral exam and comprehensive oral evaluation benefits had been 
exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation 
(D0150) provided on December 6, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a second instance of a computed tomographic angiography 
(CTA) of the chest (71275) billed for date of service October 31, 2021. 
 
You asked the Plan to pay for a second CTA of the chest. You say that the procedure at issue was a necessity 
for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met because the 
records provided do not support the service 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, the CPT Code Manual definition of code 71275 is "Computed tomographic angiography, chest (noncoronary), with contrast material(s), including noncontrast images, if performed, and image postprocessing." 
 
We find that a second instance of CPT code 71275 is not supported in the medical record. Specifically, the 
available medical records document only one instance of the procedure at issue. Based on this information, we 
decided that Medicare rules for coverage of a second CTA of the chest have not been met. Therefore, we 
decided that the Plan does not have to pay for a second instance of a computed tomographic angiography 
(CTA) of the chest (71275) billed for date of service October 31, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supplies provided to the enrollee from September 29, 
2021, to October 26, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that durable medical equipment (DME) supplies must 
be provided with a proof of delivery. 
 
The required documentation pertaining to the proof of delivery of these supplies was not provided. Based on 
this information, we decided that Medicare rules for coverage of the services have not been met. 
 
 
 
 
  
 
 Therefore, we decided that the Plan does not have to pay for the supplies provided to the enrollee from 
September 29, 2021, to October 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal scalings and root planings (D4341) and 
gingival irrigations (D4921) provided on September 29, 2021. 
 
You asked the Plan to pay for the scalings and planings and gingival irrigations. You say that you were not told 
up front that these periodontal services would not be covered by your insurance. The Plan denied your request. 
The Plan says these procedures are not benefits under the dental plan. The Plan also says that according to an e-
mail from the dental facility, you were given a credit of $415.45 and are only being charged for $268.80 for 
this date of service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
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 
periodontal scalings and root planings (D4341) and gingival irrigations (D4921) provided on September 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the depression screening bill for services provided on 
December 20, 2021. 
 
You asked the Plan to pay for the billed services. You say that a depression screening is a separately payable 
service. The Plan denied your request. The Plan says the criteria was not met. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
In this case, the CPT Code Manual definition of code G0444 is annual depression screening, 15 minutes. We 
find that CPT code G0444 is not supported in the medical record. Specifically, the records do not include a 
screening tool provided to the enrollee. The records also do not show that 15 minutes was spent on the 
screening tool. Based on this information, we decided that Medicare rules for coverage of the billed services 
have not been met. Therefore, we decided that the Plan does not have to pay for the depression screening bill 
for services provided on December 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for neuromonitoring services (95937) provided November 5, 
2021. 
 
You asked the Plan to pay for the neuromonitoring services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the claim did not include a valid diagnosis code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 95937 is not supported in the medical record. Specifically, per Local Coverage Article: 
Nerve Conduction Studies and Electromyography (A54095), M48.02 is not listed as a covered diagnosis code 
for this procedure. Based on this information, we decided that Medicare rules for coverage of the 
neuromonitoring services have not been met. Therefore, we decided that the Plan does not have to pay for 
neuromonitoring services (95937) provided November 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit rendered from July 1, 2021 to July 29, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 99213 is not covered. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. The file shows that the 
chiropractor submitted a claim for procedure code 99213 (office visit). Therefore, we decided that the Plan 
does not have to pay for the office visit rendered from July 1, 2021 to July 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supplies rendered on October 22, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are 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 CPT code. 
 
We find that CPT code A4550, A4300, and A4263 has a status indicator of B on the Physician Fee Schedule. This means that CPT code A4550, A4300, and A4263 is not separately payable. 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 pay for the supplies rendered on October 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implant placement (D6010 x 9), implant supported 
crowns (D6065 x 9), and prefabricated abutments (D6056 x 9). 
 
You asked the Plan to pre-approve the dental services. You say that you need these services. The Plan denied 
your request. The Plan says dental implants and all associated services are excluded from coverage. 
 
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 implants, implant 
supported crowns, and prefabricated abutments are not among those covered under this benefit. Therefore, we 
decided that the Plan does not have to pre-approve implant placement (D6010 x 9), implant supported crowns 
(D6065 x 9), and prefabricated abutments (D6056 x 9).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the maxillary partial denture (D5211) provided on 
January 5, 2022. 
 
You asked the Plan to pay more for the maxillary partial denture. You say that you received a pre-estimate that 
shows your responsibility was to be $339.50 and that is what you should pay. You also say that you do not 
know why the amount changed. The Plan denied your request. The Plan says one of the pre-estimates that you 
received was for a pontic (D6211), with a patient liability of $339.50, but this was not the procedure you 
received. The Plan also says that the pre-estimate that was sent to you with for the maxillary partial denture 
(D5211) showed your patient responsibility as $425.00, which is what you are liable for. 
 
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 50% 
coinsurance for the denture you received. The record shows that the pre-estimate you were went for the 
maxillary partial denture (D5211) shows you would be responsible for the amount of $425.00. Therefore, we 
decided that the Plan does not have to pay more for the maxillary partial denture (D5211) provided on January 
5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a white glass with high gold content cap for a bridge for 
teeth #28, 29 and 32, and a false tooth for a bridge for teeth #30 and #31. 
 
You asked the Plan to pre-approve the dental services. You say that this is medically necessary. The Plan 
denied your request. The Plan says the x-rays show missing teeth. 
 
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 dental services. Our reviewer says 
that the requested dental services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found a fixed bridge is considered for coverage to replace a single maxillary anterior tooth 
or two adjacent mandibular anterior teeth and if no posterior teeth are missing. In this case two posterior teeth 
are to be replaced and there was no documentation that a removable prosthesis was contraindicated. The 
documentation does not meet the criteria for coverage for a posterior fixed bridge replacing teeth #'s 30 and 31. 
 
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 dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a white glass with high gold content cap for a bridge for teeth #28, 29 and 32, and a 
false tooth for a bridge for teeth #30 and #31.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) 
provided on December 10, 2021. 
 
You asked the Plan to pay for the problem focused limited oral evaluation. You say that this service should 
have been paid because it was your consult for future care. The Plan denied your request. The Plan says this 
service exceeds the frequency limitation in your benefit plan. 
 
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, problem focused limited oral 
evaluation (D0140) is limited to one procedure per plan year. The record shows that you received a problem 
focused limited oral evaluation (D0140) on September 23, 2021 and your problem focused limited oral 
evaluation (D0140) has been exhausted. Therefore, we decided that the Plan does not have to pay for the 
problem focused limited oral evaluation (D0140) provided on December 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) 
provided December 14, 2021. 
 
You asked the Plan to pay for the limited oral exam. You say that this should be covered under emergency 
treatment of pain. The Plan denied your request. The Plan says you have exceeded the frequency limit for this 
service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the limited 
oral exam once per plan year. 
 
We looked at the file and Medicare rules. The Plan provided documentation showing that a limited oral exam 
was previously covered on June 18, 2021. Based on this information, we decided that the Plan's frequency limit for coverage of the limited oral exam has been exceeded. Therefore, we decided that the Plan does not have to 
pay for the limited oral evaluation - problem focused (D0140) provided December 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a placement of intra-socket biological dressing (D7922) 
and bone replacement graft for ridge preservation (D7953). 
 
You asked the Plan to pre-approve the placement of intra-socket biological dressing and bone replacement 
graft. The Plan denied your request. The Plan says these services are not covered under your plan. 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
placement of intra-socket biological dressing (D7922) and bone replacement graft for ridge preservation (D7953).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve partial upper denture (D5213). 
 
You asked the Plan to pre-approve the dental item. You say that the enrollee needs this service. The Plan 
denied your request. The Plan says the requested service was denied correctly. 
 
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 the requested partial upper denture 
is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for a complete 
upper denture that you received on May 9, 2017. At the time the request this was made, the 5 year time frame 
had not elapsed. Therefore, we decided that the Plan does not have to pre-approve partial upper denture (D5213).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (35371, 37221, 37220, 99233) provided 
November 15, 2021 to November 16, 2021. 
 
You asked the Plan to pay for the surgical services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the billed codes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 35371, 37221, 37220, and 99233 are not supported in the medical record. Specifically, 
a required anatomical modifier was not included for CPT codes 35371, 37221, & 37220. CPT code 99233 is 
included in the global surgery period and not separately payable. Based on this information, we decided that 
Medicare rules for coverage of the surgical services have not been met. Therefore, we decided that the Plan 
does not have to pay for surgical services (35371, 37221, 37220, 99233) provided November 15, 2021 to 
November 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiopharmaceutical localization of tumor provided to the 
enrollee on May 5, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the provider did not bill as required by Medicare coding regulations. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 78830 
is a column II code to column I code 79101. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for radiopharmaceutical localization of tumor provided to the 
enrollee on May 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crowns (D2750) for teeth #6, #8, and #11 and partial 
upper and lower dentures. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no evidence of decay or missing crown to support the need for a replacement of 
tooth #6, #8, or #11. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the services 
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 services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found necessity has not 
been shown for crowns for #6, #8 or #11. A request was made for crowns on teeth #6, 8 and 11. It appears the 
existing crowns #6 and #8  are part of a three unit bridge. The bridge abutments of #6 and #8 are intact, and 
do not appear to be defective or decayed from the supplied information. The amount of restoration on tooth #11 does not appear to be in excess of 30% of the tooth, and as such does not appear to require a full coverage 
crown to restore it. Crowns are usually considered as a restoration when there is more than 50% of the structure 
missing or damaged and that full coverage restorations would add strength to the tooth. In this instance #11 
does not have sufficient damage as to require a crown restoration.  The abutments #6 and #8 have existing full 
coverage restorations as part of the bridge, with no evidence of material failure or decay at the margins.  Given 
the lack of any damage to the crowns, there is no clear necessity for crowns on #6 and #8, which would 
necessitate the loss of the #7 pontic. The provider should reevaluate the treatment plan and provide an 
explanation of the proposed treatment if resubmitting as the current submission is unclear as to the intended 
result. 
 
We looked at this physician's review, the file, and Medicare rules. Our reviewer found that there is no medical 
support for the crowns in this case. Additionally, the plan does not cover the dentures in any situation. Based 
on this information, we decided that the Plan's rules for coverage of the services have not been met. Therefore, 
we decided that the Plan does not have to pre-approve crowns (D2750) for teeth #6, #8, and #11 and partial 
upper and lower dentures.