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

 
We decided that the Plan does not have to pay for the endodontic therapy, molar tooth (excluding final 
restoration) (D3330) for tooth 31 and unspecified diagnostic procedure, by report (D0999) provided November 
17, 2021. 
 
You asked the Plan to pay for the root canal and unspecified diagnostic procedure. You say that you would like 
these services covered. The Plan denied your request. The Plan says you have exceeded the frequency limit for 
these services. 
 
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 root canal 
and unspecified diagnostic procedure once per tooth per lifetime. 
 
We looked at the file and Medicare rules. The Plan previously covered a root canal for tooth 31 was previously 
covered on November 4, 2021. Based on this information, we decided that the Plan's frequency limit for 
coverage of the root canal for tooth has been exceeded. Therefore, we decided that the Plan does not have to 
pay for the endodontic therapy, molar tooth (excluding final restoration) (D3330) for tooth 31 and unspecified 
diagnostic procedure, by report (D0999) provided November 17, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for dental services provided by a non-participating provider on October 20, 
2021, and October 26, 2021. 
 
You asked the Plan to pay for dental services. You say that you would like the Plan to pay for this. The Plan 
denied your request. The Plan says that the benefit limit for the dental work provided has already been 
exhausted. 
 
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. The Plan has failed to provide an Evidence of Benefits for dates of service 
January 11, 2021, and September 14, 2021. Therefore, we decided that the Plan has to pay for dental services 
provided by a non-participating provider on October 20, 2021, and October 26, 2021.  
 
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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided between 10:00 PM and 08:00 
AM coded as 99053 provided on July 7, 2021. 
 
You asked the Plan to pay for the medical services. You say that you would like this claim reprocessed based 
on the medical records. The Plan denied your request. The Plan says no separate payment is made for this code 
per Medicare 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, the CPT Code Manual definition of code 99053 is service(s) provided between 10:00 PM and 8:00 
AM at 24-hour facility, in addition to basic service. 
 
We looked at the file and Medicare rules. In this case, code 99053 has a Status Code of "B" under the 
Physician Fee Schedule. As a bundled code, payment for covered services are always bundled into payment for 
other services not specified. Based on this information, we decided that Medicare rules for coverage of the 
medical services have not been met. Therefore, we decided that the Plan does not have to pay for the medical 
services provided between 10:00 PM and 08:00 AM coded as 99053 provided on July 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral exam (D0150) provided on 
December 16, 2021. 
 
You asked the Plan to pay for the comprehensive exam. You say that this service was necessary and should be 
covered. The Plan denied your request. The Plan says you had a previous limited oral exam (D0140) less than 
six months before this comprehensive exam. You are covered for one exam (D0120, D0140, D0150, D0160, 
D0170 or D0180) every 6 months. Therefore, the frequency limitation for these services was exceeded on the 
date in question. 
 
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 can cover one exam 
(D0120, D0140, D0150, D0160, D0170 or D0180) every 6 months. Though the Plan offers a dental benefit in excess of Medicare coverage, the exam is requested in a frequency 
that exceeds what is covered under this benefit. Documentation shows you had a previous oral exam (D0140) 
provided on December 1, 2021, which is less than six months before the date in question. Therefore, we 
decided that the Plan does not have to pay for the comprehensive oral exam (D0150) provided on December 
16, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on August 4, 2020. 
 
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 were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of 
service (POS) code. 
 
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a 
laboratory setting; however, the file shows that the specimen was obtained in a skilled nursing facility setting 
and should have been billed with POS code 31. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on August 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a DyAnsys auricular acupuncture device. 
 
You asked the Plan to pre-approve auricular acupuncture device. You say that your goal is to alleviate the 
enrollee's current pain and increase the ability to participate in day-to-day activities. The Plan denied your 
request. The Plan says this is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that payment may be made for implanted peripheral 
nerve stimulators in which electrodes are surgically placed under the skin around a nerve. The rules also say 
that acupuncture is only covered when provided for low back pain when furnished by a licensed acupuncturist.    
 
We looked at the file and Medicare rules. We find that this device does not meet the Medicare definition for an 
implanted nerve stimulator because the device involves needles inserted around the nerves and not electrodes 
being surgically implanted. The Food and Drug Administration (FDA) clearances for devices of this type are as 
electro-acupuncture devices. Since acupuncture is not covered by Medicare for any condition when rendered 
through a device rather than by a licensed practitioner, we find that Medicare coverage criteria for this auricular 
stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve a DyAnsys 
auricular acupuncture device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the dermatology referral.
You asked the Plan to pre-approve the dermatology referral. You say that you would like reconsideration because the requested referral is medically necessary. The Plan denied your request. The Plan says the records do not support any clinical finds of eczema or atopic dermatitis.
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 dermatology referral. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the records do not document any physical findings of eczema or atopic dermatitis. There is no clinical rationale for a Dermatology evaluation.
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 dermatology referral have not been met. Therefore, we decided that the Plan does not have to pre-approve the dermatology referral.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on August 11, 2021.
You asked the Plan to pay for the services provided. You say that testing is needed to monitor possible opioid abuse. The Plan denied your request. The Plan says the billed codes cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
The file shows that the enrollee received presumptive and definitive drug testing (codes 80307 and G0480). The claim lists a place of service as an office. However, the records indicate the enrollee was at a psychiatric facility when the specimen was obtained.
The enrollee also received mass spectrometry services (code 83789). Providers performing validity testing on urine specimens used for drug testing shall not separately bill the validity testing. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on August 11, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing (G0483) performed August 16, 2021. 
 
You asked the Plan to pay for the drug testing. You say that the testing was medically necessary. The Plan 
denied your request. The Plan says coverage criteria for definitive testing was not met. 
 
The Plan follows Medicare rules. Medicare rules say that Definitive drug testing is indicated when the results 
of the screen are presumptively positive. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the drug testing. Our reviewer says that this 
test was not medically necessary. Our physician reviewer found records do not indicate that the test was 
performed because the results of a screening test were presumptively positive or the results of the screen were negative, and this negative finding was inconsistent with the patient's medical history. 
 
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 drug testing have not been met. Therefore, we decided that the Plan does not 
have to pay for drug testing (G0483) performed August 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown - porcelain fused to high noble metal (D2750)
provided December 28, 2021.
You asked the Plan to pay for the crown. You say that you expected a $0 copayment. The Plan denied your
request. The Plan says the copayment has been applied 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. The Plan covers the crown
once per 60 months with a $125 copayment.
We looked at the file and Medicare rules. You have been asked to pay a $125 copayment for the crown. Based
on this information, we decided that the Plan's rules for coverage of the crown have not been met. 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 pay for the crown - porcelain fused to high noble metal (D2750)
provided December 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network services provided to the enrollee on 
September 28, 2021. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The provider in this case is not a network provider with the Plan. 
The Plan had network providers available who could have provided the items/services at issue in this appeal. 
The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to 
pay for these items/services. Therefore, we decided that the Plan does not have to pay for out of network 
services provided to the enrollee on September 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377, 2313, E2313) and 
power seat elevation feature (E2300). 
 
You asked the Plan to pre-approve an expandable controller and power seat elevation feature. You say that this 
is medically necessary. The Plan denied your request. The Plan says the criteria for coverage have not been 
met. 
 
The Plan follows Medicare rules. Medicare rules say that a power seat elevation feature is non covered. The 
rules say that an expandable controller is subject to the criteria listed 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 an expandable controller and power 
seat elevation feature. Our reviewer says that this equipment is not medically reasonable and necessary. Our 
physician reviewer found that the expandable controller (E2377), expandable controller harness (E2313), and 
electro connect (E2311) and other types of proportional input devices (e.g., mini-proportional or compact 
joysticks, touchpads, chin control, head control, etc.) are not medically necessary per Local Coverage Article: 
Wheelchair Options/Accessories - Policy Article (A52504). The patient does not require non-proportional input 
devices (e.g., sip and puff, head array, etc.). The patient does not require a separate display (i.e., for alternate 
control devices), other electronic devices (e.g., control of an augmentative speech device or computer through 
the chair's drive control), or an attendant control. The patient has 3 power options of tilt, recline, and power 
elevating leg rests but the patient does not need to control the power options through a joystick. The patient's 
upper extremity strength and function support that the patient can control any power options through their own 
switches. The power seat elevation feature is statutorily non covered by Medicare. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an expandable controller and power seat elevation feature have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2377, 2313, 
E2313) and power seat elevation feature (E2300).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a surgical placement of an implant body (D6010x5) for tooth #3, #14, #19, #20 and #21.
You asked the Plan to pre-approve a surgical placement of an implant body. You say that the enrollee cannot eat properly due to the missing teeth. The enrollee is also wearing a partial denture and it is affecting the existing teeth with bone loss and soreness. The Plan denied your request. The Plan says the requested 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 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 surgical placement of an implant body (D6010x5) for tooth #3, #14, #19, #20 and #21.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services provided on July 20, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says no separate 
payment is made. 
 
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 99100 is anesthesia for patient of extreme age, younger than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure). We find that CPT code 99100 is a bundled code. When these services are covered, payment for them is subsumed by the payment for the services to which they are incident. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to 
pay for the anesthesia services provided on July 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the case management services rendered on July 12, 2021 to 
July 16, 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 cod T1017 is not covered. 
 
The Plan must follow Medicare rules. The rules say that a status indicator of I represents a code that is not valid 
for Medicare purposes. 
 
We looked at the file and Medicare rules. Billed procedure code T1015 (targeted case management, each 15 
minutes) has a status indicator of I and is not valid for Medicare purposes. Therefore, we decided that the Plan 
does not have to pay for the case management services rendered on July 12, 2021 to July 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intravenous moderate (conscious) sedation/analgesia 
(D9239 and D9243). 
 
You asked the Plan to pre-approve the intravenous moderate (conscious) sedation/analgesia. You say that you 
have benefits covered under long term care plan for sedation. The Plan denied your request. The Plan says 
these services are not covered under 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, 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 
intravenous moderate (conscious) sedation/analgesia (D9239 and D9243).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia for patient of extreme age (99100) provided on 
October 13, 2021. 
 
You asked the Plan to pay for anesthesia for patient of extreme age. You say that you would like this claim 
reprocessed based on the medical documentation. The Plan denied your request. The Plan says no separate 
payment is made for these services based on Medicare 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, the CPT Code Manual definition of code 99100 is anesthesia for patient of extreme age, younger than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure). 
 
We looked at the file and Medicare rules. Specifically, 99100 has a Status Code of B under the Physician Fee 
Schedule indicating that it is a bundled code. For this bundled code, payment for covered services are always 
bundled into payment for other services not specified. Based on this information, we decided that Medicare 
rules for coverage of anesthesia for patient of extreme age have not been met. Therefore, we decided that the 
Plan does not have to pay for anesthesia for patient of extreme age (99100) provided on October 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown - porcelain/ceramic (D2740), core buildup, including any pins when required (D2950), inhalation of nitrous oxide/analgesia, anxiolysis (D9230), intraoral - periapical each additional radiographic image (D0230), 2D oral/facial photographic image obtained intra-orally or extra-orally (D0350), and comprehensive oral evaluation - new or established patient (D0150) provided February 4, 2021, and May 26, 2021.
You asked the Plan to pay for the crown, core buildup, nitrous oxide/analgesia, periapical x-ray, 2D oral/facial photographs, and comprehensive oral exam. You say that the services were necessary. The Plan denied your request. The Plan says the services were processed 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. The Plan covers the crown, and periapical x-ray once per calendar year, the comprehensive oral exam once every three calendar years and anesthesia as needed with covered procedures. We looked at the file, and Medicare rules. The Plan provided documentation showing that a periapical x-ray was covered on February 4, 2021, a crown was previously covered on April 5, 2021, and a comprehensive oral exam was previously covered on June 5, 2020. Based on this information, we decided that the Plan's frequency limits for coverage of the crown, periapical x-ray, and comprehensive oral exam have been exceeded. Though the Plan offers dental benefits in excess of Medicare coverage, the core buildup and 2D oral/facial photographs are not among those covered services. The nitrous oxide/analgesia is not covered because there was no covered procedure on the same date of service. Therefore, we decided that the Plan does not have to pay for the crown - porcelain/ceramic (D2740), core buildup, including any pins when required (D2950), inhalation of nitrous oxide/analgesia, anxiolysis (D9230), intraoral - periapical each additional radiographic image (D0230), 2D oral/facial photographic image obtained intra-orally or extra-orally (D0350), and comprehensive oral evaluation - new or established patient (D0150) provided February 4, 2021, and May 26, 2021.