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

 
We decided that the Plan does not have to pay for procedure codes 87640 and 87634 billed for date of service 
January 4, 2022. 
 
You asked the Plan to pay for procedure codes 87640 and 87634. You say that you have provided the lab 
results to support payment. The Plan denied your request. The Plan says payment for codes 87640 and 87634 is 
bundled into payment for codes 87641 and 87631. 
 
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 codes 
87640 and 87634 are column II code to column I codes 87641 and 87631. 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 procedure codes 87640 and 87634 billed 
for date of service January 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740) for tooth #2 and a surgical extraction 
(D7210) for tooth #1. 
 
You asked the Plan to pre-approve a crown and surgical extraction. You say that tooth #1 has recurrent decay, 
and tooth #2 has a large amalgam filling and recurrent decay. The Plan denied your request. The Plan says the 
second set of images submitted are not diagnostic and the teeth with associated anatomical structures cannot be 
seen on the two images. The Plan also says without diagnostic images, a decision cannot be made on benefit 
coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of a crown and surgical extraction have 
been met. Digital quality x-rays were not provided for this case. The record shows that the Plan made several 
attempts to obtain these x-rays, but they were not received. Without digital quality x-rays, we are unable to 
determine if the requested services are medically reasonable, necessary, and meet the criteria for coverage.. 
Therefore, we decided that the Plan does not have to pre-approve a crown (D2740) for tooth #2 and a surgical 
extraction (D7210) for tooth #1.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the removal of residual tooth roots (D7250) for tooth 
#2, #18, and #32. 
 
You asked the Plan to pre-approve the dental services. You say that the teeth show evidence of small fractures 
and large previous composites which endanger the teeth structure from breaking. The Plan denied your request. 
The Plan says x-rays do not show that the enrollee's tooth had a previous attempt at extraction resulting in part 
of a root being left buried in bone. To remove the remaining root there must be a failed attempt by an initial 
provider and the procedure must include removal of bone. The Plan recommends a surgical extraction (D7210). 
 
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 
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 dental services. Our reviewer says 
that the requested root removal (D7250) for tooth #2, #18, and #32 is not reasonable and necessary. Our 
physician reviewer found that the remaining teeth #2, #18 and #32 appear to be accessible without clear need 
for cutting of the bone in order to remove them. The teeth appear to be remnants of exiting teeth and not a 
result of a prior extraction attempt. The requested code is not clearly appropriate for the given situation. 
 
In this instance there does not appear to be any prior attempted removal of teeth #2, #18 or #32. It was also not 
clear if bone needs to be removed to extract these teeth as the roots can be elevated out of their sockets 
particularly on the lower arch, although #2 may require some bone cutting from its radiographic appearance. If 
bone cutting is needed, the proper code would be (D7210) and not (D7250). 
 
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 services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the removal of residual tooth roots (D7250) for tooth #2, #18, and #32.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental extractions (D7140), the removal of implants 
(D6100), dental implants (21248) and bone graft (D6104) for tooth #8, #9, #10, #11, #12, #13, #21, #22, #27, 
#28, #29, and #30. 
 
You asked the Plan to pre-approve the dental services. You say that the dental services should be fully covered 
under your medical coverage. The Plan denied your request. The Plan says the denial of authorization for these 
services is correct, because dental extractions, removal of implants, dental implants and bone grafts 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 pre-approve the 
dental extractions (D7140), the removal of implants (D6100), dental implants (21248) and bone graft (D6104) 
for tooth #8, #9, #10, #11, #12, #13, #21, #22, #27, #28, #29, and #30.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve canal preparation and fitting of preformed dowel, 
isolation of a tooth with rubber dam, and crown lengthening services (D3950, D3910, D4249) 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says 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 pre-approve canal 
preparation and fitting of preformed dowel, isolation of a tooth with rubber dam, and crown lengthening 
services (D3950, D3910, D4249)
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve microsurgical techniques requiring the use of an 
operating microscope. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the approved procedure may be 
performed safely without the use of a microscope. There is no justification in the records to support the use of 
the requested operating microscope. The services are not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve microsurgical techniques requiring the use of an operating microscope.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the retreatment of a previous root canal therapy (D3348) 
provided by a participating provider. 
 
You asked the Plan to pre-approve the retreatment of a previous root canal therapy. You say that this is 
medically necessary. The Plan denied your request. The Plan says the requested dental service is not a covered 
benefit. 
 
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 the 
retreatment of a previous root canal therapy (D3348) provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral periapical radiographic image (D0230) provided 
on June 6, 2022. 
 
You asked the Plan to pay for the dental services. You say that the provider was listed as in-network. 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 June 6, 2022. Therefore, 
we decided that the Plan does not have to pay for an intraoral periapical radiographic image (D0230) provided 
on June 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an endosteal implant and custom fabricated abutment 
(eD6010, D6057) 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says 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 pre-approve an 
endosteal implant and custom fabricated abutment (eD6010, D6057)
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scaling and root planing - four or more teeth 
per quadrant (D4341). 
 
You asked the Plan to pre-approve dental services. You say that the enrollee needs to have the requested 
services. The Plan denied your request. The Plan says the service is covered but limitations apply. 
 
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. Periodontal scaling and root 
planing - four or more teeth per quadrant (D4341)  one per three calendar years per quadrant (either D4341 or 
D4342) not allowed on same date as D1110 or D1120. 
 
  We looked at the file, the Plans rules, and Medicares rules. You previously received covered periodontal 
scaling and root planing - four or more teeth per quadrant (D4341) on January 29, 2021. Therefore, the benefits 
were exhausted on January 29, 2021. Therefore, we decided that the Plan does not have to pre-approve 
periodontal scaling and root planing - four or more teeth per quadrant (D4341).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cone beam computed tomograpy (CT) image capture 
with limited field of view  less than one whole jaw (D0380). 
 
You asked the Plan to pre-approve a cone beam CT scan. You say that you need this service. The Plan denied 
your request. The Plan says this service is not covered under your benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
cone beam computed tomograpy (CT) image capture with limited field of view  less than one whole jaw 
(D0380).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental services (D4265, D7953, D3432) 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says 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 pre-approve the 
dental services (D4265, D7953, D3432)
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing billed for date of service September 1, 2020. 
 
You asked the Plan to pay for the billed services. You say that medical records were provided. The Plan denied 
your request. The Plan says the billed services cannot be verified. 
 
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 80157, 80159, 80162, 80173, 80177, and 80201 are lab tests performed using blood 
specimen. The records do not indicate that a blood sample was provided for testing.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 lab testing billed for date of service September 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture - cast metal framework with 
resin denture bases (including retentive/clasping materials, rests and teeth) (D5213). 
 
You asked the Plan to pre-approve the dental services. You say that you are malnourished because of the lack 
of dentures that were approved for repair but they are incompatible with your mouth. 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 October 9, 2019. 
Therefore, we decided that the Plan does not have to pre-approve a maxillary partial denture - cast metal 
framework with resin denture bases (including retentive/clasping materials, rests and teeth) (D5213).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal scaling and root planning (D4341) provided 
on March 10, 2022. 
 
You asked the Plan to pay for the dental services. You say that you called and were told this service is covered. 
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 for each quadrant on dates of service June 
23, 2020, July 11, 2020, and August 1, 2020. Therefore, we decided that the Plan does not have to pay for the 
periodontal scaling and root planning (D4341) provided on March 10, 2022.  
 Your complaint about potentially receiving incomplete or incorrect information from a plan representative 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 pre-approve an occlusal guard hard appliance, partial arch (D9946). 
 
You asked the Plan to pre-approve the dental services. You say that the enrollee is in urgent need of a new 
night-guard. The Plan denied your request. The Plan says this service is not a covered benefit 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, 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 an 
occlusal guard hard appliance, partial arch (D9946).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient laparoscopy colectomy. 
 
You asked the Plan to pre-approve the services. You say that the enrollee is in pain and has had several 
episodes which led to emergency room trips. The Plan denied your request. The Plan says the enrollee's 
surgeon says removal of part of the colon may not resolve the enrollee's pain. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the patient has history of diverticula but has presented with multiple episodes of RUQ pain. The 
symptoms presented after eating fatty meals. 2 of 4 episodes of pain were reported to correspond to findings of 
diverticulitis, however, these records and or associated CT findings were not available for review. The patient 
has not had a formal work up for RUQ pain with ultrasound and hida scan and this would be recommended 
given the atypical location of pain (right upper quadrant or left lower quadrant - RUQ v. LLQ). Given the 
limited medical records, medical necessity of sigmoid colectomy as treatment for RUQ pain is not determined 
to be medically necessary at this time, as it may not be the cause of the patient's symptoms. If formal work up 
to rule out chronic or acalcuous cholecystitis, or biliary dyskinesia were to be negative, consideration for colectomy may be more appropriate at that time. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve inpatient laparoscopy colectomy.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient hospital services provided from May 3, 2022, to 
May 5, 2022. 
 
You asked the Plan to pay for outpatient hospital services. You say that these services were medically 
necessary and are supported in the medical record. The Plan denied your request. The Plan says there are 
multiple I/OCE edit errors on this claim which must be corrected. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules also say that an outpatient claim (bill 
type 12x or 13x) is returned to the provider when a procedure code has a status indicator which is not 
recognized by OPPS, such as status indicator B. In addition, a line may be rejected when a procedure is 
identified as part of another procedure on the claim coded on the same day, where the modifier was either not 
coded or is not an NCCI modifier. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of outpatient hospital services have not been met. Specifically, this claim was billed with multiple 
codes (80320 and 80329) which have a Payment Status Indicator of B on the OPPS payment system. This 
means these codes are not recognized by OPPS when submitted on an outpatient hospital Part B bill type (12x 
and 13x). The disposition for this I/OCE edit is that the claim as a whole is returned to the provider for 
correction. In addition, some services billed on this claim are denied individually as they are included in other 
services billed for this same date. Therefore, we decided that the Plan does not have to pay for outpatient 
hospital services provided from May 3, 2022, to May 5, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered on February 5, 2022, to 
March 6, 2022. 
 
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 NOA was not received timely; as such, this final claim was correctly denied. 
 The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is February 5, 2022. A valid NOA was not received for the dates of service at 
issue. Therefore, we decided that the Plan does not have to pay for the home health services rendered on 
February 5, 2022, to March 6, 2022.