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

 
We decided that the Plan does not have to pay for the gingival irrigation-per quadrant (D4921 x 4) provided on 
December 30, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not a covered benefit under 
your 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 services provided are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the gingival 
irrigation-per quadrant (D4921 x 4) provided on December 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical placement of implant body (D6010), deep 
sedation/general anesthesia, first 15 minutes (D9222), deep sedation/general anesthesia  each 15 minute 
increment (D9223), utilization of platelet rich plasma (D7921) and infiltration of a sustained-release 
therapeutic drug (D9613) provided on March 9, 2022. 
 
You asked the Plan to pay for the dental services. You say that you feel these services should be covered by the 
plan. The Plan denied your request. The Plan says these services are not on the list of covered services. 
 
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 surgical 
placement of implant body (D6010), deep sedation/general anesthesia, first 15 minutes (D9222), deep 
sedation/general anesthesia  each 15 minute increment (D9223), utilization of platelet rich plasma (D7921) 
and infiltration of a sustained-release therapeutic drug (D9613) provided on March 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost share for resin-based composite fillings on tooth #2 
and 21 (D2392) provided on January 3, 2022, and periodontal scaling and root planing (D4342) provided on 
January 19, 2022. 
 
You asked the Plan to reduce the cost share for the dental services. You say that you do not feel like you should 
be responsible for the full cost share amount. The Plan denied your request. The Plan says you have been 
charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 
deductible for comprehensive dental services every year. The Plan also says that the enrollee has a $2,000 
maximum allowance with 50% coinsurance after the deductible is met. 
 
The record shows these claims were approved, and you have a cost sharing amount. You have been asked to 
pay $28 for the periodontal scaling on January 19, 2022. You have also been asked to pay $22 for a filling on 
January 3, 2022. The deductible was not met at the time of service; therefore, $28 was applied to the deductible and $22 was applied to satisfy the remaining deductible amount. The Plan has followed Medicare rules by 
clearly disclosing in the contract that there is a $50 deductible which applies to comprehensive dental service. 
This cost sharing is a contractual obligation that had not been met at the time the dental services were received 
on January 3, 2022, and January 19, 2022.  
 
The allowed amount remaining after you paid your deductible is $74 ($96 original allowed amount - $22 
deductible paid = $74 remaining allowed amount). You have been asked to pay $37, which is 50% coinsurance 
of the remaining allowed amount for the filling on tooth #2 on January 3, 2022 ($74 remaining allowed amount 
x 50% coinsurance = $37). You have also been asked to pay $48, which is 50% coinsurance of the allowed 
amount for the filling on tooth #21 on January 3, 2022 ($96 allowed amount x 50 % coinsurance = $48). 
Fillings and periodontal scaling falls within the Dental Services benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to reduce the cost share for resin-based composite fillings on tooth #2 and 21 (D2392) provided on January 3, 
2022, and periodontal scaling and root planing (D4342) provided on January 19, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 20 additional units of ambulance ground mileage (A0425) 
provided on February 17, 2022. 
 
You asked the Plan to pay for 20 additional mileage units. You say that these services were necessary and 
should be paid. The Plan denied your request. The Plan says this service was not billed in accordance with 
Medicare rules. 
 The Plan must follow Medicare rules. Medicare rules say that services with an MAI of 1 have a claim line edit. 
If a code has an MAI of 1, appropriate use of a modifier may be used to report the same code on separate lines 
of the claim, and each claim line for that service is adjudicated against the MUE for that code.  
 
In this case, the MUE for CPT code A0425 is 250. The MAI value for this code is 1. You billed 250 units of 
this code, exceeding the MUE by 20 units. Based on this information, we decided that Medicare billing rules 
for mileage units have not been met. Therefore, we decided that the Plan does not have to pay for 20 additional 
units of ambulance ground mileage (A0425) provided on February 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for thyroid-stimulating hormone (TSH) (84443) and Thyroxine 
(84439) provided October 8, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that please review the included medical 
documentation that supports medical necessity for the rendered services. The Plan denied your request. The 
Plan says these services are not covered by Medicare. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, the laboratory services, was requested solely for screening purposes. Medicare 
does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay 
for thyroid-stimulating hormone (TSH) (84443) and Thyroxine (84439) provided October 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established 
patient (D0150) provided April 7, 2022. 
 
You asked the Plan to pay for the dental services. You say that you needed to see a new dentist because the first 
dentist was unable to perform necessary services. 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 March 8, 2022. 
Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation - new or 
established patient (D0150) provided April 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gingival irrigation (D4921 x 2), adjunctive pre-diagnostic 
test (D0431), and localized delivery of anti-microbial agents (D4381 x 5) provided on March 28, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were told these services were covered. The 
Plan denied your request. The Plan says gingival irrigation (D4921), adjunctive pre-diagnostic test (D0431), 
and localized delivery of anti-microbial agents (D4381) are not covered by 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 gingival 
irrigation (D4921 x 2), adjunctive pre-diagnostic test (D0431), and localized delivery of anti-microbial agents 
(D4381 x 5) provided on March 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abutment supported porcelain fused to metal crown (high 
noble metal) (D6059) and the custom fabricated abutmentincludes placement (D6057) provided on  
February 9, 2022. 
 
You asked the Plan to pay for these dental items. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these items are not a covered benefit under 
your 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 items provided are not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the abutment supported 
porcelain fused to metal crown (high noble metal) (D6059) and the custom fabricated abutmentincludes 
placement (D6057) provided on February 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional payment for crown - porcelain/ceramic (D2740) 
provided March 15, 2022. 
 
You asked the Plan to provide additional payment for the crown. You say that you felt this would be the least 
expensive treatment. The Plan denied your request. The Plan says no additional payment is due. 
 
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 crown 
with 50% coinsurance. If a method of treatment is more costly than is customarily provided, benefits will be 
paid on the least costly method of treatment, and you will be responsible for the remaining balance.  
 
We looked at the file and Medicare rules. The Plan has determined that crown - porcelain fused to 
predominantly base metal (D2751) was the least costly method of treatment in this case. 
 You have been asked to pay 50% of the cost of this service plus the difference between this service and the 
more expensive crown that was charged by the provider. This means you have been asked to pay the correct 
amount based on your contract with the Plan. Therefore, we decided that the Plan does not have to provide 
additional payment for crown - porcelain/ceramic (D2740) provided March 15, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 
You asked the Plan to pre-approve home health services. You say that you would like the Plan to reconsider 
their denial. The Plan denied your request. The Plan says there is no information provided from your doctor 
that states you are homebound. 
 
The Plan must follow Medicare rules. The rules say that an enrollee must be homebound for home health care 
services to be covered.  
 
The file does not show that you are homebound. Therefore, we decided that the Plan does not have to pre-
approve home health services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a percutaneous implantation of neurostimulator 
electrode array, epidural (63650). 
 
You asked the Plan to pre-approve a percutaneous implantation of neurostimulator electrode array. You say 
that the enrollee meets the criteria required for a spinal cord stimulator trail. The Plan denied your request. The 
Plan says the requested service does not meet the requirements for approval. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a percutaneous implantation of 
neurostimulator electrode array. Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found the enrollee has continuing pain. 
He has not had trials of other conservative therapy recently and there is no documentation of a surgical 
consultation. 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a percutaneous implantation of neurostimulator electrode array have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a percutaneous implantation of 
neurostimulator electrode array, epidural (63650).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve additional routine transportation. You say that you would like the Plan to 
reconsider their denial. The Plan denied your request. The Plan says you have used all 20 one-way trips for the 
2022 benefit year and additional trips will not be approved. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 20 one-way transportation trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation.  
 
Your complaint about the Plan not providing adequate notification about this benefit changing 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the expandable controller and wheelchair accessories 
represented by codes E2311, E2313, and E2377 
 
You asked the Plan to pre-approve the wheelchair accessories. You say that these accessories are medically 
necessary. The Plan denied your request. The Plan says the member's upper limb strength and function are 
adequate to control the power options using their own switches, which are included in the allowance of the 
power options. 
 
The Plan follows Medicare rules. Medicare rules say that the requested electronic accessories are only covered 
when medically necessary for the safe operation of the power wheelchair. 
 
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 wheelchair accessories. Our 
reviewer says that the requested wheelchair accessories are not medically necessary. Our physician reviewer 
found the member has a neurologic disorder with functional deficits. The requested electrical accessories are 
not medically necessary as the member does have use of the upper extremity and can operate and control the 
power options using the switches that are included in the basic wheelchair. 
 
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 wheelchair accessories have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the expandable controller and wheelchair accessories represented by codes 
E2311, E2313, and E2377
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from January 31, 
2022, to March 1, 2022. 
 
You asked the Plan to pay for the SNF care. You say that these services were medically necessary. The Plan 
denied your request. The Plan says the enrollee had no skilled therapy or skilled nursing needs on these dates of 
service.  
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 pay for the SNF care. Our reviewer says that SNF 
care was not medically necessary on these dates of service. Our physician reviewer found the enrollee did not 
have documented skilled nursing needs.  The enrollee did not have documented skilled therapy needs.  Daily 
skilled services were not required to establish a maintenance program or to prevent deterioration of the 
enrollees condition.  The enrollees care needs could, as a practical matter, be provided at a lower level of 
care. 
 
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 SNF care have not been met. Therefore, we decided that the Plan does not 
have to pay for skilled nursing facility (SNF) care provided from January 31, 2022, to March 1, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 36140 and 75710 billed for date of service 
March 30, 2021. 
 
You asked the Plan to pay for procedure codes 36140 and 75710. You say that these codes should be paid. The 
Plan denied your request. The Plan says these codes are not supported in the medical record. 
 
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 36140 is introduction of needle or intracatheter, upper or 
lower extremity artery. The CPT Code Manual definition of code 75710 Angiography, extremity, unilateral, 
radiological supervision and interpretation. 
 
We asked our coder 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 procedure codes 36140 and 75710. Our reviewer says that 
these codes are not supported in the medical record. Our reviewer found for code 36140, the operative report does not support a separate procedure, and this procedure would be included with CPT 37226. The operative 
report documents: "A flush catheter and wire were advanced into the aorta and an aortogram was 
performed...The superficial femoral artery lesion was attempted to be traversed with u catheter and wire 
unsuccessfully... After retrieval of the wire, a quick cross catheter was advanced from the left sided sheath 
down to the popliteal artery above the knee... The popliteal artery as well as the superficial femoral artery were 
then angioplastied with a 4 mm, 5 run, and finally a 6 mm balloon proximally... These areas were pre 
angioplastied with a 6 mm x 10 cm Dora do balloon and post plasty after placement of the stents." This 
procedure would be included with primary procedure.  For code 75710, the operative report does not support a 
separate procedure, and this procedure would be included with CPT 37226. The operative report documents: 
"A flush catheter and wire were advanced into the aorta and an aortogram was performed...The superficial 
femoral artery lesion was attempted to be traversed with u catheter and wire unsuccessfully... After retrieval of 
the wire, a quick cross catheter was advanced from the left sided sheath down to the popliteal artery above the 
knee... The popliteal artery as well as the superficial femoral artery were then angioplastied with a 4 mm, 5 run, 
and finally a 6 mm balloon proximally... These areas were pre angioplastied with a 6 mm x 10 cm Dora do 
balloon and post plasty after placement of the stents." This procedure would be included with primary 
procedure. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 36140 and 75710 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 36140 and 75710 billed for date of service March 30, 
2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from July 30, 
2021, to August 28, 2021. 
 You asked the Plan to pay for the SNF care. You say that these SNF services were medically necessary. The 
Plan denied your request. The Plan says the enrollee did not meet Medicare criteria for SNF coverage on these 
dates of service. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 pay for the SNF care. Our reviewer says that SNF 
care was not medically necessary from July 30, 2021, to August 28, 2021. Our physician reviewer found the 
enrollee did not have documented skilled nursing needs.  The enrollee did not have documented skilled therapy 
needs.  Daily skilled services are not required to establish a maintenance program or to prevent deterioration of 
the enrollees condition.  The enrollees care needs were custodial and could, as a practical matter, be provided 
at a lower level of care. 
 
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 SNF care have not been met. Therefore, we decided that the Plan does not 
have to pay for skilled nursing facility (SNF) care provided from July 30, 2021, to August 28, 2021.