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

 
We decided that the Plan does not have to pre-approve transfer handles. 
 
You asked the Plan to pre-approve transfer handles. You say that you would like the Plan to reconsider their 
denial. The Plan denied your request. The Plan says transfer handles do not serve a medical purpose and are not 
covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve transfer handles.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture (D5211) and a mandibular 
partial denture (D5212). 
 
You asked the Plan to pre-approve the partial dentures. The Plan denied your request. The Plan says these 
services are not covered under your benefit package. 
 
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 
maxillary partial denture (D5211) and a mandibular partial denture (D5212).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a consultation (D9310) and sales tax (D9985) provided on 
March 17, 2022. 
 
You asked the Plan to pay for a consultation and sales tax. You say that you were told this visit would be 
covered. The Plan denied your request. The Plan says a consultation (D9310) and sales tax (D9985) 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 a 
consultation (D9310) and sales tax (D9985) provided on March 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custom shoes (L3250). 
 
You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says these items are not a covered benefit under your 
contractual policy or by Medicare for your condition. 
 
Medicare rules state that supportive devices for the feet (such as custom shoes) are only covered for patients 
with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
 Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
custom shoes may be appropriate for you, neither Medicare nor the Plan provides coverage of custom shoes for 
your condition. Additionally, with the exception of the situations described, orthopedic footwear billed using 
code L3250 will be denied as non-covered. Therefore, we decided that the Plan does not have to pre-approve 
custom shoes (L3250).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), intraoral imaging (D0220 
and D0230), bitewings (D0274), prophylaxis (D1110), and fluoride varnish (D1206), provided by an out-of-
network provider on April 5, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were told that this provider would be in-
network after April 1, 2022. The Plan denied your request. The Plan says the dental services were received 
from an out-of-network provider and are not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a periodic oral evaluation (D0120), intraoral imaging (D0220 and D0230), bitewings (D0274), 
prophylaxis (D1110), and fluoride varnish (D1206), provided by an out-of-network provider on April 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services rendered on February 28, 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 procedure code 01402 is not supported. 
 
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 01402 is anesthesia for open or surgical arthroscopic 
procedures on knee joint; total knee arthroplasty. 
 
We find that CPT code 01402 is not supported in the medical record. Specifically, there is no documentation of 
anesthesia for open or surgical arthroscopic procedures on knee joint; total knee arthroplasty. 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 anesthesia services rendered on February 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the removal of an impacted tooth (D7220) provided by a 
participating provider on April 29, 2022. 
 
You asked the Plan to pay for the removal of an impacted tooth. You say that you were unaware that this was 
not covered. The Plan denied your request. The Plan says the rendered dental service is not a covered dental 
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 pay for the 
removal of an impacted tooth (D7220) provided by a participating provider on April 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two gingival irrigations (D4921 x2). 
 
You asked the Plan to pre-approve the gingival irrigations. You say that you have diabetes, and need gum 
streamer and medication. The Plan denied your request. The Plan says gingival irrigation is not a covered 
benefit 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 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 two 
gingival irrigations (D4921 x2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan (D0365). 
 
You asked the Plan to pre-approve a CT scan. You say that this service is medically necessary. The Plan denied 
your request. The Plan says the requested service is not medically necessary. 
 
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 computed tomography (CT) scan 
(D0365). The Plan has made multiple attempts to obtain the medical records. Therefore, we decided that the 
Plan does not have to pre-approve a computed tomography (CT) scan (D0365).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting 
from May 31, 2022, to June 3, 2022. 
 You asked the Plan to pay for the self-administered drugs. You say that the coding issues should be waived as 
this is a hospital error. The Plan denied your request. The Plan says self-administered drugs provided in an 
outpatient setting are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
provided in an outpatient setting from May 31, 2022, to June 3, 2022.  
 
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for a partial maxillary denture (D5211) 
provided on May 11, 2022. 
 
You asked the Plan to waive the cost share for a partial denture. You say that you should not have to pay this. 
The Plan denied your request. The Plan says your annual dental allowance has been exhausted. 
 
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 this benefit includes 
coverage up to $1,000 for preventive and comprehensive dental services. The record shows your annual dental allowance has been exhausted. You are responsible for any amount above 
the allowance amount. A partial denture 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 waive the cost share for a partial maxillary denture (D5211) provided on May 11, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 96360 billed for date of service January 10, 
2022. 
 
You asked the Plan to pay for procedure code 96360. You say that the records support the medical necessity of 
the claim billed. The Plan denied your request. The Plan says procedure code 96361 has been approved. The 
Plan also says payment for procedure code 96360 is considered bundled into payment for procedure code 
96365. 
 
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 96360 
is a column II code to column I code 96365. 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 code 96360 billed for date of service January 10, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete maxillary denture (D5110) and a complete 
mandibular denture (D5120) provided on May 26, 2022. 
 
You asked the Plan to pay for the dental services. You say that your original dentures broke, and you need new 
ones. The Plan denied your request. The Plan says your benefit for the requested items or services 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 items or services was exhausted on date of service April 7, 2021.  
 
 
 
 
  
 
 
Therefore, we decided that the Plan does not have to pay for a complete maxillary denture (D5110) and a 
complete mandibular denture (D5120) provided on May 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120) and bitewings (D0274) 
provided by an out-of-network provider on May 25, 2022. 
 
You asked the Plan to pay for the dental services. You say that you do not understand why these services are 
not covered. The Plan denied your request. The Plan says the dental services were received from an out-of-
network provider and are not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have to pay for a periodic oral evaluation (D0120) and bitewings (D0274) provided by an out-of-network provider 
on May 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a resin-based composite (D2392) provided by a participating 
provider on May 16, 2022. 
 
You asked the Plan to pay for a resin-based composite. You say that you were unaware that this would not be 
covered. The Plan denied your request. The Plan says the enrollee did not have comprehensive dental coverage. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a resin-
based composite (D2392) provided by a participating provider on May 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 25, 2022, billed with 
codes 81225, 81227, 81230, 81231, 81232, 81291, 81306, 81355, 81335, 0031U, 0032U, 0033U, 81479, 
81407, 81406, and 81238. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
April 25, 2022, billed with codes 81225, 81227, 81230, 81231, 81232, 81291, 81306, 81355, 81335, 0031U, 
0032U, 0033U, 81479, 81407, 81406, and 81238.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a 3D photo image (D0351) provided by an out-of-
networkon March 9, 2022. 
 
You asked the Plan to pre-approve a 3D photo image. You say that you knew you were covered for x-rays, and 
you assumed this would be covered as well. The Plan denied your request. The Plan says the rendered 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 a 3D 
photo image (D0351) provided an out-of-network provider on March 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), teeth cleaning (D1110), 
intraoral periapical radiographic images (D0220, D0230), and bitewing radiographic images (D0274) provided 
on May 16, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were not informed that your plan had 
changed. The Plan denied your request. The Plan says at the time the services were rendered you were not 
enrolled in the optional supplemental benefit plan. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for a periodic oral evaluation 
(D0120), teeth cleaning (D1110), intraoral periapical radiographic images (D0220, D0230), and bitewing 
radiographic images (D0274) provided on May 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional payment for osseous, osteoperiosteal, or cartilage 
graft of the mandible or maxilla - autogenous or nonautogenous, by report (D7950) provided April 14, 2022. 
 
You asked the Plan to provide additional payment for the graft of upper/lower jaw. You say that this was a 
necessary dental procedure. The Plan denied your request. The Plan says your claim has been reprocessed and 
paid up to your annual dental allowance. 
 
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 graft of 
upper/lower jaw up to the $2,000 annual dental allowance. 
 
We looked at the file and Medicare rules. The Plan provided documentation showing that at the time the claim 
was reprocessed you had $383 remaining in your dental allowance. This amount was applied towards your 
claim. You have been asked to pay the remaining amount above your dental allowance. 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 osseous, osteoperiosteal, or cartilage graft of the mandible or 
maxilla - autogenous or nonautogenous, by report (D7950) provided April 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical extraction of tooth #13, 15, 17, 18, 21, 22, and 
31 (D7210), deep sedation (D9222, D9223), and therapeutic parenteral drugs (D9610). 
 
You asked the Plan to pre-approve the dental services. You say that you need to be sedated to have your teeth 
extracted. The Plan denied your request. The Plan says surgical extractions (D7210), deep sedation (D9222, 
D9223), and therapeutic parenteral drugs (D9610) 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 pre-approve 
surgical extraction of tooth #13, 15, 17, 18, 21, 22, and 31 (D7210), deep sedation (D9222, D9223), and 
therapeutic parenteral drugs (D9610).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pontic (D6245) for tooth #11 and retainer crowns 
(D6740) for tooth #'s 10 and 12. 
 
You asked the Plan to pre-approve a fixed bridge. You say that the bridge is necessary due to several factors. 
The Plan denied your request. The Plan says the information provided does not state why a denture cannot be 
used to replace the enrollee's missing teeth. 
 
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 pontic and 
retainer crowns 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 pontic and retainer crowns. Our 
reviewer says that the enrollee does not meet the Plan's criteria for coverage for a fixed bridge. Our physician 
reviewer found there has been no showing of any physical or neurological disorders that would prevent the use 
of a removable appliance. Our reviewer also found that the documentation supplied shows the damaged tooth 
and adjacent teeth, but no indication of any issue for the enrollee as to replacing the tooth with a removable 
appliance in terms of an inability to wear one. 
 
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 pontic and retainer crowns have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a pontic (D6245) for tooth #11 and retainer crowns (D6740) for tooth #'s 
10 and 12.