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

 
We decided that the Plan does not have to pay for procedure code 76942 billed for date of service November 
23, 2021. 
 
You asked the Plan to pay for procedure code 76942. You say that medical records are attached, and the claim 
should be reconsidered. The Plan denied your request. The Plan says payment for code 76942 is bundled into 
payment for code 55874. 
 
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 76942 
is a column II code to column I code 55874. 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 76942 billed for date of service November 23, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Intensity Modulated Radiation Treatment (IMRT) 
(77386, 77370, 77014), 
 
You asked the Plan to pre-approve IMRT. You say that thus is medically necessary. The Plan denied your 
request. The Plan says this is not supported in the records. 
 
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 IMRT. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the submitted records include no quantifiable dosimetric measures. IMRT can be considered medically 
necessary when justified by quantitative dose measures and the dose-volume exposure of critical structures in 
unacceptable without IMRT.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IMRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Intensity Modulated Radiation Treatment (IMRT) (77386, 77370, 77014),
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the complete upper overdenture (D5863), the complete 
lower overdenture (D5865), the surgical placement of implant body (D6010), and the prefabricated abutment 
(D6056) for tooth #5, #7, #10, and #12. 
 
You asked the Plan to pre-approve the dental services. You say that the dentures you received did not fit and 
they have to be redone. The Plan denied your request. The Plan says your benefit for the surgical placement of 
implant body and the prefabricated abutment has already been exhausted. The denial of authorization for the 
overdentures is correct, because they 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, certain limitations apply. The record 
shows your benefit for the surgical placement of implant body and the prefabricated abutment was exhausted 
on the date of service of October 7, 2022. The overdentures are not covered under the Plans dental benefit. 
Therefore, we decided that the Plan does not have to pre-approve the complete upper overdenture (D5863), the 
complete lower overdenture (D5865), the surgical placement of implant body (D6010), and the prefabricated 
abutment (D6056) for tooth #5, #7, #10, and #12.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive oral evaluation and one dental implant 
or bridge to be performed by an oral surgeon. 
 
You asked the Plan to pre-approve a comprehensive oral evaluation and one dental implant or bridge to be 
performed by an oral surgeon. You say that the services are necessary. The Plan denied your request. The Plan 
says based on the documentation provided, coverage criteria has not been met. 
 
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 says covered dental 
services must be performed by a participating general dentist.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of a comprehensive oral evaluation and one dental implant or bridge to be performed by an oral 
surgeon have not been met. Therefore, we decided that the Plan does not have to pre-approve a comprehensive 
oral evaluation and one dental implant or bridge to be performed by an oral surgeon.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial denture (D5213) 
 
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 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 22, 2022. 
Therefore, we decided that the Plan does not have to pre-approve a partial denture (D5213)
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a power seat elevation system, expandable controller 
with harness, and electronic connection. 
 
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 a Group 3 PWC with multiple power options is 
covered when specific criteria are met. 
 
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 criteria for coverage are not met. Our physician reviewer found the records show you have a diagnosis of 
amyotrophic lateral sclerosis (ALS). The records document you have mostly four out of five to five out of five 
arm strength and 80 pounds of right arm grip strength, thus indicating you have adequate upper extremity 
strength to function and operate the approved wheelchair power options with their own switches. The 
expandable controller with harness and electronic connection are therefore not medically necessary. The power 
seat elevation system is not covered because it does not serve a purpose that is primarily medical in nature. 
 
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 a power seat elevation system, expandable controller with harness, and electronic 
connection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a stance flexion feature (L5845) and an alignable 
system (L5920) for lower-limb prosthetics. 
 
You asked the Plan to pre-approve a stance flexion feature and an alignable system. You say that the requested 
items are a medical necessity for the enrollee. The Plan denied your request. The Plan says the request is 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 a stance flexion feature and an 
alignable system. Our reviewer says that the requested items are not considered medically reasonable and 
necessary in this case. Our physician reviewer found that the requested alignable system exceeds the enrollee's 
medical need. The available medical documentation does not support that the current L5920 alignable system is 
unable to be used for an approved replacement socket. The requested stance flexion feature is not reasonable 
and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed 
body member. The approved knee already includes stance control; therefore, the request exceeds the enrollee's 
needs. 
 
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 stance flexion feature and an alignable system have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a stance flexion feature (L5845) and an alignable system 
(L5920) for lower-limb prosthetics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a dental consultation (D9310) provided on February 11, 
2022. 
 
You asked the Plan to pay for the dental consultation. 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 pay for a dental 
consultation (D9310) provided on February 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a surgical placement of implant body: endosteal implant 
tooth #'s 6, 11, 22 and 27 (D6010). 
 
You asked the Plan to pre-approve the surgical placement of implant body: endosteal implant tooth #'s 6, 11, 22 
and 27 (D6010). You say that you need the implants as you are unable to get dentures and unable to eat. The 
Plan denied your request. The Plan says this service is not covered under the 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 
surgical placement of implant body: endosteal implant tooth #'s 6, 11, 22 and 27 (D6010).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a medical eye examination (92014) 
provided on August 15, 2022. 
 
You asked the Plan to waive the copayment for a medical eye examination. You say that you want the Plan to 
pay for the service. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 
copayment for each Medicare-covered outpatient visit for services to diagnose and/or treat a disease or 
condition of the eye.  
 
   
You have been asked to pay a $50 copayment for a medical eye examination. This item/service falls within the 
vision 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 copayment for a medical eye examination 
(92014) provided on August 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral periapical radiographic image (D0230), a 3-
dimensional photographic image (D0351), and oral/facial photographic images (D0350 x2) provided on July 6, 
2022. 
 
You asked the Plan to pay for the dental services. You say that you want the Plan to pay for the services. The 
Plan denied your request. The Plan says your benefit for the intraoral periapical radiographic image has already 
been exhausted. 3-dimensional photographic image, and oral/facial photographic images are not covered 
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, certain limitations apply. The record 
shows your benefit for the intraoral periapical radiographic image was exhausted on date of service July 6, 
2022. Additionally, 3-dimensional photographic image, and oral/facial photographic images are not covered 
services. Therefore, we decided that the Plan does not have to pay for an intraoral periapical radiographic 
image (D0230), a 3-dimensional photographic image (D0351), and oral/facial photographic images (D0350 x2) 
provided on July 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the local anesthesia (D9215). 
 
You asked the Plan to pre-approve the dental service. You say that you are appealing the denied dental service. 
The Plan denied your request. The Plan says the denial of authorization for this service is correct, because local 
anesthesia is 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 
local anesthesia (D9215).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cone beam CT scan (D0364) provided on August 1, 2022. 
 
You asked the Plan to pay for the cone beam CT scan. 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 pay for a cone 
beam CT scan (D0364) provided on August 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial denture and plaque removal services (D4346, 
D5214) 
 
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 your benefit for partial dentures (D5214) 
has already been exhausted, the contract states that you can only receive this service once every 5 plan years. 
Coverage for plaque removal services (D4346) is denied as it does 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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service October 21, 2019. 
Therefore, we decided that the Plan does not have to pre-approve a partial denture and plaque removal services 
(D4346, D5214)
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the application of a desensitizing resin (D9911) 
 
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 
application of a desensitizing resin (D9911)
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99223 billed for date of service June 25, 
2022. 
 
You asked the Plan to pay for procedure code 99223. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says payment for code 99223 is bundled into 
payment for code 11043. 
 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 99223 
is a column II code to column I code 11043. 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 99223 billed for date of service June 25, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on March 1, 2022.

You asked the Plan to pay for the lab services. You say that the specimens are received from providers who have performed biopsies. The Plan denied your request. The Plan says the specimen was obtained in an office setting.

The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory directly.


We looked at the file and Medicare rules. This claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on March 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildup, including any pins when required 
(D2950). 
 
You asked the Plan to pre-approve the core buildup, including any pins when required (D2950). The Plan 
denied your request. The Plan says this service is not covered under the 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 core 
buildup, including any pins when required (D2950).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve mandibular partial denture - cast metal framework with 
resin denture bases (D5214). 
 
You asked the Plan to pre-approve dental services. You say that you did not receive this service previously and 
you need teeth in order to eat. 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. This benefit includes 
mandibular partial denture - cast metal framework with resin denture bases (D5214)  one procedure every five 
plan years. 
 
We looked at the file, the Plans rules, and Medicares rules. You previously received covered mandibular 
partial denture - cast metal framework with resin denture bases (D5214) on July 26, 2019. Therefore, these 
benefits were exhausted as of July 26, 2019. Therefore, we decided that the Plan does not have to pre-approve 
mandibular partial denture - cast metal framework with resin denture bases (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildup, including any pins when required 
(D2950). 
 
You asked the Plan to pre-approve the core buildup, including any pins when required (D2950). You say that 
your front tooth is the problem as your upper lip gets caught in the crack of your tooth. The Plan denied your 
request. The Plan says this service is not covered under the 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 core 
buildup, including any pins when required (D2950).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the one simple extraction (D7140) provided on June 
29, 2022. 
 
You asked the Plan to pay more for the one simple extraction. You say that you tried to stay in-network and 
believe these expenses should be covered. The Plan denied your request. The Plan says your Annual Maximum 
dental benefit 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 annual maximum dental benefit was exhausted on date of service August 10, 2022. Therefore, we 
decided that the Plan does not have to pay more for the one simple extraction (D7140) provided on June 29, 
2022.