Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes 36556 and 93312 provided on February 7, 2023 
 
You asked the Plan to pay for procedure codes 36556 and 93312. You say that you would like Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not 
covered. 
 
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 36556 is Insertion of non-tunneled centrally inserted central venous catheter; age 5 years or older. 
 
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 code 36556. Our reviewer says that the medical 
records support the billing of procedure codes 36556. Our reviewer found there is satisfactory documentation 
that a central line was placed via the internal jugular vein. There is satisfactory documentation that the line was 
placed centrally.  As most central lines placed perioperatively are not placed under fluoroscopic guidance, the 
exact location of the tip cannot be documented, and it is not reasonable to require this information to justify 
billing. 
 
Additionally, we have confirmed that code 93312 is a column II code to column I code 00562; however, 93312 
was billed with a modifier. While there is a NCCI edit between 93312 and 00562, the medical documentation 
confirms that the anesthesia billed was for the main procedure not only for the transthoracic echocardiogram 
(TEE). TEE was performed while the patient was in surgery. 
 
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 36556 and 93312 have been met. Therefore, we decided that 
the Plan has to pay for procedure codes 36556 and 93312 provided on February 7, 2023  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown - porcelain/ceramic (D2740). 
 
You asked the Plan to pre-approve the crown. The Plan denied your request. The Plan says your benefit for the 
requested 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 crown was exhausted on date of service August 13, 2020. Therefore, we 
decided that the Plan does not have to pre-approve a crown - porcelain/ceramic (D2740).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the insulin infusion pump supplies provided 
on April 10, 2023. 
 
You asked the Plan to waive the cost share for the insulin infusion pump supplies. You say that these items are 
medically necessary. 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. Your 
contract with the Plan says that there is a $800 deductible which applies to durable medical equipment and 
related medical supplies. Your contract with the Plan clearly says that you must pay 10% of the approved 
amount. You have been asked to pay $33.31, which is 10% coinsurance of the allowed amount for the maintenance 
supplies ($333.12 allowed amount x 10% = $33.31). You have also been asked to pay $9.15, which is 10% 
coinsurance of the allowed amount for the pump supplies ($91.50 allowed amount x 10% = $9.15). These 
items/services fall within the durable medical equipment and related medical supplies 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. 
 
You have also been asked to pay $299.81 towards your deductible for the maintenance supplies. You have also 
been asked to pay $82.35 towards your deductible for the pump supplies. The items or services you asked the 
Plan to waive the cost share for fall within the durable medical equipment and related medical supplies benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $800 
deductible which applies to durable medical equipment and related medical supplies. This cost sharing is a 
contractual obligation that had not been met at the time the insulin infusion pump supplies was received on 
April 10, 2023. Therefore, we decided that the Plan does not have to waive the cost share for the insulin 
infusion pump supplies provided on April 10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the extraction of an erupted tooth requiring removal of 
bone and/or sectioning of tooth (D7210) and the extraction of an erupted tooth or exposed root (D7140). 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing due to medical necessity. 
The Plan denied your request. The Plan says dental services from an out-of-network provider 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. 
 
You are requesting 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 pre-approve the 
extraction of an erupted tooth requiring removal of bone and/or sectioning of tooth (D7210) and the extraction 
of an erupted tooth or exposed root (D7140).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the genicular nerve block. 
 
You asked the Plan to pre-approve the genicular nerve block. You say that you are still in pain and there was 
nothing else being offered to you. You say that the nerve medication that was given to you was not effective.  
The Plan denied your request. The Plan says  the genicular nerve block is considered experimental and 
investigational.  
 
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 genicular nerve block. Our reviewer 
says that the genicular nerve block is considered experimental. Our physician reviewer found that the genicular 
nerve block is considered experimental for knee pain. 
 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 genicular nerve block have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the genicular nerve block.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a porcelain crown (D2750), core buildup (D2950) and 
provisional crown (D2799). 
 
You asked the Plan to pre-approve a porcelain crown (D2750), core buildup (D2950) and provisional crown 
(D2799). You say that you are appealing with supporting records. The Plan denied your request. The Plan says 
core buildup (D2950) and provisional crown (D2799) are not covered under this benefit. The Plan also says 
that the benefit for a porcelain crown (D2750) has 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, core buildup (D2950) and provisional 
crown (D2799) are not among those covered under this benefit. The record shows that the benefit for porcelain 
crowns (D2750) has been exhausted. Therefore, we decided that the Plan does not have to pre-approve a 
porcelain crown (D2750), core buildup (D2950) and provisional crown (D2799).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture services and infrared therapy provided on 
July 24, 2023. 
 
You asked the Plan to pay for the acupuncture services and infrared therapy. You say that the claim should be 
reprocessed for payment. The Plan denied your request. The Plan says the acupuncture services were provided 
by an unqualified provider.  
 
  The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the provider is not and was not supervised by a 
physician, physician assistant, or nurse practitioner/clinical nurse specialist. Therefore, we decided that the Plan 
does not have to pay for the acupuncture services and infrared therapy provided on July 24, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided on June 8, 2023, to June 
13, 2023. 
 
You asked the Plan to pay for self-administered drugs. You say that it is against the hospital policy to bring in 
your own medication and administer them to yourself. The Plan denied your request. The Plan says that self-
administered drugs do not fall under Medicare Part B coverage. 
 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 self-administered drugs provided 
on June 8, 2023, to June 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional trips. 
 
You asked the Plan to pre-approve additional trips. You say that you need additional rides to make it to your 
appointments as you do not drive. The Plan denied your request. The Plan says your EOC states that coverage 
is provided for up to 12 one-way trips to a Plan network approved location within 30 miles. The Plan also says 
that you have used 12 trips. 
 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 12 one-way 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 trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the re-cement or re-bond inlay, onlay, veneer or partial 
coverage restoration (D2910) provided on May 31, 2023. 
 
You asked the Plan to pay for the re-cement or re-bond inlay, onlay, veneer or partial coverage restoration. You 
say that you expected the repair of a veneer that fell off and needed to be re-bonded would be covered in some 
part. The Plan denied your request. The Plan says this service is not covered 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 pay for the re-
cement or re-bond inlay, onlay, veneer or partial coverage restoration (D2910) provided on May 31, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the compression stockings identified with code A6549 that 
were issued on June 8, 2023. 
 
You asked the Plan to pay for the compression stockings. You say that a representative told you the service was 
coded incorrectly, and you should not have to pay for the compression stockings. The Plan denied your request. 
The Plan says this item is not covered by Medicare or the Plan. 
 The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the compression 
stockings identified with code A6549 that were issued on June 8, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for vertical bitewings - 7 to 8 radiographic images (D0277) 
provided on June 21, 2023. 
 
You asked the Plan to pay for the vertical bitewings. You say that your plan clearly states that exams and x-
rays are covered. You also say that these are the only services you received on this visit so you should not have 
a copayment. The Plan denied your request. The Plan says this procedure is not covered 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 pay for vertical 
bitewings - 7 to 8 radiographic images (D0277) provided on June 21, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional outpatient rehabilitation therapy visits to be 
provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve outpatient rehabilitation therapy visits. You say that You say that you 
disagree with the denial for additional therapy visits. The Plan denied your request. The Plan says these 
services can be provided by an in-network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
additional outpatient rehabilitation therapy visits to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a resin-based composite crown (D2710). 
 
You asked the Plan to pre-approve a resin-based composite crown (D2710). You say that you want to appeal 
the denial of the crown since it had previously been approved for you. You also say you have $5,000 in 
coverage. The Plan denied your request. The Plan says this is not included in your dental Plan 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 pre-approve a 
resin-based composite crown (D2710).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prophylaxis-adult (D1110) and periodic oral evaluation 
(D0120). 
 
You asked the Plan to pre-approve the dental services. You say that this should be 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 on date of service June 28, 2023. Therefore, 
we decided that the Plan does not have to pre-approve prophylaxis-adult (D1110) and periodic oral evaluation (D0120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implant placement (D6010). 
 
You asked the Plan to pre-approve implant placement. You say that this is medically necessary. The Plan 
denied your request. The Plan says this is not a covered service. 
 
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 
implant placement (D6010).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve partial upper denture (D5213). 
 
You asked the Plan to pre-approve the dental services. You say that this should be 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 on date of service January 12, 2023. 
Therefore, we decided that the Plan does not have to pre-approve partial upper denture (D5213).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary complete denture (D5110) and a mandibular 
complete denture (D5120). 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says dental services from an out-of-network provider 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. 
 
 
  You are requesting 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 pre-approve a maxillary 
complete denture (D5110) and a mandibular complete denture (D5120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve occlusal guard (D9945). 
 
You asked the Plan to pre-approve occlusal guard. You say that you were diagnosed with Bruxism and need 
this mouthguard. The Plan denied your request. The Plan says this is not a covered service. 
 
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 
occlusal guard (D9945).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve blepharoplasty (15823 x 2, 15822 x 2), repair of brow 
ptosis (67900 x 2), ectropion (67917x 2) and canthoplasty (67950 x 2). 
 
You asked the Plan to pre-approve blepharoplasty, repair of brow ptosis, ectropion and canthoplasty. 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. 
 
The Plan follows Medicare rules. Medicare rules say that upper blepharoplasty 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 and canthoplasty. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found based on the medical records 
provided there is no documentation that the blepharoplasty, repair of brow ptosis, ectropion and canthoplasty at 
issue in this case meet all Medicare and LCD criteria for medically reasonable and necessary for the enrollee. 
Provided records in this case do not document a margin reflex distance (MRD) of 2.0 mm or less as required by 
the LCD. Records do not include color photographs to support the upper eyelid surgery as medically necessary 
as required by the LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of and canthoplasty have not been met. Therefore, we decided that the Plan does 
not have to pre-approve blepharoplasty (15823 x 2, 15822 x 2), repair of brow ptosis (67900 x 2), ectropion 
(67917x 2) and canthoplasty (67950 x 2).