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

 
We decided that the Plan does not have to pre-approve guided tissue regeneration - resorbable barrier, per site 
(D4266), and bone replacement graft for ridge preservation - per site (D7953). 
 
You asked the Plan to pre-approve the guided tissue regeneration and bone replacement graft. You say that you 
disagree with the denial and would like the plan to reconsider coverage. The Plan denied your request. The 
Plan says procedure codes D7953 and D4266 are not listed as covered and therefore 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, 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 
guided tissue regeneration - resorbable barrier, per site (D4266), and bone replacement graft for ridge 
preservation - per site (D7953).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the decalcification procedure (88311) provided on August 31, 2022. 
 
You asked the Plan to pay for the decalcification procedure. The Plan denied your request. The Plan says that  
this service is not covered when provided OON. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for the decalcification procedure by a contract provider. The file does not show that 
the plan provided notice that the decalcification procedure would not be covered. Under Medicare rules, this 
means the decalcification procedure is considered approved by the plan. Therefore, we decided that the Plan 
has to pay for the decalcification procedure (88311) provided on August 31, 2022.  
 
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 pay for the local anesthesia in conjunction with operative or surgical 
procedures (D9215 x 2) provided from September 13, 2022, to October 21, 2022. 
 
You asked the Plan to pay for the dental services. You say that your provider may have used the wrong billing 
codes for these procedures. The Plan denied your request. The Plan says this service is not a covered benefit 
under your dental plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the local 
anesthesia in conjunction with operative or surgical procedures (D9215 x 2) provided from September 13, 
2022, to October 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve composite restoration-posterior tooth for teeth 22,26, 
and 27 (D2394) and medication for sensitivity (D9910). 
 
You asked the Plan to pre-approve composite restoration-posterior tooth and medication for sensitivity. You 
say that this should be covered. 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 
composite restoration-posterior tooth for teeth 22,26, and 27 (D2394) and medication for sensitivity (D9910).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care to be provided by an 
out-of-network (OON) provider.  
 
You asked the Plan to pre-approve OON SNF care. You say that there is not an in-network facility that will 
accept the enrollee. The Plan denied your request. The Plan says an in-network SNF stay is approved however, 
it is denied at an OON facility as the enrollee has no OON benefits. 
 
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 
skilled nursing facility (SNF) care 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 pay for retainer crowns (D6740), and pontics (D6245) provided on 
March 14, 2022. 
 
You asked the Plan to pay for D6740 and D6245. You say that these should be covered services. The Plan 
denied your request. The Plan says the rendered dental services 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, 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 retainer 
crowns (D6740), and pontics (D6245) provided on March 14, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the critical care services provided from August 16, 2022, to August 17, 
2022. 
 
You asked the Plan to pay for the critical care services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that they were unable to make a determination 
within the allotted time frame. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. In this case, the Plan has not provided enough evidence to support the denial of 
payment for the critical care services provided from August 16, 2022, to August 17, 2022 based on Medicare 
criteria. Therefore, we decided that the Plan has to pay for the critical care services provided from August 16, 
2022, to August 17, 2022.  
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 93308 and 93321 billed for date of service 
January 12, 2023. 
 You asked the Plan to pay for the billed services. You say that the diagnosis code is payable. The Plan denied 
your request. The Plan says the appropriate diagnosis code was not billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that CPT code 93308 and 93321 was billed with primary diagnosis code I31.4. This diagnosis code has 
a code first note, which means the code is not permitted to be used as the primary diagnosis code. Based on 
this information, we decided that Medicare rules for coverage of the billed services have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes 93308 and 93321 billed for date 
of service January 12, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an MRI of the brain. 
 
You asked the Plan to pre-approve an MRI of the brain. You say that you would like reconsideration because 
the services are medically necessary. The Plan denied your request. The Plan says an MRI of the brain is not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
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 an MRI of the brain. Our reviewer says 
that an MRI of the brain is not medically necessary. Our physician reviewer found that while the most recent 
neuro exam was negative there were no prior MRI reports of the brain included in the records. Although the 
enrollee has glaucoma if meningioma is the diagnosis of concern, then it would be important to know the 
location and size of the tumor. Also, the monitoring of any space occupying lesion in the cranium would 
require pre and post contrast administration. Therefore, the absence of any information concerning the 
enrollee's meningioma the medical necessity of the requested MRI of the brain has not been established. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI of the brain have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an MRI of the brain.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a CT scan of the heart. 
 
You asked the Plan to pre-approve a CT scan of the heart. You say that the enrollee is at risk of coronary 
disease and the requested CT scan would help to determine on whether they will require statin therapy. The 
Plan denied your request. The Plan says that a CT scan of the heart is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
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 CT scan of the heart. Our reviewer 
says that a CT scan of the heart is medically necessary. Our physician reviewer found that the enrollee has 
hypertension, essential and a diagnosis of idiopathic cardiomyopathy. Also, they have 2 clinical factors that 
support the request of a CT coronary calcium scoring. Therefore, the requested CT scan of the heart is 
medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a CT scan of the heart have been met. Therefore, we decided that the Plan has to 
pre-approve a CT scan of the heart.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression devices provided on November 
10, 2022. 
 
You asked the Plan to pay for the billed services. You say that this device was provided for use during the 
patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a procedure is 
not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  The items at issue in this appeal are for use outside of the home. Although the items may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression devices provided on November 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ANX crown provided on January 10, 2023. 
 
You asked the Plan to pay for ANX crown. You say that this is medically necessary. The Plan denied your 
request. The Plan says records do not show over 50% of the tooth is lose due to a large defective restoration on 
x-ray or photos. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the records to determine if Medicare rules for coverage of ANX crown have been met. Multiple 
attempts to request dental records were made on March 21, 23, 25, 2023 but have been unsuccessful as the documentation requested has not been received. Therefore, we decided that the Plan does not have to pay for an 
ANX crown provided on January 10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve biologic materials to aid in tissue regeneration with 
periradicular surgery (D3431). 
 
You asked the Plan to pre-approve biologic materials to aid in tissue regeneration with periradicular surgery. 
You say that this should be covered. 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 
biologic materials to aid in tissue regeneration with periradicular surgery (D3431).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a positron emission tomography (PET) scan with concurrently 
acquired computed tomography (CT) scan. 
 
You asked the Plan to pre-approve the PET/CT scan. You say that given there were changes on the last 
PET/CT, it is important to repeat the scan for re-staging. You say regardless of the number of PET scans the 
enrollee has had, it is medically necessary for the enrollee to have this PET/CT to closely follow and treat their 
disease. The Plan denied your request. The Plan says that medical necessity has not been found to allow for 
prior authorization of the PET/CT.  
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
medically necessary.  
 
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 PET/CT scan. Our reviewer says 
that the request for a PET/CT scan is medically necessary. Our physician reviewer found the enrollee has 
known metastatic disease and the most recent PET/CT scan showed increased abnormal uptake in several 
areas. The scan is necessary and should be approved to determine if management should include any change in 
chemo-immunotherapy. 
 
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 PET/CT scan have been met. Therefore, we decided that the Plan has to pre-
approve a positron emission tomography (PET) scan with concurrently acquired computed tomography (CT) 
scan.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
January 16, 2023.  
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service January 16, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional occupational therapy visits. 
 
You asked the Plan to pre-approve the therapy services. You say that this is medically necessary. The Plan 
denied your request. The Plan says this is not medically necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the enrollee has previously been treated with outpatient therapies and 
should be independent with a home exercise program. There is no documentation of a recent injury or decline 
in function. The additional therapy services are not an appropriate duration and frequency for treatment of the 
enrollees medical condition and therefore are not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 10 additional occupational therapy visits.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G2067 billed for date of service July 14, 
2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says this claim is a 
duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
 
 We looked at the file and Medicare rules. The file shows that the billed code was reimbursed by the Plan on 
August 26, 2022. A comparison of the two claim lines shows these are exact duplicates. There is no evidence to 
support that the billed code was provided twice on the same date. Based on this information, we decided that 
the Medicare rules for the billed services have not been met. Therefore, we decided that the Plan does not have 
to pay for procedure code G2067 billed for date of service July 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of a ventilator. 
 
You asked the Plan to pre-approve ventilator. You say that a ventilator is the only thing that can help the 
enrollee now. The Plan denied your request. The Plan says a ventilator is not covered by Medicare for this 
purpose and the needed therapy could be provided by some bilevel positive airway pressure (BiPAP) devices. 
 
The Plan must follow Medicare rules. Medicare rules say that ventilator products used to provide positive 
airway pressure (PAP) therapy, regardless of the underlying medical condition, shall not be covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve use 
of a ventilator.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the services (73110) provided on February 1, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that the billed code is 
not separately payable. 
 
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 73110 is "Radiologic examination, wrist; complete, minimum of 3 views". 
 
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 the services. Our reviewer says that the use of code 73110 is 
supported by the records provided. Our reviewer found that the 3-view left wrist series x-ray obtained on 
February 1, 2023, was fully documented by a report similar to that expected of a radiologist and was used to 
compare current findings to a prior outside abnormal exam. As such, the 3-view left series x-ray is supported 
and payable in this case. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
the services (73110) provided on February 1, 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.