Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93042 billed for date of service August 7, 2021. 
 
You asked the Plan to pay for procedure code 93042. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment for code 93042 is bundled into 
payment for code 93010. 
 
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 93042 
is a column II code to column I code 93010. 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 93042 billed for date of service August 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140), pontics on tooth #5 and 10 
(D6245), two retainer crowns (D6740), and panoramic x-rays (D0330) provided on December 4, 2021. 
 
You asked the Plan to pay for an evaluation, pontics, two crowns, and x-ray. You say that you located the 
provider on the Plan's website. The Plan denied your request. The Plan says a limited oral evaluation (D0140) 
and pontics (D6245) are not covered by your supplemental benefits. The Plan also says that two retainer 
crowns are covered per calendar year and one set of full mouth x-rays every five years. 
 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, a limited oral evaluation and pontics 
are not covered under this benefit. The record shows your benefit for a full mouth x-ray was exhausted on date 
of service April 20, 2021. The record also shows your benefit for two retainer crown was approved on this 
claim. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140), pontics 
on tooth #5 and 10 (D6245), two retainer crowns (D6740), and panoramic x-rays (D0330) provided on 
December 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a soft tissue graft procedure on tooth #19 (D4277) provided 
on March 9, 2022. 
 
You asked the Plan to pay for the graft procedure. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says a soft tissue graft procedure (D4277) is 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 soft 
tissue graft procedure on tooth #19 (D4277) provided on March 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the second dance class purchased during the 2021 benefit year. 
 
You asked the Plan to pay for the second dance class. You say that you sent in copies of proof of payment 
with the original request you submitted. The Plan denied your request. The Plan says proof of payment was not 
provided for the second class. 
 
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 record to determine if Medicare rules for coverage of the second dance class purchased 
during the 2021 benefit year have been met. The contract clearly says to in order to obtain reimbursement for 
qualified memberships, you must submit a Wellness Allowance reimbursement form along with proof of 
payment and any additional information outlined on the form. The record shows that you only submitted proof 
of payment for one of the two dance classes. No proof of payment or additional information was submitted by 
you showing paid for a second dance class. Therefore, we decided that the Plan does not have to pay for the 
second dance class purchased during the 2021 benefit year.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a lumbar-sacral orthosis provided on 
January 26, 2022. 
 
You asked the Plan to waive the coinsurance for a lumbar-sacral orthosis. You say that you disagree with the 
amount of this back brace. The Plan denied your request. The Plan says you were charged the correct cost 
sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20 
percent coinsurance for each in-network Medicare-covered durable medical equipment item.  
 
 You have been asked to pay $203.05 in coinsurance, which is 20 percent of the allowed amount for a lumbar-
sacral orthosis ($1,015.24 allowed amount x 20% coinsurance = $203.05). A lumbar-sacral orthosis falls within 
the durable medical equipment (DME) and related 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. Therefore, we decided that the Plan does not have 
to waive the coinsurance for a lumbar-sacral orthosis provided on January 26, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the interpretation of the abdominal ultrasound provided on 
August 31, 2021, billed with code 76705. 
 
You asked the Plan to pay for the ultrasound interpretation as billed. You say that this should be paid in full. 
The Plan denied your request. The Plan says the evaluation and management services have been approved; 
however, the code 76705 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 76705 is Ultrasound, abdominal, real time with image documentation; limited (eg, single organ, quadrant, follow-up). 
 
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 ultrasound interpretation as billed. Our reviewer says that 
the documentation does not support the billing of this code. Our reviewer found the medical record documents 
"computed tomography of Abdomen and Pelvis without Contrast" was performed on August 31, 2021. The 
documentation does not include ultrasound abdominal, real time with image documentation, limited, and 
therefore, this code cannot be verified.  
 
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 ultrasound interpretation as billed have not been met. Therefore, we decided 
that the Plan does not have to pay for the interpretation of the abdominal ultrasound provided on August 31, 
2021, billed with code 76705.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a fixed partial denture sectioning (D9120) provided by a 
participating provider on August 6, 2020. 
 
You asked the Plan to pay for dental services. You say that you would like the Plan to pay for this. The Plan 
denied your request. The Plan says the rendered dental work 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 pay for a fixed 
partial denture sectioning (D9120) provided by a participating provider on August 6, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Computer-assisted surgical navigational procedure for 
musculoskeletal procedures (20935) and inpatient hospital services. 
 You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that the clinical value and effectiveness of computer assisted surgical 
navigation in the setting of a hip arthroplasty surgery has not been demonstrated in the peer-reviewed literature. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that inpatient hospital care is covered when the doctor expects the 
patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may 
be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 
 
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 requested services are not considered medically reasonable and necessary in this case. There is limited 
published, large-scale, long-term peer-reviewed literature that show computer-assisted navigational total hip 
arthroplasty to be an effective and/or safe treatment for the enrollees pathology. Overall ultimate outcomes 
regarding improved functionality and decreased pain have not been documented via large volume long term 
studies (with computer-assisted navigational total hip arthroplasty). Further research is needed. There is no 
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception to guidelines. Detailed documentation is not evident regarding a significant past and/or 
current medical history that would place this enrollee at increased risk for peri-surgical complications requiring 
an inpatient stay. The record does not show that at the time of inpatient admission, the admitting physician 
reasonable expects that the patients necessary hospital care (including earlier ED and/or observation care) 
would span two midnights. Our physician reviewer found that the enrollee's condition does not meet criteria for 
coverage of these services. 
 
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 Computer-assisted surgical navigational procedure for musculoskeletal procedures (20935) 
and inpatient hospital services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection between wheelchair controller 
and two or more power seating system motors (E2311), a harness for an upgrade to an expandable controller 
(E2313) and an expandable controller (E2377). 
 
You asked the Plan to pre-approve power wheelchair accessories. You say that you cannot walk and have 
Spina Bifida (birth defect). You believe this equipment should be covered under your plan. The Plan denied 
your request. The Plan says the notes state that these are needed when 2 or more actuators are being used. 
Although there are three approved power options on this wheelchair (tilt, recline and elevating leg rests), there 
is not a medical need to control these power options through the joystick. 
 
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 an electronic connection between wheelchair controller and 
two or more power seating system motors (E2311), a harness for an upgrade to an expandable controller 
(E2313) and an expandable controller (E2377).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Osteopromotive allograft (CPT code 20930). 
 
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says medical studies have not proven that the service(s) or procedure(s) is helpful for 
treatment of your health problem. 
 
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 service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no documentation of failure of previous fusion with nonunion. Iliac crest autograft 
remains the gold standard procedure for bone graft in the posterior lumbar spine. Osteopromotive allograft is 
not medically needed. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Osteopromotive allograft (CPT code 20930).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services (81206, 81292) provided on 
November 8, 2021. 
 
You asked the Plan to pay for the genetic testing services. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says this claim has not been billed as 
required by Medicare coding regulations. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We looked at the file and Medicare rules. In this case, the services provided should have been billed as a single 
procedural service. Based on this information, we decided that Medicare rules for coverage of the genetic 
testing services have not been met. Therefore, we decided that the Plan does not have to pay for the genetic 
testing services (81206, 81292) provided on November 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown - porcelain/ceramic (D2740) provided April 18, 2022. 
 
You asked the Plan to pay for the dental services. You say that your crown came off and you had no choice but 
to have another crown placed. The Plan denied your request. The Plan says you have exceeded the frequency 
limit for this service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's 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 April 22, 2019. 
Therefore, we decided that the Plan does not have to pay for the crown - porcelain/ceramic (D2740) provided 
April 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mends andropause creme (82627) unlisted supplies and 
materials (99070) miscellaneous, durable medical equipment (DME) (E1399) and sales tax/shipping and 
handling (S9999) provided November 18, 2021. 
 
You asked the Plan to pay for the DME. You say that you are submitting this claim for reimbursement of 
payments. The procedure that was performed on November 18, 2021 was the same procedure that was done 
April 27, 2020. The Plan denied your request. The Plan says this claim has been processed correctly per the 
Evidence of Coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
Medicare rules say that providers must report services correctly. Providers must report services with the 
appropriate CPT code. 
 
The mens Andropause cream is not covered under Medicare Part B. This may be covered under Part D 
benefits. The payment for 99070 is bundled into the ASC payment for the procedure and is not separately 
payment. There is no documentation to describe what E1399 refers to and sales tax is not covered. 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 pay for mends andropause creme (82627) unlisted supplies and materials (99070) 
miscellaneous, durable medical equipment (DME) (E1399) and sales tax/shipping and handling (S9999) 
provided November 18, 2021.  
 
Benefits for the DME 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 pay for a filling provided on January 24, 2022. 
 
You asked the Plan to pay for a filling. You say that the provider should have used a silver filling but used a 
white filling instead. The Plan denied your request. The Plan says your dental benefit includes coverage only 
for anterior resin fillings. 
 
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. The record shows you received a resin filling. Although posterior resin 
fillings are not covered, the plan has agreed to pay a portion of the cost. You are responsible for the difference 
between the charge for the resin filling and the plan payment. Therefore, we decided that the Plan does not 
have to pay for a filling provided on January 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) and intraoral imaging 
(D0220), provided by a participating provider on March 8, 2022. 
 
You asked the Plan to pay for a limited oral evaluation and intraoral imaging. You say that you had tooth 
sensitivity. You say that these should be covered because you needed to know what was wrong. 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 a limited 
oral evaluation (D0140) and intraoral imaging (D0220), provided by a participating provider on March 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for prophylaxis (D1110) and a periodic oral 
evaluation (D0120) provided on February 10, 2022. 
 
You asked the Plan to waive the cost share for prophylaxis and an evaluation. You say that you were not 
properly informed that your dental benefits had changed. The Plan denied your request. The Plan says you have 
been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 50% 
coinsurance for out-of-network preventive and comprehensive dental services. The contract also says when 
receiving these services from an out-of-network provider you can be billed up to the total billed amount. 
 
The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay a 
total of $120.30 for prophylaxis and an evaluation on February 10, 2022.  
 Code Total Billed 
Amount 
Allowed Amount 50% Coinsurance Total 
D1110 $111 $69.70 $34.85 $76.15 
D0120 $62 $35.70 $17.85 $44.15 
    $120.30 
 
Prophylaxis and an evaluation fall 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 prophylaxis (D1110) and a periodic oral evaluation (D0120) provided on February 
10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus Gene Panel provided April 15, 2021. 
 
You asked the Plan to pay for the laboratory service. You say that the Tempus Gene Panel will be useful for 
patients at initial diagnosis or for a patient with refractor disease. The Plan denied your request. The Plan says 
does not meet Medicare NCD/LCD criteria. 
 
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 find that CPT code 81206, 81292 is not supported in the medical record. Specifically, Medicare 
denies coverage when a laboratory assays two or more genes in a patient in parallel. Those two or more genes 
will be considered part of the same panel. A panel constitutes a single procedural service, so one CPT code 
must be submitted for the panel. Based on this information, we decided that Medicare rules for coverage of the 
laboratory service have not been met. Therefore, we decided that the Plan does not have to pay for the Tempus 
Gene Panel provided April 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two plastic standard side guards. 
 
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 covered. 
 
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. Therefore, we 
decided that the Plan does not have to pre-approve two plastic standard side guards.