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

 
We decided that the Plan has to pay for a resin-based composite filling on tooth #7 (D2330) provided on May 
12, 2022. 
 
You asked the Plan to pay for a filling. You say that you disagree with denial of dental service. The Plan denied 
your request. The Plan says that the enrollee's annual dental allowance has been met. 
 
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. The Plan did not provide the correct Evidence of Coverage (EOC) that was in 
effect during the date of service. Without the correct EOC we are unable to confirm your annual dental 
allowance amount. Therefore, we decided that the Plan has to pay for a resin-based composite filling on tooth 
#7 (D2330) provided on May 12, 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 pre-approve an unspecified preventive procedure (D1999). 
 
You asked the Plan to pre-approve preventive procedure. You say that you urgently need this service. The Plan 
denied your request. The Plan says that an unspecified preventive procedure (D1999) 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 pre-approve an 
unspecified preventive procedure (D1999).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the 2D oral/facial photographic images obtained intra-orally 
or extra-orally (D0350 x 4) and the gingival irrigation-per quadrant (D4921 x 4) provided on May 13, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not covered under your 
contractual policy. 
 
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 services provided are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 2D oral/facial 
photographic images obtained intra-orally or extra-orally (D0350 x 4) and the gingival irrigation-per quadrant 
(D4921 x 4) provided on May 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on May 12, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 83789 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 83789 is mass spectrometry and tandem mass 
spectrometry (eg, MS, MS/MS, MALDI, MS-TOF, QTOF), non-drug analyte(s) not elsewhere specified, 
qualitative or quantitative, each specimen. 
 
We find that CPT code 83789 is not supported in the medical record. Specifically, there is no documentation of 
a complete description of the not elsewhere specified portion of the code. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the 
Plan does not have to pay for the laboratory services rendered on May 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740) and an addition to crown (D2954) for 
tooth #10 
 
You asked the Plan to pre-approve the dental services. You say that you need this procedure done. 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 of December 7, 2020. 
Therefore, we decided that the Plan does not have to pre-approve a crown (D2740) and an addition to crown 
(D2954) for tooth #10
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodic oral evaluation - established patient (D0120) and 
prophylaxis - adult (D1110) provided April 7, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the dental services. You say that you were not aware that you did not have OON 
coverage. The Plan denied your request. The Plan says the dental services were received from an out-of-
network provider and are not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for periodic oral evaluation - established patient (D0120) and prophylaxis - adult (D1110) provided 
April 7, 2022, by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve enhanced external counterpulsation (ECP) therapy for 
the enrollee. 
 
You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your 
request. The Plan says alternative services include physical therapy, injections, oral medications, and activity 
modification. 
 
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 therapy. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that although the ECP device was approved by the FDA for use in treating a number of cardiac 
conditions, including stable or unstable angina pectoris and acute myocardial infarction, there has not been 
sufficient clinical evidence to support the use of ECP for the requested indication in this patient with what is 
thought to reflect post-acute COVID syndrome. In summary, there is insufficient documentation to support the 
medical necessity for the use of ECP in this patients clinical management. 
 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 have not been met. Therefore, we decided that the Plan does not 
have to pre-approve enhanced external counterpulsation (ECP) therapy for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 83789 billed for date of service March 14, 
2022. 
 You asked the Plan to pay for procedure code 83789. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 83789 is bundled into payment for code 80307 and 
G0481. 
 
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 83789 
is a column II code to column I code 80307 and G0481. 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 83789 billed for date of service 
March 14, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiological supervision services coded 75726-59 
provided on April 25, 2022. 
 You asked the Plan to pay for the radiological supervision services as billed. You say that you would like this 
claim reprocessed based on the medical records. The Plan denied your request. The Plan says procedure code 
75726-59 is not eligible for separate payment as it is considered inclusive to 37236. 
 
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 75726 is a column II code to column I code 37236; however, 75726 
was billed with a modifier.  
 
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 radiological supervision services as billed. Our reviewer 
says that the documentation does not support separate payment for 75726-59. Our reviewer found the medical 
documentation does not support the use of procedure code 75726-59 as the procedure was not distinct and 
separate from the procedure code 37236. The use of the 59 modifier to bypass the NCCI edit is not supported 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 radiological supervision services as billed have not been met. Therefore, we 
decided that the Plan does not have to pay for the radiological supervision services coded 75726-59 provided 
on April 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the extremity study (93970), and pulmonary ventilation 
and perfusion imaging (78582) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the diagnostic services. You say that the enrollee needs these services. The 
Plan denied your request. The Plan says the requested services can be provided in-network. 
 
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 the extremity study (93970), and pulmonary ventilation and perfusion imaging (78582) to be provided by an 
out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service May 16, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service May 16, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an MRI performed on May 22, 2022. 
 
You asked the Plan to waive the copayment for an MRI. You say that you are experiencing financial hardship 
and cannot afford to pay this. The Plan denied your request. The Plan says the cost share has been applied 
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 $225 
copayment for in-network advanced imaging services.  
 
You have been asked to pay $223.41 for an MRI. An MRI falls within the Outpatient Diagnostic Tests and 
Therapeutic Services and Supplies benefit category. Your contract with the Plan clearly says that you must pay 
a $225 copayment for an MRI. However, you have only been asked to pay $223.41, which is less than $225 
copayment amount. 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 Magnetic Resonance Imaging 
(MRI) scan performed on May 22, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve massage therapy. 
 
You asked the Plan to pre-approve massage therapy. You say that you are tired of taking medications that do 
not help me and you want to get off them. You say that this is not an invasive treatment, and you don't 
understand why it's not covered. The Plan denied your request. The Plan says massage therapy is only 
medically reasonable and necessary as adjunctive treatment to another therapeutic procedure on the same day. 
 
The rules say that massage therapy may be medically reasonable and necessary as adjunctive treatment to 
another therapeutic procedure on the same day. The records do not show massage therapy is being requested 
for treatment with another therapy. In addition, the requested provider is not a covered provider to perform 
therapy services. Therefore, we decided that the Plan does not have to pre-approve massage therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for moderate sedation services (99153) provided on December 3, 
2021. 
 
You asked the Plan to pay for moderate sedation services (99153). The Plan denied your request. The Plan says 
CPT code 99153 remains denied.  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 99153 is moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; each additional 15 minutes intraservice time (List 
separately in addition to code for primary service). 
 
We find that CPT code 99153 is not supported in the medical record. Specifically, CPT code 99153 is a TC 
only code and the claim indicates that this service was rendered in a facility setting. Payment for CPT code 
99153 is made to the facility and is the responsibility of the facility to any physician or vendor. Based on this 
information, we decided that Medicare rules for coverage of moderate sedation services (99153) have not been 
met. Therefore, we decided that the Plan does not have to pay for moderate sedation services (99153) provided 
on December 3, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the single-photon emission computed 
tomography (SPECT) myocardial perfusion imaging studies with stress test provided on March 30, 2022. 
 
You asked the Plan to waive the copayment for the SPECT with stress test. You say that you were not 
expecting to pay this amount and cannot afford to pay the bill in full. The Plan denied your request. The Plan 
says the copayment applied was correct. 
 
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 $175 
copayment for each in-network Medicare-covered outpatient diagnostic procedure and test in an outpatient 
facility.  
 
You have been asked to pay a $175 copayment for the SPECT with stress test. A SPECT with stress test falls 
within the Outpatient Diagnostic Tests and Therapeutic Services and 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 copayment for the single-photon emission 
computed tomography (SPECT) myocardial perfusion imaging studies with stress test provided on March 30, 
2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that you need SNF care. The Plan denied your request. 
The Plan says you do not appear to require the daily services required to qualify for a SNF stay. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve one surgical placement of an endosteal implant (D6010) 
and one custom fabricated abutment (D6057). 
 
You asked the Plan to pre-approve a surgical placement of an endosteal implant (D6010) and a custom 
fabricated abutment (D6057). You say that you are appealing with supporting records. The Plan denied your 
request. The Plan says they have denied codes D6010 for one and D6057 for one as plan limits have been met 
for calendar year 2022. 
  
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers up to two 
dental implants and up to two custom fabricated abutments per year. 
 
We looked at the file, the Plans rules, and Medicares rules. The Plan approved coverage for two dental 
implants and two custom fabricated abutments; therefore, the benefit for one dental implant and one custom 
fabricated abutment has been exhausted. Therefore, we decided that the Plan does not have to pre-approve one 
surgical placement of an endosteal implant (D6010) and one custom fabricated abutment (D6057).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transport provided on May 5, 
2022. 
 
You asked the Plan to waive the copayment for ambulance transport. You say that you were mistreated so this 
should be covered. The Plan denied your request. The Plan says the copayment applied is correct. 
 
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 $265 
copayment for each Medicare covered, one-way ground ambulance trip.  
 
You have been asked to pay $265 copayment for ambulance transport. Ambulance transport falls within the 
Ambulance 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 ambulance transport 
provided on May 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit, telehealth services and electrocardiogram 
to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the evaluation and management services. You say that you are currently 
under oncologist care. You say that you would like to continue care with your current oncologist whom you 
trust. You also say that you have been seeing this provider for over 12 years. The Plan denied your request. The 
Plan says the enrollee is not under active treatment. The Plan also says that the services can safely be provided 
in-network. 
 
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 no longer a network provider with the Plan. The Plan has confirmed there are network providers available who can provide the evaluation and management services at issue in this 
appeal. We found no exception that would require the Plan to pre-approve these evaluation and management 
services. Therefore, we decided that the Plan does not have to pre-approve an office visit, telehealth services 
and electrocardiogram to be provided by an out-of-network (OON) provider.