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

 
We decided that the Plan does not have to pay for an epidural injection provided on November 15, 2021. 
 
You asked the Plan to pay for an epidural injection. The Plan denied your request. The Plan says the Health 
Plan has not received the required clinical records to support the medical necessity of the service for the date of 
service requested. The records provided are undated and unsigned. There is insufficient documentation of 
response to prior injections. 
 
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 an epidural injection provided on 
November 15, 2021 have been met. The Health Plan has not received the required clinical records to support 
the medical necessity of the service. Therefore, we decided that the Plan does not have to pay for an epidural 
injection provided on November 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the filling (D2332) provided on September 13, 2021, by the 
out of network provider. 
 
You asked the Plan to pay for the dental service. The Plan denied your request. The Plan says services rendered 
by out of network providers are not covered. 
 
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, you pay 100% for dental services 
received out of network. Therefore, we decided that the Plan does not have to pay for the filling (D2332) 
provided on September 13, 2021, by the out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete 
series of intraoral x-rays (D0210) provided on November 4, 2021. 
 
You asked the Plan to pay for the comprehensive oral evaluation and complete series of intraoral x-rays. You 
say that prior to receiving these services you were not advised that you could only receive these services so 
many times. You also say that it is not your mistake and you feel you should not be held responsible. The Plan 
denied your request. The Plan says these services do not meet the frequency requirements of the Plan. 
 
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, comprehensive oral evaluation 
(D0150) and complete series of intraoral x-rays (D0210) are each limited to one procedure every three plan 
years. The record shows that you received a comprehensive oral evaluation (D0150) and complete series of 
intraoral x-rays (D0210) on August 4, 2020 and your comprehensive oral evaluation (D0150) and complete 
series of intraoral x-rays (D0210) benefits have been exhausted. Therefore, we decided that the Plan does not 
have to pay for the comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210) 
provided on November 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation services rendered on August 23, 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 99152 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 99152 is moderate sedation services by other qualified 
health care professional requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status, patient 5 years of age or older, first 15 minutes.  
We find that CPT code 99152 is not supported in the medical record. Specifically, there is no documentation of 
the first 15 minutes of an independent trained observer to assist in monitoring the patient's level of 
consciousness and physiological status. 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 moderate 
sedation services rendered on August 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete series of intraoral x-rays (D0210), two 
dimensional (2D) oral/facial photographic image (D0350), periodontal scalings and root planings (D4342), and 
periodontal procedure (D4999), or pay more for the comprehensive oral evaluation (D0150) provided on 
February 15, 2022, and February 28, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the complete series of intraoral x-rays, 2D oral/facial photographic image, 
scalings and planings, and periodontal procedure, and to pay more for the comprehensive oral evaluation. You 
say that you would like the Plan's decision to be reconsidered, and the provider to be reimbursed for the billed 
charges. The Plan denied your request. The Plan says the complete series of intraoral x-rays, 2D oral/facial 
photographic image, scalings and planings, and periodontal procedure are not covered expenses under your 
dental plan. The Plan also says that these services were performed by a non-participating provider, and you are 
responsible for any difference between the Maximum Allowable Fee and the amount the provider bills you for 
the services. 
 
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, complete series of intraoral x-rays 
(D0210), 2D oral/facial photographic image (D0350), periodontal scaling and root planing (D4342), and 
unspecified periodontal procedure (D4999) are not among those covered under this benefit. The contract says 
that you are responsible for a 50% coinsurance for the comprehensive oral evaluation (D0150), plus the 
difference between the billed amount and allowed amount because this service was rendered by an OON 
provider. Therefore, we decided that the Plan does not have to pay for the complete series of intraoral x-rays 
(D0210), two dimensional (2D) oral/facial photographic image (D0350), periodontal scalings and root planings 
(D4342), and periodontal procedure (D4999), or pay more for the comprehensive oral evaluation (D0150) 
provided on February 15, 2022, and February 28, 2022 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve retainer crowns - porcelain/ceramic (D6740) and pontic 
- porcelain/ceramic (D6245). 
 
You asked the Plan to pre-approve retainer crowns and pontic. You say that the enrollee requires a replacement 
bridge. The Plan denied your request. The Plan says these services are not covered under the enrollee's 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 
retainer crowns - porcelain/ceramic (D6740) and pontic - porcelain/ceramic (D6245).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on December 
14, 2021. 
 
You asked the Plan to pay for 2021. You say that the service should be covered. The Plan denied your request. 
The Plan says 1 limited oral evaluation is covered per plan year. The Plan also says that the frequency limit has 
been exceeded. 
 
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 and 1 limited oral evaluation is covered 
per plan year, the frequency limit has been exceeded. The record shows that the Plan paid for a limited oral 
evaluation that you received on December 10, 2021. Therefore, we decided that the Plan does not have to pay 
for the limited oral evaluation (D0140) provided on December 14, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the general health panel (GHP) provided on May 27, 2021, 
billed with code 80050. 
 
You asked the Plan to pay for the GHP testing. You say that you have this same testing regularly, and it has 
always been covered in full. You feel that it is not correct that you are being charged for this now. The Plan 
denied your request. The Plan says all other testing was covered, but code 80050 is noncovered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that code 80050 (general health panel) is considered a non-
covered code. 
 
Of note, the coding manual definition of code 80050 is General health panel. This panel must include the 
following: Comprehensive metabolic panel (80053) Blood count, complete (CBC), automated and automated 
differential WBC count (85025 or 85027 and 85004) OR Blood count, complete (CBC), automated (85027) 
and appropriate manual differential WBC count (85007 or 85009) Thyroid stimulating hormone (TSH) (84443). 
 
You have requested payment for services billed under code 80050. Medicare does not cover or pay for services 
billed under this code. Therefore, we decided that the Plan does not have to pay for the general health panel 
(GHP) provided on May 27, 2021, billed with code 80050.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient hospital services provided from November 29, 2021, to 
November 30, 2021. 
 
You asked the Plan to pay for the inpatient hospital services. You say that you believe that this admission was 
medically necessary. The Plan denied your request. The Plan says that the enrollee had active coverage that 
ended on November 30, 2021 and there is no active plan for this enrollee effective from December 1, 2021 
onward. The Plan also says that the services were denied at the time authorization/pre-certification was 
requested. 
 
The Plan must follow Medicare rules. The rules say that an emergency exists based on a prudent layperson 
standard, not a retrospective medical review. For symptoms to be considered emergent in nature, they must be 
such that a prudent layperson with an average knowledge of medicine would reasonably expect the absence of 
immediate medical attention would result in serious jeopardy to their health.  
 
We decided that this case does meet prudent layperson criteria for emergency care. A prudent layperson with 
an average knowledge of medicine would reasonably expect the absence of immediate medical care to 
seriously jeopardize their health in this case. Therefore, we decided that the Plan has to pay for the inpatient 
hospital services provided from November 29, 2021, to November 30, 2021.  
 
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: Favorable

 
We decided that the Plan has to pay for the computerized ophthalmic diagnostic imaging (92134) provided on 
November 16, 2021. 
 
You asked the Plan to pay for diagnostic imaging. You say that you should have a $0 copayment for this 
service. Retinal imaging is covered with your insurance, and you have this test done often. The Plan denied 
your request. The Plan says that only one glaucoma screening is covered with a $0 copayment per year. You 
had a previous glaucoma screening on January 19, 2021, which was covered by the Plan. Therefore, this 
service is denied. 
 
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 denied payment of this service on the basis that you had a previous 
glaucoma screening earlier in the year, and therefore this service is not covered. However, code 92134 is not 
the billing code for a glaucoma screening, which is best reported with either G0117 or G0118. In addition, this 
claim was billed with medical diagnoses rather than a screening diagnosis. All documentation indicates that 
this was a diagnostic procedure provided in conjunction with a covered medical eye exam. The Plans denial is 
not substantiated in this case. Therefore, we decided that the Plan has to pay for the computerized ophthalmic 
diagnostic imaging (92134) provided on November 16, 2021.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aranesp. 
 
You asked the Plan to pre-approve Aranesp. You say that the requested Aranesp is medically necessary. The 
Plan denied your request. The Plan says the enrollee does not meet criteria for the requested Aranesp. 
 
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 Aranesp. Our reviewer says that the 
enrollee does not meet criteria for the requested Aranesp. Our physician reviewer found the record indicates 
that the enrollee has anemia of chronic inflammation/chronic disease secondary to chronic liver disease and 
Hereditary hemolytic anemia.  This is not an indication for which coverage is available, by rule. The elements 
of the coverage criteria are not satisfied.  The requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Aranesp have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Aranesp.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the TERT testing rendered on June 30, 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 81345 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, we have confirmed that code 81345 
is a column II code to column I code 0089U. 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 the TERT testing rendered on June 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the charge for services provided between 10:00 PM and 8:00 
AM at 24-hour facility on September 9, 2021, billed with code 99053. 
You asked the Plan to pay for the overnight service charge. You say that the claim should be paid as billed. The 
Plan denied your request. The Plan says payment was approved for the emergency room evaluation, but no 
payment can be made for code 99053. 
 
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 find that CPT code 99053 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99053 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of the overnight service charge have not been met. Therefore, we decided that the Plan does not have to pay for 
the charge for services provided between 10:00 PM and 8:00 AM at 24-hour facility on September 9, 2021, 
billed with code 99053.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Bioimpedance Spectroscopy (93702 x 4). 
 
You asked the Plan to pre-approve the Bioimpedance Spectroscopy. You say that the service is medically 
necessary. The Plan denied your request. The Plan says the service is experimental. 
 
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 Bioimpedance Spectroscopy. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found there is insufficient literature to establish the requested test as safe and effective, 
as defined by Medicare rules, for the enrollee's specific clinical condition 
 
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 Bioimpedance Spectroscopy have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the Bioimpedance Spectroscopy (93702 x 4).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for fundus photography with interpretation and report (92250) 
provided on January 7, 2022. 
 
You asked the Plan to pay for fundus photography. You say that this service was necessary. The Plan denied 
your request. The Plan says retinal imaging is not covered by your supplemental vision benefit. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case.  
 
The documentation indicates that this service was provided with a routine eye exam (S0621) and eye refraction 
(92015). These services were both covered by the Plan. All three services were billed with an H52 diagnosis 
code, which is a category of disorders of refraction and accommodation. H52 diagnoses are used to indicate 
routine (i.e., non-medical) services. That means that these services are considered routine in nature, and 
therefore are covered by the Plans supplemental benefit rather than Original Medicare. Though the Plan offers 
a supplemental benefit in excess of Medicare coverage, the requested fundus photography is not among the 
items/services covered under this benefit. Therefore, we decided that the Plan does not have to pay for fundus 
photography with interpretation and report (92250) provided on January 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pain management services provided to the enrollee on 
November 15, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the plan has not received the required clinical records to support the medical necessity of the 
services for the date of service requested. 
 
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 pain management services provided to the enrollee on November 15, 2021 have been met. The records sent in by the provider are incomplete, as they 
are unsigned and undated. The services cannot be verified in this case. Therefore, we decided that the Plan does 
not have to pay for pain management services provided to the enrollee on November 15, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical flap creation provided on October 1, 2021, billed 
with 15734 and 15734-59. 
 
You asked the Plan to pay for the surgical services as billed. You say that this was billed correctly and should 
be paid. The Plan denied your request. The Plan says the code 15734 is not supported as being performed. 
 
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 15734 is Muscle, myocutaneous, or fasciocutaneous flap; 
trunk. 
 
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 surgical services as billed. Our reviewer says that the 
reporting of these codes is not supported by the records. Our reviewer found the operative report does not 
describe a flap from the donor site rotated to the site needing repair. As such, this procedure 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 surgical services as billed have not been met. Therefore, we decided that the 
Plan does not have to pay for the surgical flap creation provided on October 1, 2021, billed with 15734 and 
15734-59.