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

 
We decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on January 18, 2022. 
 
You asked the Plan to pay for the panoramic x-ray. You say that you were not notified that this service is 
covered once every three years, and you do not want to pay for this service. You also say that if you had known 
the panoramic x-ray would not be covered, you would not have had it performed. The Plan denied your request. 
The Plan says this benefit has been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, you are limited to 1 complete (full 
mouth) or panoramic series every 3 years.  
The record shows that you received a panoramic x-ray (D0330) on December 17, 2019 and your complete (full 
mouth) or panoramic series benefit has been exhausted. Therefore, we decided that the Plan does not have to 
pay for the panoramic x-ray (D0330) provided on January 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mandibular partial denture (D5212). 
 
You asked the Plan to pre-approve a mandibular partial denture. You say that you would like the approval of 
this service to be reconsidered for coverage. The Plan denied your request. The Plan says partial dentures are 
not a covered benefit with 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. The only type of dentures that are covered under your plan are 
complete dentures. Therefore, we decided that the Plan does not have to pre-approve a mandibular partial 
denture (D5212).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a white glass crown (D2750) provided by a participating 
provider on December 16, 2021. 
 
You asked the Plan to pay for a white glass crown. You say that you feel like these services were medically 
necessary and should be covered. The Plan denied your request. The Plan says D2750 is not a covered dental 
benefit. 
 
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, 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 white 
glass crown (D2750) provided by a participating provider on December 16, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on August 31, 
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 code cannot be verified. 
 
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 11005 is "Debridement of skin, subcutaneous tissue, 
muscle and fascia for necrotizing soft tissue infection; abdominal wall, with or without fascial closure." 
 
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 services at issue in 
this case were not supported by the medical records. Our reviewer found the documentation does not support a 
more extensive procedure performed during the reopening of a recent laparotomy. Therefore, debridement 
would be considered inclusive to the reopening, as it is not a more extensive procedure or a separate distinct 
procedure than CPT 49002.  
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 not been met. Therefore, we decided that the Plan does not 
have to pay for surgical services provided to the enrollee on August 31, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the post and core in addition to crown (D2952) provided on 
December 27, 2021. 
 
You asked the Plan to pay for the post and core. You say that you were not advised that you would be billed a 
separate charge for this service. You also say that you are on a fixed income, and cannot afford to pay the $400. 
The Plan denied your request. The Plan says this service is not a covered expense under your dental plan. The 
Plan also says that prior to this date of service, both you and the provider were advised that your plan is code 
specific. 
 
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, 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 post 
and core in addition to crown (D2952) provided on December 27, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH care is medically necessary. The 
Plan denied your request. The Plan says admission to an LTACH is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was admitted to the acute care hospital with acute respiratory failure and 
pneumonia requiring antibiotics and mechanical ventilation support. A trach and PEG were placed. Recent 
notes describe the enrollee as no longer requiring mechanical ventilation. The enrollee is undergoing additional 
weaning but requires physical therapy, occupational therapy, speech therapy and ongoing tube feeds. The 
enrollee appears to be more stable and improving and should only require short-term additional acute care 
services that can be safely administered at the current facility until more appropriate for a lower level of care. 
The enrollee does not require services at the LTACH that are not already available at the current facility. Transfer to an LTACH is not medically necessary as it would not be clinically advantageous. Transfer may be 
considered when treatment has completed. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cone beam capture (D0367), an extraction (D7140), a 
maxillary partial denture (D5211), and a bone replacement graft (D7953) provided by an out-of-network 
provider on October 26, 2021, and November 2, 2021. 
 
You asked the Plan to pay for a cone beam capture, an extraction, a maxillary partial denture, and a bone 
replacement graft. You say that all of the dental work was medically necessary. The Plan denied your request. 
The Plan says the dental services that were provided 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 Plan's 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 cone 
beam capture (D0367), an extraction (D7140), a maxillary partial denture (D5211), and a bone replacement 
graft (D7953) provided by an out-of-network provider on October 26, 2021, and November 2, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service January 1, 
2022. 
 
You asked the Plan to pay for procedure code 76705. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for 
code 93976. 
 
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 76705 
is a column II code to column I code 93976. 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 76705 billed for date of service January 1, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head or brain 
without contrast (70450-26-XU) provided on November 16, 2021. 
 
You asked the Plan to pay for the CT scan services. You say that the use of the modifier XU should allow 
payment for the claim as billed. The Plan denied your request. The Plan says the documentation does not 
support the use of the XU modifier for payment. 
 
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 70450-26-XU is computed tomography, head or brain; 
without contrast. 
 
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 CT scan services. Our reviewer says that the 
documentation does not support payment for the CPT code as billed.  Our reviewer found the medical documentation indicates that the provider performed a Head CT with and 
without contrast during same session. There is a more appropriate code to report for this procedure performed 
with and without contrast. 
 
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 CT scan services have not been met. Therefore, we decided that the Plan 
does not have to pay for the computed tomography (CT) scan of the head or brain without contrast (70450-26-
XU) provided on November 16, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the adjacent tissue transfer (14001) and the surgical 
preparation or creation of recipient site (15002) provided on September 30, 2021.  You asked the Plan to pay for the adjacent tissue transfer (14001) and the surgical preparation or creation of 
recipient site (15002). You say that the attached medical records outline the care provided. The Plan denied 
your request. The Plan says procedure code 14301 was approved, and CPT code 15002 is not supported in the 
medical records submitted. The Plan also says that CPT code 14001 was not billed with an appropriate 
modifier to bypass the edit. 
 
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 14001 
is a column II code to column I code 14301. 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 for procedure code 
14002.  
 
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 for CPT code 15002. Our reviewer says that the documentation 
submitted was reviewed and does not meet the criteria for coverage. Our reviewer found that the operative 
report does not support surgical preparation or creation of surgical site for a free skin graft. In this case, 
procedure code 15002 cannot be verified. Therefore, we decided that the Plan does not have to pay for the 
adjacent tissue transfer (14001) and the surgical preparation or creation of recipient site (15002) provided on 
September 30, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for cardiac rehabilitation services (93798, 
93797) provided from October 14, 2021, to December 29, 2021. 
 
You asked the Plan to waive the copayment for the cardiac rehabilitation services. You say that the services 
should be covered as you disagree with the charges and were not made aware of them beforehand. The Plan 
denied your request. The Plan says the cost-sharing applied correctly based on the services provided. 
 
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 $50 
copayment for each Cardiac rehabilitation visit.  
 
 You have been asked to pay a $1,535 copayment for 31 cardiac rehabilitation visits. 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 cardiac rehabilitation services (93798, 93797) provided from October 14, 2021, to 
December 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the contact lenses (V2522) provided on December 2, 2021. 
 
You asked the Plan to pay for the contact lenses. You say that you were told you had extra benefits to use for 
eye wear when you called the Plan, and as a result you ordered more boxes of contact lenses thinking they 
would be covered. The Plan denied your request. The Plan says they have paid the full $250 annual allowance 
toward the cost of your eye wear in 2021, and you are responsible for the remaining cost. 
 
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 Plan covers these services up to $250 per year. 
 
We looked at the file and the Plan's rules. The documentation shows that you used $65 of your annual 
allowance on contact lenses purchased on June 1, 2021, and the remaining $185 ($250 - $65 = $185) of your 
benefit allowance was paid toward the contact lenses purchased on December 2, 2021. The provider billed 
$208 for the contact lenses provided on the date in question, and you are responsible for the $23 difference 
between what the provider billed and what the Plan paid. This means you have been asked to pay the correct 
amount based on your contract with the Plan. Therefore, we decided that the Plan does not have to pay an 
additional amount for the contact lenses (V2522) provided on December 2, 2021.  
 
Your complaint about potential misinformation from the Plan is not a valid appeal for medical coverage. This 
part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service January 8, 
2022. 
 
You asked the Plan to pay for procedure code 76705. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for 
code 93976. 
 
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 76705 
is a column II code to column I code 93976. 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 76705 billed for date of service January 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay the in network rate for the oral evaluation (D0150), prophylaxis 
(D1110), and bitewing x-rays (D0274) provided on November 9, 2021. 
 
You asked the Plan to pay the in network rate for the dental services. You say that you were not informed that 
the provider in this case was out of network. You also say that you feel you were given misinformation by the 
dental office. The Plan denied your request. The Plan says the claim processed correctly. 
 
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 comprehensive oral evaluation is 
covered every 3 calendar years, the frequency limit has been exceeded. The record shows that the Plan paid for 
a comprehensive oral evaluation that you received on June 27, 2019. The record shows there is a 50% 
coinsurance for bitewing x-rays and prophylaxis when you receive these services out of network. This is a 
contractual obligation you agreed to when you enrolled in the Plan's dental coverage. Additionally, out of 
network providers may bill you for any amount greater than what the plan pays the provider. Therefore, we 
decided that the Plan does not have to pay the in network rate for the oral evaluation (D0150), prophylaxis 
(D1110), and bitewing x-rays (D0274) provided on November 9, 2021.  
 
Your complaint about being misinformed by the dental office is not a valid appeal for medical coverage. This 
part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the interrogation device evaluation provided on December 
10, 2021, by an OON provider. 
 
You asked the Plan to pay for the interrogation device evaluation. You say that prior authorization was 
obtained from the enrollee's previous plan. The Plan denied your request. The Plan says the services were 
provided out-of-network and were not approved in advance. The enrollee started with this Plan on December 1, 
2021. 
 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 pay for care from out-of-network providers only in cases involving emergencies, 
out-of-area urgent care, and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the interrogation device evaluation provided on 
December 10, 2021, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for deep sedation (D9222 and D9223) provided by a 
participating provider on June 22, 2021. 
 
You asked the Plan to pay for deep sedation and tooth extractions. You say that the quote you were given was 
not the amount you were billed. The Plan denied your request. The Plan says this claim has been processed 
correctly. 
 
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 deep 
sedation (D9222 and D9223) provided by a participating provider on June 22, 2021.  Tooth extractions (D7210 and D7140) were covered with an applied coinsurance amount of 50%.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive periodontal evaluation (D0180), and 
gingival irrigation (D4921) provided by a participating provider on October 28, 2021, and November 15, 2021. 
 
You asked the Plan to pay for a comprehensive periodontal evaluation and gingival irrigation. You say that you 
would like the Plan to pay for this. The Plan denied your request. The Plan says D0180 and D4921 are not 
covered dental benefits. 
 
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, 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 
comprehensive periodontal evaluation (D0180), and gingival irrigation (D4921) provided by a participating 
provider on October 28, 2021, and November 15, 2021.