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 16, 2021. 
 
You asked the Plan to pay for procedure code 93042. You did not provide a specific argument with your appeal 
request. The Plan denied your request. The Plan says payment for code 93042 is bundled into payment for 
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 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fixed partial denture sectioning (code D9120) you 
received on December 29, 2021. 
 
You asked the Plan to pay for the fixed partial denture sectioning. You say that the bridge was affixed to your 
wisdom tooth, so it needed to be removed.  You believe this should be covered. The Plan denied your request. 
The Plan says this is not a covered service under your dental plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. Your dental benefit includes 
coverage only for the following services: oral exams, cleanings, x-rays, fillings, crowns, extractions, bridges, 
implants, and dentures.  It does not list fixed partial denture sectioning as a covered service, so this service 
would not be covered for any reason.  
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 fixed 
partial denture sectioning (code D9120) you received on December 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for partial dentures you received on January 18, 2022. 
 
You asked the Plan to pay for the partial dentures. You say that you thought these dentures would be covered.  
You said that you cannot afford these dentures. The Plan denied your request. The Plan says you were not 
eligible for coverage of partial dentures on the date of service in question. 
 
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's rules state that 
partial dentures are covered once every 5 calendar years.  Records show that the Plan already paid for partial 
dentures for you on December 26, 2018, which is less than 5 years prior to the date of service in question in 
this appeal. 
 
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 partial 
dentures you received on January 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (code D0140) you received on 
January 17, 2022. 
 
You asked the Plan to pay for the limited oral evaluation. You say that the dentist did not tell you this service 
would not be covered. The Plan denied your request. The Plan says this is not a covered service under 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. According to your contract, 
the only types of dental exams that are covered are routine oral exams and comprehensive oral exams.  Limited 
oral exams are not listed as a covered benefit. 
 
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 
limited oral evaluation (code D0140) you received on January 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Mass spectrometry and tandem mass spectrometry 
(83789) provided on March 31, 2021. 
 
You asked the Plan to pay for code 83789. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We looked at the file and the rules. We find that code 83789 was billed for specimen validity testing. Validity testing on urine specimens used for drug testing shall not be separately billed. Therefore, we decided that the 
Plan does not have to pay for the Mass spectrometry and tandem mass spectrometry (83789) provided on 
March 31, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental crown (code D2740) you received on December 
16, 2021. 
 
You asked the Plan to pay for the dental crown. You say that you had a broken tooth and called the dentist.  
You said that this was an emergency and it should be covered. The Plan denied your request. The Plan says this 
is not a covered service under your dental plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. Your dental benefit only 
covers the following dental services: oral exams, x-rays, cleanings, fillings, periodontal cleaning, scaling and 
root planing, full mouth debridement, surgical extractions, and minor treatment for pain relief. 
 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 dental 
crown (code D2740) you received on December 16, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital services provided to the enrollee on December 22, 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 provider is not participating with Medicare and is out-of-network with the plan. 
 
The Plan must follow Medicare rules. Medicare rules say that services must be provided by providers who are 
enrolled in the Medicare program. 
 
The rendering provider is not eligible to bill Medicare. The Plan did not pre-approve the services. We found no 
exception that would require the Plan to pay for these items/services. 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 hospital services provided to the enrollee on December 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gauze supplies (A6223) provided on December 9, 2021. 
 
You asked the Plan to pay for gauze. You say that you have provided records to support the services at issue. 
The Plan denied your request. The Plan says rules for payment have not been met.  
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 A6223 has a status indicator of P on the Physician Fee Schedule. This means that CPT 
code A6223 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of gauze have not been met. Therefore, we decided that the Plan does not have to pay for gauze supplies 
(A6223) provided on December 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (code D0180) you 
received on December 7, 2021. 
 
You asked the Plan to pay for the comprehensive periodontal evaluation. You say that you cannot believe that 
this service is not covered.  You said that you expect your dental benefit to cover this service. The Plan denied 
your request. The Plan says this service is not covered under 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 Plan's coverage rules apply in this case. The Plan's rules state you have 
coverage only for those dental services explicitly listed in your covered dental benefits chart. Comprehensive 
periodontal exams (code D0180) are not listed as a covered service. 
 
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 
comprehensive periodontal evaluation (code D0180) you received on December 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the denture you received on October 13, 2021. 
 
You asked the Plan to pay more for the denture. You say that you believe this denture should be paid in full 
because you selected a more expensive dental plan. You said that you were told that dentures were fully 
covered. The Plan denied your request. The Plan says your dental claim was paid appropriately. 
 
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. The Plan's dental benefit 
clearly states that you pay 70% of the cost of dentures.  This means that the Plan covers 30% of the cost of 
dentures.  Your dentist charged $700 for the denture you received, so the Plan's 30% coverage of this denture 
was $210.  This is the exact amount that the Plan reimbursed you.  Your contract does not say that dentures are 
covered in full.  Therefore, we decided that the Plan does not have to pay more for the denture you received on 
October 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 2D oral/facial photographic images (D0350) provided by a 
participating provider on January 24, 2022. 
 
You asked the Plan to pay for 2D oral/facial photographic images. You say that these images should be covered 
because they were preventative. The Plan denied your request. The Plan says this claim has been correctly 
processed and denied. 
 
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 2D 
oral/facial photographic images (D0350) provided by a participating provider on January 24, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for initial hospital care (99223) partial removal of foot or heal bone 
(28120) provided October 27, 2020 to October 28, 2020. 
 
You asked the Plan to pay for the hospital services. You say that the claim was originally submitted 12/03/2020 
and then resubmitted 01/21/2022. Records were submitted and monies were recouped for lack of records. The 
claim then partially paid. You are submitted records to support the charges. The Plan denied your request. The 
Plan says that the billed CPT codes 28120, 99223 and 15275 was denied as a duplicate claim line because it has 
been previously processed under another claim dated 10/12/2021. 
 
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 records do show that CPT codes 99223 and 28120 was processed as the plan 
indicted in the summary. The provided records show that it was CPT codes 15275, 11043 and 15276 that were 
processed on claim the Plan indicated for check dated 10/12/21. CPT code 11043 was processed on check 
dated 1/21/22 and processed again on check dated 3/15/2022. The records do not support that CPT codes 99223 
and 28120 are duplicates and have been previously paid. Therefore, we decided that the Plan has to pay for 
initial hospital care (99223) partial removal of foot or heal bone (28120) provided October 27, 2020 to October 
28, 2020.  
 
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 guided tissue regeneration (D4266), bone replacement 
grafts (D7953) and gingival irrigation (D4921). 
 
You asked the Plan to pre-approve dental services. You say that these services are necessary. The Plan denied 
your request. The Plan says these services are not covered by your dental 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 pre-approve 
guided tissue regeneration (D4266), bone replacement grafts (D7953) and gingival irrigation (D4921).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a consultation and 2 extractions to be provided by an 
oral surgeon. 
 
You asked the Plan to pre-approve the dental services. You say that the services are medically necessary. You 
say that a general dentist is unable to help due to the medications you are on. You also say that you cannot 
chew properly with 2 broken front teeth. The Plan denied your request. The Plan says services must be 
performed by a participating general dentist. The contract also says service performed by an oral surgeon 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, the request for dental services to be 
performed by an oral surgeon are not among those covered under this benefit. Therefore, we decided that the 
Plan does not have to pre-approve a consultation and 2 extractions to be provided by an oral surgeon.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary implant/abutment supported removable 
denture for edentulous arch (D6110). 
 
You asked the Plan to pre-approve a maxillary implant/abutment supported removable denture. The Plan 
denied your request. The Plan says this service is not covered under your benefit package. 
 
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 a 
maxillary implant/abutment supported removable denture for edentulous arch (D6110).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 5 additional home health physical therapy visits. 
 You asked the Plan to pre-approve 5 additional home health physical therapy visits. You say that additional 
home health physical therapy services are medically necessary. The Plan denied your request. The Plan says 
the criteria for this home health care have not been met. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 5 additional home health physical 
therapy visits. Our reviewer says that the requested additional home health services are not medically 
reasonable and necessary. Our physician reviewer found that the documentation does not support that you 
require additional skilled rehab services to provide treatment that is medically necessary. In addition, you do 
not require additional skilled rehab services to effectively provide treatment, care, and/or services in order to 
improve your condition, perform a maintenance program to maintain your condition and/or prevent 
deterioration. You have been medically stable without any recent exacerbations of chronic medical problems or 
hospitalizations. The requested home health services are not medically necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 5 additional home health physical therapy visits have not been met. Therefore, 
we decided that the Plan does not have to pre-approve 5 additional home health physical therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Wheelchair accessory, power seat elevation system, any 
type (E2300). 
 
You asked the Plan to pre-approve the power seat elevation system. You say that the elevated seat will allow 
independence in your home and will allow you to do more things. The Plan denied your request. The Plan says 
this item is not primarily medical in nature and is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the power seat elevation system have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Wheelchair accessory, power seat elevation system, any type (E2300).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental extractions (D7140) provided on January 4, 2022. 
 
You asked the Plan to pay for extractions. You say that you are upset that your insurance covers so little. The 
Plan denied your request. The Plan says extractions are 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 the dental 
extractions (D7140) provided on January 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the 2 crowns (D2740) provided on June 23, 2021. 
 
You asked the Plan to pay for the dental services. You say that you received a predetermination letter that 
approved coverage for these services. You also say that the services should be covered. 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the crowns are not among those 
covered under this benefit. Additionally, The record shows that the predetermination approval was for 
December 3, 2020, to March 31, 2021. The date of service in this case is outside of the approved date.  
 Therefore, we decided that the Plan does not have to pay for the 2 crowns (D2740) provided on June 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an occlusal guard (D9945). 
 
You asked the Plan to pre-approve a dental guard. You say that you need this mouth guard to prevent grinding 
your teeth at night. The Plan denied your request. The Plan says this item is not covered by your 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 pre-approve an 
occlusal guard (D9945).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377), expandable controller 
harness (E2313) and electronic connection (E2311). 
 
You asked the Plan to pre-approve these services. You say that these items are medically necessary. The Plan 
denied your request. The Plan says that you are able to control the power options using their own switches. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. The requested 
accessories are not medically necessary as you have use of your hands and can operate and control the power 
options using the switches that are included in the basic wheelchair. Our physician reviewer found that your 
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 an expandable controller (E2377), expandable controller harness (E2313) and electronic 
connection (E2311).