Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasonic guidance for needle placement rendered on 
August 3, 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 76942 is not separately payable. 
 
The rules say that if the modifier indicator is 0, the Column 2 code cannot be paid regardless of whether a 
modifier is used.  
We looked at the file and Medicare rules. The provider submitted a claim for procedure codes 76942 
(ultrasonic guidance for needle placement) and 36475 (endovenous ablation). Code 76942 is a column II code 
with a modifier indicator of 0 when billed with column I code 36475. No separate payment is made for code 
76942. Therefore, we decided that the Plan does not have to pay for the ultrasonic guidance for needle 
placement rendered on August 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established 
patient (D0150) provided November 10, 2021. 
 
You asked the Plan to pay for the comprehensive oral exam. You say that this was your first cleaning in 2 
years. The Plan denied your request. The Plan says you have exceeded the frequency limit for these 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. The Plan covers the 
comprehensive oral exam once every 36 months.  
 
We looked at the file and Medicare rules. The Plan provided documentation showing that a comprehensive 
exam was previously covered on January 16, 2020. Based on this information, we decided that the Plan's 
frequency limit for coverage of the comprehensive oral exam has been exceeded. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established patient (D0150) provided November 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unspecified preventative procedure (D1999), extraction 
(D7140), limited exam (D0140) an unspecified adjunctive procedure (D9999) provided on February 10, 2021. 
 
You asked the Plan to pay for the dental services. You say that your dentist referred you for these services due 
to a dental emergency. The Plan denied your request. The Plan says the provider in this case has chosen to opt-
out of Original Medicare. Dental services performed by providers who have chosen to opt-out of Medicare are 
not covered by your benefit under any condition. 
 
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 covers the dental 
services when they are performed by a licensed dental provider who has not opted out of Original Medicare.  
We looked at the file and the Plan's rules. The provider in this case has chosen to opt-out of Original Medicare. 
Based on this information, we decided that the Plan's rules for coverage of the dental services have not been 
met. Therefore, we decided that the Plan does not have to pay for the unspecified preventative procedure 
(D1999), extraction (D7140), limited exam (D0140) an unspecified adjunctive procedure (D9999) provided on 
February 10, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for a replacement crown (D2740) provided by a participating provider on 
December 14, 2021. 
 
You asked the Plan to pay for a replacement crown. You say that this replacement crown was medically 
necessary. The Plan denied your request. The Plan says that there is no radiographic evidence or an explanatory 
provider narrative describing the presence of marginal decay or other significant clinical breakdown that would 
support the need for crown replacement. 
 
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 a replacement 
crown when the services are medically necessary and reasonable. 
 
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 pay for a replacement crown. Our reviewer says that 
a replacement crown is being requested. Our physician reviewer found enough evidence was provided to show 
that a replacement crown is medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of a replacement crown have been met. Therefore, we decided that the Plan has to 
pay for a replacement crown (D2740) provided by a participating provider on December 14, 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: Unfavorable

 
We decided that the Plan does not have to pay for the crown (D2751) provided on November 4, 2021. 
 
You asked the Plan to pay for the dental service. You say that you found the name of this provider in the plan's 
provider directory. You say that you were advised the crown would be covered. You also say that you were not 
aware that the provider was out of network. The Plan denied your request. The Plan says crown is not listed as 
a covered service. 
 
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 crown is not among those covered 
under this benefit. Therefore, we decided that the Plan does not have to pay for the crown (D2751) provided on 
November 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental implants (D6010) and unspecified preventative 
procedure (D1999) provided on November 5, 2021. 
 
You asked the Plan to pay for the dental services. You say that these services were necessary and should be 
covered. The Plan denied your request. The Plan says the implants are covered; however, the Plan will pay a 
maximum of $800 per implant. This amount has been reimbursed to you for each of the two implants; however, 
you are responsible for the remaining cost. 
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 covers dental 
implants when they are medically necessary. The fee to be paid for the service provided will be the rate 
established by the Plan for that procedure and not necessarily the rate submitted by the provider for that 
rendered service. The Plan's rate for each surgical placement of implant body: endosteal implant (D6010) is 
$800. 
 
We looked at the file and the Plan's rules. The unspecified preventative procedure is not among those services 
listed as covered by this benefit. The Plan has agreed to cover both dental implants and has provided 
reimbursement of $800 for each implant. However, the record shows that you paid $1,300 for each implant. 
The Plan has paid their full allowed rate for each of these services, and you are responsible for the amount that 
exceeds this rate. Therefore, we decided that the Plan does not have to pay an additional amount for the dental 
implants (D6010) and unspecified preventative procedure (D1999) provided on November 5, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from April 1, 
2021, to April 6, 2021, and April 9, 2021. 
 
You asked the Plan to pay for SNF care provided from April 1, 2021, to April 6, 2021, and April 9, 2021. You 
say that the services are coverable under the Medicare Act. The Plan denied your request. The Plan says the 
enrollee did not require skilled services on the dates of service in this case. 
 
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 pay for SNF care provided from April 1, 2021, to 
April 6, 2021, and April 9, 2021. Our reviewer says that daily skilled services are not necessary. Our physician 
reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, 
knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs 
that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did 
not require daily skilled nursing and/or skilled therapy on an inpatient basis in a 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 provided from April 1, 2021, to April 6, 2021, and April 9, 2021 have 
not been met. Specifically, the file shows that the enrollee did not receive skilled services on the dates of 
service in this case. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility 
(SNF) care provided from April 1, 2021, to April 6, 2021, and April 9, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the arthrodesis, open, SI joint, including obtaining bone 
graft, including instrumentation, when performed (CPT code 27280). 
 
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says the clinical value and effectiveness of an open SI joint fusion procedure in absence of 
sacroiliac joint instability, fracture, or tumor have not been demonstrated in the peer-reviewed literature. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found Si joint fusion for degenerative back pain without instability, fracture or lesion is experimental. 
More research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the arthrodesis, open, SI joint, including obtaining bone graft, including instrumentation, 
when performed (CPT code 27280).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Optimizer Smart implantable pulse generator. 
 
You asked the Plan to pre-approve an Optimizer Smart implantable pulse generator. You say that the services 
are necessary. The Plan denied your request. The Plan says medical necessity has not been established. 
Therefore, coverage criteria have not been met. 
 
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 an Optimizer Smart implantable pulse 
generator. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found while the clinical studies led to FDA approval in 2019, 
Optimizer Smart device (CCM) remains the subject of multiple studies examining long-term efficacy, as well 
as randomized, controlled, double-blinded trials to quantify clinical efficacy. Until such statistically rigorous 
studies are completed, it is premature to presume clinical outcomes and benefit. At the current time, a CCM 
system is not considered to be medically necessary in this enrollee. 
 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Optimizer Smart implantable pulse generator have not been met. Therefore, 
we decided that the Plan does not have to pre-approve an Optimizer Smart implantable pulse generator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the adjunctive pre-diagnostic test that aids in detection of 
mucosal abnormalities including premalignant and malignant lesions, not to include cytology or biopsy 
procedures (D0431), re-cement or re-bond crown (D2920), gingival irrigation  per quadrant (D4921), drugs or 
medicaments dispensed in the office for home use (D9630) provided November 15, 2021. 
 
You asked the Plan to pay for the adjunctive pre-diagnostic test, re-cement or re-bond crown, gingival 
irrigation and drugs dispensed in the office for home use. You say that you were not advised that these services 
are not covered. The Plan denied your request. The Plan says these services are not covered under your 
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 
adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities including premalignant and 
malignant lesions, not to include cytology or biopsy procedures (D0431), re-cement or re-bond crown (D2920), 
gingival irrigation  per quadrant (D4921), drugs or medicaments dispensed in the office for home use (D9630) 
provided November 15, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing provided on September 20, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the genetic testing. You say that the service was medically necessary. You say 
you do not have direct access or interaction with the enrollee prior to performing the service. The Plan denied 
your request. The Plan says no prior authorization was obtained. 
 
 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 did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The 
records provided for review do not show that the service at issue was urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for genetic testing provided on September 20, 2021, by an out-of-
network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bone replacement graft for ridge preservation (D7953) 
provided by a participating provider on October 18, 2021. 
 
You asked the Plan to pay for a bone replacement graft for ridge preservation. You say that this provider was 
in-network. You say that you would like the Plan to pay for this. The Plan denied your request. The Plan says 
D7953 is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a bone 
replacement graft for ridge preservation (D7953) provided by a participating provider on October 18, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a collection of a blood specimen using established central or 
peripheral catheter (36592) provided on October 13, 2021. 
 
You asked the Plan to pay for a collection of a blood specimen. You say that the service at issue was a medical 
necessity for the enrollee. 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. 
Per the Outpatient Prospective Payment System (OPPS), CPT code 36592 has a status indicator of Q1. This 
means that CPT code 36592 is not separately payable if billed on the same claim as a HCPCS code assigned 
status indicator "S", "T", or "V." CPT code 36430 is also on the claim and has a status indicator of "S." CPT 
code 36592 is not separately payable when billed with a code that has an "S" indicator. Based on this 
information, we decided that Medicare rules for coverage of a collection of blood specimen have not been met. 
Therefore, we decided that the Plan does not have to pay for a collection of a blood specimen using established 
central or peripheral catheter (36592) provided on October 13, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound on November 5, 2021. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that the ultrasound is part of the 
wellness exam and needs to be paid by the plan. The Plan denied your request. The Plan says the copayment of 
$79.94 you are being charged is correct since the amount due is under the normal $150 copayment. 
 
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 $150 
copayment for an ultrasound.  
 
You have been asked to pay a $150 copayment for an ultrasound. An ultrasound 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 an ultrasound on November 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychiatric office visits provided on January 19, 2021, to 
August 18, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the psychiatric office visit. You say that the Plan has approved your services 
from this provider in the past and you feel another exception should be granted. The Plan denied your request. 
The Plan says no prior authorization was obtained. 
 
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 did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The 
records provided for review do not show that the services at issue were urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for psychiatric office visits provided on January 19, 2021, to August 
18, 2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for fluoroscopic guidance for needle placement (eg, biopsy, 
aspiration, injection, localization device) (List separately in addition to code for primary procedure) (CPT code 
77002-59-TC) provided on December 7, 2020. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the service is 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 CPT code. 
 
Code 77002 (Fluoroscopic guidance for needle placement (eg, biopsy, aspiration, injection, localization device) 
(List separately in addition to code for primary procedure) has a mutually exclusive relationship with code 
64624 (Destruction by neurolytic agent, genicular nerve branches including imaging guidance, when 
performed). Mutually exclusive edits consist of combinations of procedures that differ in technique or 
approach but lead to the same outcome. In some instances, the combination of procedures may be anatomically 
impossible. Procedures that represent overlapping services are considered mutually exclusive. In addition, 
reporting an initial service and subsequent service is considered mutually exclusive. The Centers for Medicare 
& Medicaid Services (CMS) has the Column 1/Column 2 correct coding edit table. The Column 1 code list 
more comprehensive codes and the Column 2 list component codes. These codes should not be billed together 
on the same date of service. Our records show you have billed 64624-RT for this date of service. The records 
provided do not support an exception. Therefore, separate charges for code(s) 77002-59-TC are not eligible for 
payment. Based on this information, we decided that Medicare rules for coverage of the service have not been 
met. Therefore, we decided that the Plan does not have to pay for fluoroscopic guidance for needle placement 
(eg, biopsy, aspiration, injection, localization device) (List separately in addition to code for primary 
procedure) (CPT code 77002-59-TC) provided on December 7, 2020.