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

 
We decided that the Plan does not have to pay for the medical services provided on March 31, 2021, billed with 
codes 96365 and 99070. 
 
You asked the Plan to pay for the services as billed. You say that all billed codes are payable due to the nature 
of these services. The Plan denied your request. The Plan says 96365 cannot be paid to the same provider on 
the same date of service as 43762 without an NCCI modifier. Code 99070 is never 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 96365 
is a column II code to column I code 43762. This claim has not been billed with an appropriate modifier to 
bypass the edit.  
 
In addition, code 99070 has a status indicator of "B" on the Physician Fee Schedule. This means that payment 
for this service is always bundled in payment for other services. 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 medical services 
provided on March 31, 2021, billed with codes 96365 and 99070.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prophylaxis (D1110), comprehensive oral evaluation 
(D0150), and complete series of radiographic images (D0210), provided on October 14, 2021, and October 15, 2021. 
 
You asked the Plan to pay for the routine dental services. You say that the services should be covered. The Plan 
denied your request. The Plan says you obtained these services through an out-of-network provider and the 
complete series 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 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 
prophylaxis (D1110), comprehensive oral evaluation (D0150), and complete series of radiographic images 
(D0210), provided on October 14, 2021, and October 15, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care first hour (99291) provided on August 14, 2021, 
to August 18, 2021. 
 
You asked the Plan to pay for critical care first hour. You say that the doctor spent more than 30 minutes with 
this enrollee on each date. The Plan denied your request. The Plan says the record does not document the time 
spent proving critical care on these dates. It cannot be confirmed that Medicare coverage criteria are 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. 
 
In this case, the CPT Code Manual definition of code 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, the time spent proving 
services is not indicated in the medical records.  Based on this information, we decided that Medicare rules for coverage of critical care first hour have not been met. Therefore, we decided that the Plan does not have to pay for critical care first hour (99291) provided on August 14, 2021, to August 18, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care first hour (99291) provided on August 6, 2021. 
 
You asked the Plan to pay for critical care first hour. You say that these services were medically necessary and 
are supported in the medical record. The Plan denied your request. The Plan says that this service is not 
supported in the medical record. 
 
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 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, the provided records do not 
clearly show that critical care was provided to this enrollee for 30-74 minutes on this date. Based on this 
information, we decided that Medicare rules for coverage of critical care first hour have not been met. 
Therefore, we decided that the Plan does not have to pay for critical care first hour (99291) provided on August 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services provided on April 12, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says no separate 
payment is made. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  In this case, the CPT Code Manual definition of code 99100 is Anesthesia for patient of extreme age, younger 
than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure). We find 
that CPT code 99100 is a bundled code. When these services are covered, payment for them is subsumed by the 
payment for the services to which they are incident. Based on this information, we decided that Medicare rules 
for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to 
pay for the anesthesia services provided on April 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the guided tissue regeneration (D4266 x 2), 
biologic materials to aid in soft and osseous tissue regeneration (D4265), bone replacement graft, initial site 
(D4263), bone replacement graft, each additional site (D4264 x 2), and osseous surgery (D4260) provided on 
September 22, 2021. 
 
You asked the Plan to reimburse you for the dental services. You say that your insurance cover periodontal 
services. You say that that is what you received. You say that you should be reimbursed for these services. You also say that the Evidence of Coverage is misleading. The Plan denied your request. The Plan says that the 
services you received are not listed as covered dental 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, the dental services you received are not 
among those covered under this benefit. The Evidence of Coverage lists the specific dental codes and services 
that are covered. The services you received are not listed and therefore are not covered. Therefore, we decided 
that the Plan does not have to reimburse you for the guided tissue regeneration (D4266 x 2), biologic materials 
to aid in soft and osseous tissue regeneration (D4265), bone replacement graft, initial site (D4263), bone 
replacement graft, each additional site (D4264 x 2), and osseous surgery (D4260) provided on September 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bacterial decontamination (D4999), oral cancer screening 
(D0431), drug or medicaments (D9630 x 2), endosteal implant (D6010), cone beam CT (D0367), and guided 
tissue regeneration (D4266 x 2) provided on October 23, 2021. 
 
You asked the Plan to pay for the dental services. You say that the bacterial decontamination and drugs or 
medicaments should be covered as they were performed in conjunction with covered services. You say that at 
least 50% of these services should be paid. You say that your plan has only paid $572.94 so far this year. You 
also say that you need help with this bill. 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 services at issue in this case are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
bacterial decontamination (D4999), oral cancer screening (D0431), drug or medicaments (D9630 x 2), 
endosteal implant (D6010), cone beam CT (D0367), and guided tissue regeneration (D4266 x 2) provided on 
October 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical extraction (D7210), bone replacement graft for 
ridge preservation (D7953), and inhalation of nitrous oxide/analgesia (D9230) provided on June 25, 2020 by a 
Medicare opt out provider. 
 
You asked the Plan to pay for the surgical extraction, bone replacement graft, and inhalation of nitrous 
oxide/analgesia. You say that you contacted the Plan and asked if you were covered for a tooth to be pulled and 
you were told you were covered. You also say that you were never told to check if the dentist opted out of 
Medicare. The Plan denied your request. The Plan says you received these services from a provider who chose 
not to receive Medicare funds. The Plan also says that they contacted the provider's office and were advised 
that the providers have opted out of Medicare and that the practice informed their patients verbally. 
 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 
covered when they are received by a provider who has opted out of Medicare. Therefore, we decided that the 
Plan does not have to pay for the surgical extraction (D7210), bone replacement graft for ridge preservation 
(D7953), and inhalation of nitrous oxide/analgesia (D9230) provided on June 25, 2020 by a Medicare opt out 
provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the anterior resin-based composite (D2331) and 
posterior resin-based composite (D2392) provided on April 20, 2020. 
 
You asked the Plan to pay more for the resin-based composites. You say that you would like to be refunded for 
these services. The Plan denied your request. The Plan says this claim was processed correctly. The Plan also 
says that you did not contact the Plan prior to the date of service to verify benefits and provider eligibility. 
 
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 are responsible for a 50% 
coinsurance for each covered restoration that is received in-network. Therefore, we decided that the Plan does 
not have to pay more for the anterior resin-based composite (D2331) and posterior resin-based composite 
(D2392) provided on April 20, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the column chromatography and mass spectrometry provided 
along with drug testing on March 11, 2021. 
 
You asked the Plan to pay for the column chromatography and mass spectrometry. You say that this should be 
paid as billed. The Plan denied your request. The Plan says these services are not separately payable along with 
drug testing. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
We looked at the file and Medicare rules. The testing described by these codes is considered specimen validity 
testing. Based on this information, we decided that Medicare rules for coverage of the column chromatography 
and mass spectrometry have not been met. Therefore, we decided that the Plan does not have to pay for the 
column chromatography and mass spectrometry provided along with drug testing on March 11, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 4 additional physical therapy (PT) visits. 
You asked the Plan to pre-approve 4 additional PT visits. You say that the requested visits are medically 
necessary. The Plan denied your request. The Plan says the additional PT visits are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 4 additional PT visits. Our reviewer 
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the 
enrollee's condition. Our physician reviewer found the medical records provided there is no documentation that 
the requested therapy is generally accepted as specific and effective therapy for the enrollee's condition. 
Further utilization of the home exercise program appears appropriate at this point. Provided records do not 
document any acute or unstable medical conditions or changes in medication or treatment which would 
necessitate any further skilled therapy visits beyond what have already been approved. No medical notes from 
the enrollee's treating physician are provided documenting an order or need for additional skilled therapy 
services beyond what have already been approved. Therefore, the reviewer found that the requested additional 
visits are not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 4 additional PT visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 4 additional physical therapy (PT) visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral radiographic image (x-ray) (D0220, D0230), 
topical application (D1206), and core buildup (D2950), provided on October 14, 2021, and October 22, 2021. 
 
You asked the Plan to pay for the routine dental services. You say that the services should be covered. The Plan 
denied your request. The Plan says you have exhausted the Plan benefit of one intraoral x-ray per a year and the 
topical application and core buildup 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 the intraoral radiographic image (x-ray) (D0220, D0230), topical application (D1206), and core buildup (D2950), provided on October 14, 2021, and October 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the incomplete endodontic therapy (D3332) provided on 
October 21, 2021. 
 
You asked the Plan to pay for the incomplete endodontic therapy. You say that you do not have a deductible on 
your insurance and feel the charge should be between your insurance and the provider. The Plan denied your 
request. The Plan says this service is not covered. 
 
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 
incomplete endodontic therapy (D3332) provided on October 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bitewing x-rays (D0274) provided on October 18, 2021. 
 
You asked the Plan to pay for the dental service. You say that the dentist needed an x-ray. You say that you do 
not understand why this was denied. The Plan denied your request. The Plan says 1 set of bitewing x-rays are 
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 set of bitewing x-rays is covered 
per plan year, the frequency limit has been exceeded. The record shows that the Plan paid for a set of bitewing 
x-rays that you received on April 30, 2021. Therefore, we decided that the Plan does not have to pay for the 
bitewing x-rays (D0274) provided on October 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown (D6740), pontic (D6245), and preventative 
procedure (D1999), provided on April 6, 2021. 
 
You asked the Plan to pay for the routine dental services. You say that the services should be covered. The Plan 
denied your request. The Plan says you have exceeded the limits set for these benefits and the preventative 
procedure 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 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 crown 
(D6740), pontic (D6245), and preventative procedure (D1999), provided on April 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) provided on September 
28, 2021. 
 
You asked the Plan to pay for the periodic oral evaluation. You say that you feel you should not have to pay for 
this visit. The Plan denied your request. The Plan says you met the benefit total of $240.00 and you are 
responsible for any charges that exceed the $240.00 benefit amount. 
 
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 maximum amount payable for 
preventative services per calendar year is $240. The contract says that after your annual maximum benefit 
maximum has been met, you are responsible for the full charges of any additional dental services. The record 
shows that you met the annual maximum benefit on September 21, 2021 and your annual maximum benefit has 
been exhausted. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation 
(D0120) provided on September 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), gingival irrigation 
(D4921), and complete series of full mouth radiographic images (x-rays) (D0120), provided on September 27, 
2021. 
 
You asked the Plan to pay for the routine dental services. You say that the services should be covered. The Plan 
denied your request. The Plan says you have exhausted the Plan's benefits 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. 
 
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 oral evaluation (D0150), gingival irrigation (D4921), and complete series of full mouth radiographic images (x-rays) (D0120), provided on September 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral image (D0210), and a comprehensive oral 
evaluation (D0150) provided by a contracted provider on December 8, 2021. 
 
You asked the Plan to pay for an intraoral image and a comprehensive oral evaluation. You say that you 
thought these services were covered. The Plan denied your request. The Plan says D0210 is not a covered 
benefit. The Plan says that D0150 is provided once every three years. 
 
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 one 
comprehensive oral evaluation every three years. The Plan does not cover an intraoral image. 
 
We looked at the file and Medicare rules. Evidence was provided to show that D0150 was provided on July 8, 
2020. Based on this information, we decided that the Plan's rules for a comprehensive oral evaluation have already been met. D0210 is not a covered benefit. Therefore, we decided that the Plan does not have to pay for an intraoral image (D0210), and a comprehensive oral evaluation (D0150) provided by a participating provider on December 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve tooth extractions (D7210) provided by an oral surgeon. 
 
You asked the Plan to pre-approve tooth extractions. You say that you are diabetic, and you have really bad 
teeth. You say that you would like the Plan to approve and pay for these services. The Plan denied your 
request. The Plan says services must be provided by a general dentist. 
 
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 tooth 
extractions when the services are provided by a general dentist.  
 
We look at the file and Medicare rules. Services provided by oral surgeons are not covered benefits. Based on 
this information, we decided that the Plan's rules for coverage of tooth extractions have not been met. 
Therefore, we decided that the Plan does not have to pre-approve tooth extractions (D7210) provided by an oral 
surgeon.