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

 We decided that the Plan does not have to pay for procedure code 99153 billed for date of service May 17, 
2022. 
 
You asked the Plan to pay for the services provided. You say that the enrollee had multiple claims on this date 
of service. The Plan denied your request. The Plan says payment is the responsibility of the facility. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that CPT code 99153 is a technical component only code. Payment for this service would have been 
included under the facility claim. Payment to you for this service is the responsibility of the facility. Based on 
this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 99153 billed for date of service May 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 80051, 82040, 82247, 82310, 82465, 82565, 
82947, 84075, 84155, 84450, 84460, 84520, 82607, and 82746 billed for date of service February 17, 2022. 
 
You asked the Plan to pay for procedure codes 80051, 82040, 82247, 82310, 82465, 82565, 82947, 84075, 
84155, 84450, 84460, 84520, 82607, and 82746. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says payment for the codes billed are bundled into payment for other codes 
billed on the claim. The Plan also say that screening tests are not a covered benefit. 
 
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 codes 
80051, 82040, 82247, 82310, 82565, 82947, 84075, 84155, 84450, 84460, and 84520 are column II codes to 
column I code 80053. This claim has not been billed with an appropriate modifier to bypass the edit. 
 
We have also confirmed that code 82465 is a column II code to column I code 80061 with a modifier indicator 
of 0. The column II code is therefore not payable. 
 
Medicare does not cover this test solely for screening purposes. The documentation shows that codes 82607 
and 82746 were tested with no relation to a diagnosis for the health of the enrollee. This makes these codes 
screening services and are therefore, not covered. 
 
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 codes 80051, 82040, 82247, 82310, 82465, 82565, 82947, 84075, 84155, 
84450, 84460, 84520, 82607, and 82746 billed for date of service February 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the dental cleaning (D1110), periodic oral 
evaluation (D0120), and the bitewings x-rays-four radiographic images (D0274) provided on May 10, 2022. 
 
You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayments have been applied correctly to 
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 $10 
copayment per service during the visit for covered routine dental services when rendered by an in-network 
provider.  
 
You have been asked to pay $30 ($10 copayment x 3) for the routine dental services rendered by an in-network 
provider. 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 copayments for the dental cleaning (D1110), 
periodic oral evaluation (D0120), and the bitewings x-rays-four radiographic images (D0274) provided on  
May 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the 2D photographic imaging (D0350), complete series x-ray 
(D0210), and panoramic x-ray (D0330) provided on July 11, 2022. 
 
You asked the Plan to pay for the dental services. You say that all the x-rays you received were not covered. 
You say that you were never told beforehand that this was the case. You also say that this is unacceptable. The 
Plan denied your request. The Plan says your benefit for the full mouth x-ray has already been exhausted. The 
Plan also says 2D photographic image 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, certain limitations apply. The record 
shows your benefit for the complete series x-ray or panoramic x-ray was exhausted on date of service 
December 14, 2020. Additionally, 2D photographic image is not covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 2D photographic imaging (D0350), complete series x-ray 
(D0210), and panoramic x-ray (D0330) provided on July 11, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the deluxe frames (V2025) and bifocal lenses (V2200) provided on
May 20, 2022, by an out-of-network (OON) provider.

You asked the Plan to pay for the glasses. You say that you spent $262.88, and only received $149.98 back
from the Plan. You also say that you expected the full $250 allowed by the Plan to be reimbursed to you. The
Plan denied your request. The Plan says that this benefit has been exhausted.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. The Plan did not provide a copy of the applicable 2022 Evidence of Coverage
for this case. Without this information we cannot determine that the Plan's coverage rules support the denial of
payment in this case, or that the enrollee has been adequately notified of the Plan's coverage rules and benefits.
Consequently, the Plan has not substantiated their denial of payment in this case. Therefore, we decided that
the Plan has to pay for the deluxe frames (V2025) and bifocal lenses (V2200) provided on May 20, 2022, by an
out-of-network (OON) provider.

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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 83789 billed for date of service March 22, 
2022. 
 
You asked the Plan to pay for procedure code 83789. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 83789 is bundled into payment for code G0480. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules state that providers may bill services 
with a -59 modifier if the service billed with the modifier indicates a distinct procedural service.  
 
In this case, we have confirmed that code 83789 is a column II code to column I code G0480. While code 
83789 was billed with modifier -59, the medical records provided do not show that the service billed with the  
-59 modifier is a distinct procedural service. 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 83789 billed for date of 
service March 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 83789 billed for date of service March 3, 
2022. 
 
You asked the Plan to pay for procedure code 83789. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 83789 is bundled into payment for code G0481. 
 
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 83789 
is a column II code to column I code G0481. While code 83789 was billed with modifier -59, the medical 
records provided do not show that the service billed with the -59 modifier is a distinct procedural service. 
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 83789 billed for date of service March 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial hospital care services coded 99222 provided on 
March 30, 2022. 
 
You asked the Plan to pay for the initial hospital care services. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the services billed are not supported by the documentation. 
 
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 99222 is initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and medical decision making of moderate complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) 
requiring admission are of moderate severity. Typically, 50 minutes are spent at the bedside and on the patient's 
hospital floor or unit. 
 
We find that CPT code 99222 is not supported in the medical record. Specifically, this initial observation care 
evaluation and management code requires a comprehensive history, a comprehensive examination and medical 
decision making of high complexity. However, the medical records submitted don't support a comprehensive 
history. Based on this information, we decided that Medicare rules for coverage of the initial hospital care 
services have not been met. Therefore, we decided that the Plan does not have to pay for the initial hospital 
care services coded 99222 provided on March 30, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve the upper partial denture (D5213) to be provided by a network 
provider. 
 
You asked the Plan to pre-approve the upper partial denture (D5213). You say that the services are medically 
necessary. The Plan denied your request. The Plan says that your benefit for the requested item or service has 
already been exhausted. 
 
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.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The Plan has 
not made reasonable and diligent efforts to gather and forward to us information regarding their decision to 
deny your request. There is no evidence, such as a claim form or Explanation of Benefits, showing your benefit 
for the upper partial denture (D5213) was previously exhausted. Therefore, we decided that the Plan has to pre-
approve the upper partial denture (D5213) to be provided by a network provider.  
 
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 more for the porcelain/ceramic retainer crowns (D6740 x 2) and 
the porcelain ceramic pontic (D6245) provided on December 1, 2021. 
 
You asked the Plan to pay more for the dental services. You say that you are requesting a reconsideration of the 
Plan's denial for additional payment. The Plan denied your request. The Plan says the enrollee is responsible for 
the difference in cost for any optional dental treatment.  
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 enrollee has been asked to pay the difference in cost for the optional dental treatment provided in this case. 
Specifically, the Plan contract states that if you select a more expensive service than is customarily provided, 
the Plan may make an allowance for certain services based on the fee for the customarily provided service. The 
enrollee is responsible for the difference in cost. The Plan issued payment for these dental services as metallic 
work for the same procedures, which paid at a lower rate. Therefore, the enrollee is responsible for the 
difference of the billed amount and the Plans payment for the upgraded porcelain dental services. Therefore, 
we decided that the Plan does not have to pay more for the porcelain/ceramic retainer crowns (D6740 x 2) and 
the porcelain ceramic pontic (D6245) provided on December 1, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a 3-dimensional (3D) mammogram
provided on May 7, 2022.

You asked the Plan to waive the copayment for a 3D mammogram. You say that this was for your annual
routine mammogram and should be considered under your preventative benefit. The Plan denied your request.
The Plan says the copayment applied was correct.

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 there is no copayment
for covered screening mammograms. Your contract with the Plan also clearly says that you must pay a $60
copayment for Medicare-covered x-rays and ultrasounds.

You are not being asked to pay for your screening mammogram (77066). During your screening exam,
additional services were performed. You have been asked to pay a $60 copayment for a 3-dimensional (3D)
diagnostic mammogram (77062). A 3D mammogram 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 a
3-dimensional (3D) mammogram.
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 3, 2022. 
 
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 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. Based on this information, we decided that Medicare rules for coverage of code 83789 have not been met. Specifically, we find that the testing described by the billed code is 
considered specimen validity testing which is not separately payable. Therefore, we decided that the Plan does 
not have to pay for the Mass spectrometry and tandem mass spectrometry (83789) provided on March 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 2D oral/facial photographic images (D0350) provided on 
May 2, 2022. 
 
You asked the Plan to pay for images. You say that you were not informed that the service was not covered. 
The Plan denied your request. The Plan says 2D oral/facial photographic images (D0350) 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 2D 
oral/facial photographic images (D0350) provided on May 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an unspecified preventive procedure (D1999) provided on 
April 11, 2022. 
 
You asked the Plan to pay for a preventive procedure. You say that you disagree with the denial of dental 
services. The Plan denied your request. The Plan says an unspecified preventive procedure (D1999) is 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 an 
unspecified preventive procedure (D1999) provided on April 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on April 6, 2022. 
 
You asked the Plan to pay for the testing services. You say that the lab tests for prescribed drugs and drugs of 
abuse. The Plan denied your request. The Plan says the code cannot be separately reimbursed. 
 
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. We find that the testing described by billed code 83789 is considered 
specimen validity testing which is not separately payable. Based on this information, we decided that Medicare 
rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the lab 
testing services provided on April 6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 81015 and 82947 billed for date of service 
May 26, 2020. 
 
You asked the Plan to pay for procedure codes 81015 and 82947. You say that you have provided records to 
support the services at issue. The Plan denied your request. The Plan says payment for code 82947 is bundled 
into payment for code 80053 and that payment for code 81015 is bundled into payment for code 81000. 
 
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 82947 
is a column II code to column I code 80053. This claim line has not been billed with an appropriate modifier to 
bypass the edit. Additionally, we have confirmed that code 81015 is a column II code to column I code 81000 
with a modifier indicator of 0. The column II code is therefore not payable. 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 codes 81015 and 82947 billed for date of service May 26, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve DBX cancellous allograft services. 
 
You asked the Plan to pre-approve DBX cancellous allograft services. You say that this procedure is medically 
necessary for the enrollee's condition. The Plan denied your request. The Plan says there is insufficient reliable 
evidence to establish safety and efficacy of the requested procedure. 
 
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 DBX cancellous allograft services. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that the enrollee is a 70-year-old female being treated for spinal stenosis. 
Past medical history was positive for anemia and arthritis. She presented with neck and bilateral upper 
extremity pain. The exam reveals tenderness to palpation over the bilateral paraspinal muscles. There is a full functional range of motion. The sensation is decreased on the bilateral C5, C6, and C7 dermatomes. The plan 
approved the C4-7 discectomy and fusion procedure. 
 
In this case, there is limited published, large-scale, long-term peer-reviewed literature that shows DBX 
cancellous Allograft to be an effective and/or safe treatment for the noted pathology. The peer-reviewed 
literature indicates that further research is needed to determine the efficacy of the request. There is no 
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. Therefore, the requested DBX cancellous Allograft, in this case, is not medically 
reasonable or 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 DBX cancellous allograft services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve DBX cancellous allograft services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation  (D0140) provided on June 13, 
2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the charges. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service 04/13/2022. Therefore, 
we decided that the Plan does not have to pay for a limited oral evaluation  (D0140) provided on June 13, 2022.