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

 
We decided that the Plan does not have to pre-approve osseous surgeryfour or more contiguous teeth bounded 
spaces per quadrant (D4260). 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says this service requested is not covered under your contractual 
policy. Additionally, dental services must be performed by a participating general dentist.  
 
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 service is not among  
those covered under this benefit. Additionally, dental services must be performed by a participating general 
dentist. In this case, you had requested this service to be performed by a periodontist. Therefore, we decided 
that the Plan does not have to pre-approve osseous surgeryfour or more contiguous teeth bounded spaces per 
quadrant (D4260).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient services provided February 17, 2022. 
 
You asked the Plan to pay for the inpatient services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid 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. 
 
We find that the inpatient services are not supported in the medical record. Specifically, the inpatient services 
were not billed with a valid DRG code. Based on this information, we decided that Medicare rules for coverage 
of the inpatient services have not been met. Therefore, we decided that the Plan does not have to pay for 
inpatient services provided February 17, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (96372) provided April 13, 2022. 
 
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the code billed is not eligible for separate payment. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 96372 is not supported in the medical record. Specifically, this service was billed the 
same date as code 99284. The service billed is not separately payable from the Emergency Room code. Based 
on this information, we decided that Medicare rules for coverage of the physician services have not been met. 
Therefore, we decided that the Plan does not have to pay for physician services (96372) provided April 13, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on February 15, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the service was medically necessary. 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 
office visit. We found no exception that would require the Plan to pay for the office visit. The records provided 
for review do not show that the office visit was urgent or emergent. Therefore, we decided that the Plan does 
not have to pay for the office visit provided on February 15, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing billed with codes 81298, 81317, and 81321 
for date of service February 6, 2022. 
 
You asked the Plan to pay for codes 81298, 81317, and 81321. You say that the Tempus Gene Panel will be 
useful for patients at initial diagnosis or for patients with refractory disease. You say that the records provided 
support the medical necessity of the genetic testing in dispute. The Plan denied your request. The Plan says the 
services provided were billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that the submission of claims using individual gene 
CPT codes, when either 5-50 or more than 50 gene panels are ordered, is considered incorrect coding. 
 
We looked at the file and Medicare rules. The records show that more than 5 gene tests were ordered on the 
date of service in dispute. This means that a panel code should be billed rather than the individual gene codes. 
Based on this information, we decided that Medicare rules for coverage of codes 81298, 81317, and 81321 
have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing billed with 
codes 81298, 81317, and 81321 for date of service February 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the periodic oral evaluation (D0120) and prophylaxis 
(D1110) provided on April 5, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay more for the dental services. You say that you were told by the Plan and the dentist 
that the facility you went to was in-network. You also say that you were later told this provider cancelled their 
network status with the Plan on December 31, 2021. The Plan denied your request. The Plan says you are 
responsible for any charged amount above the Plans cost-sharing amount when your services are received 
from an OON provider. 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. 
 
 
 
 You have been asked to pay the difference between the OON providers charges and the Plans payment. 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 pay more for the periodic oral evaluation (D0120) and prophylaxis (D1110) 
provided on April 5, 2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service April 26, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service April 26, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service April 25, 
2022. 
 You asked the Plan to pay for procedure code 76705. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for 
code 93976. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 76705 
is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 76705 billed for date of service April 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 83789 billed for December 28, 2021. 
 
You asked the Plan to pay for procedure code 83789. You say that these services are supported in the medical 
records provided. The Plan denied your request. The Plan says they have agreed to pay for the drug testing 
services (G0481, 80307); however, specimen validity testing should not be billed separately. 
 
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 procedure 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 procedure code 83789 billed for December 28, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 37252, 37253 and 75710 billed on October 
20, 2021. 
 
You asked the Plan to pay for procedure codes 37252, 37253 and 75710. You say that the documents indicate 
the procedures were performed to ameliorate a medical condition. You say that the services meet the medical 
necessity requirements, and the physician should be paid. The Plan denied your request. The Plan says 
procedure codes 37252 and 37253 are not supported by the medical records submitted. The Plan also says 
procedure code 75710 is considered inclusive to procedure code 37229. 
 
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 asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for procedure codes 37252 and 37253. Our reviewer says that 
the documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer found 
that the procedure report does not describe an intravascular ultrasound during diagnostic evaluation and 
therapeutic intervention or an ultrasound during a diagnostic evaluation and/or therapeutic intervention of 
additional non-coronary vessel. Therefore, procedure codes 37252 and 37253 cannot be verified. 
 
In this case, we have confirmed that code 75710 is a column II code to column I code 37229; however, 75710 
was billed with a modifier.  
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for procedure code 75710. Our reviewer found that the 
procedure report does not support code 75710 as a separate procedure from code 37229. Radiological 
supervision would be performed as part of the intervention performed. Therefore, procedure code 75710 cannot 
be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 37252, 37253 and 75710 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 37252, 37253 and 75710 billed on October 20, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on January 25, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for laboratory services provided on January 25, 2022, 
by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the group psyhotherapy services and telehealth services 
provided on March 3, 2022, to March 31, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the group psyhotherapy services and telehealth services. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says the services provided are not a 
covered benefit. 
 
 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the group psyhotherapy services and telehealth 
services provided on March 3, 2022, to March 31, 2022 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for durable medical equipment (DME) supplies provided on 
March 21, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for durable medical equipment (DME) supplies. You say that you would like to 
request reconsideration of the denied claim. The Plan denied your request. The Plan says the provider is out-of-
network, and it was determined these services can be received in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for durable medical equipment (DME) supplies 
provided on March 21, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the periodic oral evaluation (D0120). 
 
You asked the Plan to pay more for the dental services. You say that there should be no copayment for these 
services. The Plan denied your request. The Plan says you are responsible for any charged amount above the 
Plans cost-sharing amount when your services are received from an out-of-network provider. 
 
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. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for the periodic oral evaluation (D0120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a removable unilateral partial denture  one piece cast 
metal (including retentive/clasping materials, rests, and teeth), maxillary (D5282). 
 
You asked the Plan to pre-approve a removable unilateral partial denture. You say that you need the partial 
dentures because you were unable to do the impressions for full dentures. The Plan denied your request. The 
Plan says this service is 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 pre-approve a 
removable unilateral partial denture  one piece cast metal (including retentive/clasping materials, rests, and 
teeth), maxillary (D5282).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service March 4, 
2022. 
 You asked the Plan to pay for procedure code 76705. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for 
code 93976. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 76705 
is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 76705 billed for date of service March 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the refraction services (92015) provided on September 14, 
2021. 
 
You asked the Plan to pay for the vision care. You say that you feel that you have met your maximum out-of-
pocket at this time. The Plan denied your request. The Plan says non-covered services do not go toward the 
maximum out-of-pocket amount. 
 
The Plan must follow Medicare rules. Medicare rules say that plans must pay for a medical service or item if 
regular Medicare would pay for it in this case.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the vision care have not been met. Therefore, we decided that the Plan does not have to pay for the 
refraction services (92015) provided on September 14, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service May 6, 2022. 
 
You asked the Plan to pay for procedure code 70450. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code 70450 is bundled into payment for code 70496. 
 
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 70450 is a column II code to column I code 70496. 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 70450 billed for date of service May 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay the in-network rate for the complete series x-ray (D0210) 
provided on June 9, 2021. 
 You asked the Plan to pay the in-network rate for the complete series x-ray. You say that the provider in this 
case was listed as in-network. You say that The Plan denied your request. The Plan says complete series x-ray 
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 complete series x-ray is not among 
those covered under this benefit, regardless of the providers network status. Therefore, we decided that the 
Plan does not have to pay the in-network rate for the complete series x-ray (D0210) provided on June 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pulpal debridement (D3221) provided on September 30, 
2021. 
 
You asked the Plan to pay for the pulpal debridement. You say that you would like to appeal this service. The 
Plan denied your request. The Plan says this service is not covered under the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.  
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the pulpal 
debridement (D3221) provided on September 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete series of intraoral x-rays (D0210) provided on 
May 31, 2022. 
 
You asked the Plan to pay for the complete series of intraoral x-rays. You say that you were advised that the 
Plan would cover 100% of the charges. The Plan denied your request. The Plan says your benefit for the 
requested item or service has already been exhausted. The Plan also says that their call logs confirm you were 
not misquoted. 
 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 December 16, 2020. 
Therefore, we decided that the Plan does not have to pay for the complete series of intraoral x-rays (D0210) 
provided on May 31, 2022.