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

 
We decided that the Plan does not have to pay for the core build up (D2950) and root canal (D3310) provided 
on June 1, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were advised the services would cost $547. 
You say that now the office is saying you may owe more money. You also say that you should not have to pay 
more for these services. The Plan denied your request. The Plan says 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the core build up and root canal are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the core 
build up (D2950) and root canal (D3310) provided on June 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120) and prophylaxis (D1110) 
provided on April 14, 2021, the extraction of tooth #14 (D7210) provided on September 22, 2021, core build 
up on tooth #3 (D2950) and gum surgery on tooth #3 (D4212) provided on October 4, 2021, and a resin-based 
composite filling on tooth #29 (D2392) provided on November 22, 2021. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says your annual dental allowance has been exhausted. 
 
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 this benefit includes 
coverage up to a $1,000 dental allowance for preventive and comprehensive dental services. The contract says 
that you are responsible for any amount above the benefit coverage limit. 
 
The record shows your annual dental allowance has been exhausted. You have been asked to pay $136 for the 
extraction of tooth #14 on September 22, 2021. You have also been asked to pay $869 for the dental services 
received on April 14, 2021, October 4, 2021, and November 22, 2021. These items/services fall within the 
dental services 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 pay for a periodic oral evaluation (D0120) and 
prophylaxis (D1110) provided on April 14, 2021, the extraction of tooth #14 (D7210) provided on September 
22, 2021, core build up on tooth #3 (D2950) and gum surgery on tooth #3 (D4212) provided on October 4, 
2021, and a resin-based composite filling on tooth #29 (D2392) provided on November 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88363 billed for services provided on 
December 14, 2021. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the 
documentation does not support how the claim was coded. 
 
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 88363 is examination and selection of retrieved archival 
(ie, previously diagnosed) tissue(s) for molecular analysis (e.g., KRAS mutational analysis). We find that CPT 
code 88363 is not supported in the medical record. 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 
88363 billed for services provided on December 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a stair glide provided on May 27, 2022. 
 
You asked the Plan to pay for a stair glide. You say that this was ordered by your doctor. The Plan denied your 
request. The Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pay for a stair glide provided on May 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a medical eye examination (92004), a 
determination of refractive state (92015), and fundus photography (92250) provided on February 17, 2022. 
 
You asked the Plan to waive the deductible for a medical eye examination (92004), a determination of 
refractive state (92015), and fundus photography (92250). You say that the first time you called about this 
claim for an annual eye examination, you were told that this was not subject to a deductible, and it should have 
been paid. You also say that you called again and were told that since there was a diagnosis it was not covered 
as an annual eye examination. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $250 deductible which applies to Vision Services.  
 
You have been asked to pay $188.99 towards your deductible. The services you asked the Plan to waive the 
deductible for fall within the Vision Services benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $250 deductible which applies to Vision Services. This cost sharing is a 
contractual obligation that had not been met at the time a medical eye examination (92004), a determination of 
refractive state (92015), and fundus photography (92250) was received on February 17, 2022. Therefore, we 
decided that the Plan does not have to waive the deductible for a medical eye examination (92004), a 
determination of refractive state (92015), and fundus photography (92250) provided on February 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital discharge day management; more than 30 minutes 
provided to the enrollee on December 22, 2021. 
 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says the services are not supported without the required 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 99239 is "Hospital discharge day management; more than 
30 minutes." 
 
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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the medical documentation does 
not support both CPT 99223 and 99239 to be billed on the same date of service. It cannot be billed by the same 
provider on the same day.  
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for hospital discharge day management; more than 30 minutes provided to the enrollee on 
December 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the implant placement (D6010), custom abutment 
(D6057), abutment supported to a crown (D6059), the implant placement (D6010), and the bone replacement 
graft (D7953) for tooth #7 and #8. 
 
You asked the Plan to pre-approve the dental services. You say that you need the dental services done so you 
can eat better. The Plan denied your request. The Plan says the denial of authorization for these services is 
correct, because dental implants and all associated services along with bone replacement grafts are not covered 
by 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 pre-approve the 
implant placement (D6010), custom abutment (D6057), abutment supported to a crown (D6059), the implant 
placement (D6010), and the bone replacement graft (D7953) for tooth #7 and #8.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve extraction, erupted tooth requiring removal of bone 
and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated tooth #'s 
1,2,3,5,6,7,8,9,10,11,12,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32 (D7210), and unspecified 
diagnostic procedure, by report (D0999). 
 
You asked the Plan to pre-approve the dental service.. You say that you have been advised by several dental 
providers the enrollee needs to have all of her teeth removed. The Plan denied your request. The Plan says this 
service is not covered under the benefit package. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.  
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of 
mucoperiosteal flap if indicated tooth #'s 
1,2,3,5,6,7,8,9,10,11,12,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32 (D7210), and unspecified 
diagnostic procedure, by report (D0999).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 93313-59 billed for date of service May 27, 2022. 
 
You asked the Plan to pay for code 93313-59. You say that this code was billed with the appropriate modifier 
and should be paid. The Plan denied your request. The Plan says the use of the 59 modifier for code 93313 is 
not supported in the medical record. This code is included in code 01926 and is not separately reimbursed. The 
medical records do not support that the procedure or service was distinct or independent from other services 
performed. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
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 code 93313-59 Our reviewer says that the 
use of the -59 modifier to allow for separate payment of code 93313 is not supported in the medical record. Our 
physician reviewer found the medical record describes transthoracic echocardiography was provided for 
monitoring during anesthesia, as no interpretation and report was included to support a separate and distinct 
procedure. Therefore, modifier -59 cannot be verified. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 93313-59 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 93313-59 billed for date of service May 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and a partial 
mandibular denture (D5214). 
 
You asked the Plan to pre-approve dentures. You say that your lower dentures do not fit properly. The Plan 
denied your request. The Plan says your benefit for the requested items or services 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 items or services was exhausted on date of service March 3, 2022. 
Therefore, we decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and a 
partial mandibular denture (D5214).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a chiropractic office visit (99202) on June 15, 2022. 
 
You asked the Plan to pay for a chiropractic office visit. You say that the provider at issue is a network 
provider. The Plan denied your request. The Plan says rules for payment for chiropractic services have not been 
met. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for a chiropractic office visit (99202) on June 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95937 billed for date of service April 14, 
2022. 
 
You asked the Plan to pay for code 95937. You say that this service was billed correctly and this claim has 
been underpaid. The Plan denied your request. The Plan says code 95937 is not supported in the medical record 
for separate payment. The records indicate that the provider performed Train-of-Four testing, which does not 
meet the definition of code 95937. Train-of-Four monitoring is bundled with the intraoperative 
neuromonitoring of electromyography or motor evoked potentials. 
 
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 95937 is neuromuscular junction testing (repetitive 
stimulation, paired stimuli) each nerve, any one method. 
 
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 code 95937. Our reviewer says that code 95937 is not 
supported in the medical record. Our reviewer found there is a more appropriate code that can be used with to more accurately capture the description of the procedure performed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 95937 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 95937 billed for date of service April 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prophylaxis (D1110) provided by an out-of-network provider 
on August 11, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for this. The Plan 
denied your request. The Plan says the dental services were received from an out-of-network provider and are 
not covered by your supplemental 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. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for prophylaxis (D1110) provided by an out-of-network provider on August 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88341 and 88342 billed for date of service 
May 13, 2022. 
 
You asked the Plan to pay for procedure code 88341 and 88342. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says payment for code 88341 
and 88342 is bundled into payment for code 88360. 
 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 88341 
and 88342 is a column II code to column I code 88360. 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 88341 and 88342 billed for date of 
service May 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator (E1392). 
 
You asked the Plan to pre-approve a portable oxygen concentrator. You say that you are at a fall risk and 
require this equipment. The Plan denied your request. The Plan says there is no medical need for the member's 
need for a portable oxygen concentrator. 
 
The Plan must follow Medicare rules. The rules say that patients who are mobile in the home and would benefit 
from the use of portable oxygen in the home, may qualify for coverage of a portable oxygen system either by 
itself, or to use in addition to a stationary oxygen system. Oxygen is coverable when medically necessary for 
patients with hypoxemia who meet certain blood gas evidence requirements. In reviewing the arterial PO2 
levels and the arterial oxygen saturation percentages, variations in oxygen measurements that may result from 
such factors as the patient's age, the patients skin pigmentation, the altitude level, or the patient's decreased 
oxygen carrying capacity, must be taken into account. For patients who do not exhibit hypoxemia according to 
the above criteria, oxygen may be coverable when medically reasonable and necessary for patients who do not 
have a non-covered indication.  
 
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 a portable oxygen concentrator Our 
reviewer says that the requested equipment is not medically reasonable and necessary. Our physician reviewer 
found you have been on portable oxygen since discharge from the hospital in August 2022. There is a history 
of asthma and worsening dyspnea, but dyspnea has improved recently. There is no documentation of oxygen 
need. In this case, there is no documentation of why portable tanks do not your needs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a portable oxygen concentrator have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a portable oxygen concentrator (E1392).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64488 billed for date of service March 4, 
2022. 
 You asked the Plan to pay for procedure code 64488. The Plan denied your request. The Plan says payment for 
code 64488 is bundled into payment for code 00844. 
 
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 64488 is a column II code to column I code 00844. 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 64488 
billed for date of service March 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an oral exam (D0120), a cleaning (D1110), the filling 
(D2392), x-rays (D0220 and D0230) for tooth #4 provided on January 3, 2022, January 13, 2022, and May 31, 
2022. 
 
You asked the Plan to pay for the dental services. You say that the out-of-network (OON) provider is the only 
dentist you could find that has the special equipment that the enrollee needs. The Plan denied your request. The 
Plan says the dental services were received from an OON provider and are not covered by your supplemental 
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. 
 
  The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an OON provider. Therefore, we decided that the Plan does not have to pay for 
an oral exam (D0120), a cleaning (D1110), the filling (D2392), x-rays (D0220 and D0230) for tooth #4 
provided on January 3, 2022, January 13, 2022, and May 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on August 16, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the specimen was 
obtained in an office setting. 
 
 The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. In this case, the claim was billed with the laboratory POS code. The 
records do not support that the sample was taken in a laboratory setting. Based on this information, we decided 
that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan 
does not have to pay for lab services provided on August 16, 2021.