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

 
We decided that the Plan does not have to waive the coinsurance for an immediate maxillary denture (D5130) 
and does not have to pay for deep sedation (D9222, D9223), an unspecified removable prosthodontic procedure (D5899), and the surgical extraction of tooth #4, 6, 7, 8, 9, 10, 11, 12, and 13 (D7210) provided on June 28, 
2022. 
You asked the Plan to waive the coinsurance for an immediate denture and to pay for sedation, a prosthodontic 
procedure, and extractions. You say that you told the provider that you could not afford their prices. The Plan 
denied your request. The Plan says you have been charged the correct cost sharing amount for dentures. The 
Plan also says that deep sedation (D9222, D9223), an unspecified removable prosthodontic procedure (D5899), 
and surgical extractions (D7210) are not covered by your dental benefits. 
 
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 50% 
coinsurance for an immediate maxillary denture.  
 
You have been asked to pay $408, which is 50% coinsurance of the allowed amount for an immediate denture 
($816 allowed amount x 50% coinsurance = $406). This item/service falls 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.  
 
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, deep sedation, an unspecified 
removable prosthodontic procedure, and surgical extractions are not among those covered under this benefit. 
Therefore, we decided that the Plan does not have to waive the coinsurance for an immediate maxillary denture 
(D5130) and does not have to pay for deep sedation (D9222, D9223), an unspecified removable prosthodontic 
procedure (D5899), and the surgical extraction of tooth #4, 6, 7, 8, 9, 10, 11, 12, and 13 (D7210) provided on 
June 28, 2022.
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 April 7, 2022. 
 
You asked the Plan to pay for procedure 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 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 the Mass spectrometry and tandem mass spectrometry (83789) provided on 
April 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service June 7, 2022. 
 
You asked the Plan to pay for procedure code 99100. You say that this service was billed correctly. The Plan 
denied your request. The Plan says procedure code 99100 is considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code.  
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service June 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an unspecified oral surgery procedure, by report (tooth #s 21, 
29, and 30) (D7999), gingival irrigation  per quadrant (lower left, lower right quadrants)  (D4921).  The 
extraction, erupted tooth requiring removal of bone tooth #30 (D2710) and extraction, erupted tooth or exposed 
root tooth #'s 21 29 (7140) provided on May 31, 2022. 
 
You asked the Plan to pay for dental services.. You say that you are providing your statement dated May 31, 
2022 from the provider. You say that the charges were $593.20, you paid $430.20, and you do not recognize 
the charges. The Plan denied your request. The Plan says these services are not covered under your 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 pay for an 
unspecified oral surgery procedure, by report (tooth #s 21, 29, and 30) (D7999), and gingival irrigation  per 
quadrant (lower left, lower right quadrants)  (D4921) provided on May 31, 2022. 
 
You have been asked to pay a total of $75.00 ($25 x 3 extractions = $75.00) for the extraction, erupted tooth 
requiring removal of bone tooth #30 (D2710) and extraction, erupted tooth or exposed root tooth #'s 21 29 
(7140).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 92929 billed for date of service December 
23, 2021. 
 You asked the Plan to pay for procedure code 92929. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says procedure code 92929 is considered bundled 
and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 92929 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 92929 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 92929 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 92929 billed for date of service December 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the sedation services (D9222, D9223 x 9) provided on July 
14, 2021. 
 
You asked the Plan to pay for the sedation services. You say that the sedation was necessary due to the 
enrollee's medical condition. The Plan denied your request. The Plan says the sedation services were not 
medically necessary. 
 
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 pay for the sedation services. Our reviewer says that the sedation services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the provided documentation indicates the enrollee has restless leg syndrome (RLS). The 
reviewer found that this diagnosis alone does not necessarily require sedation for dental procedures. The 
reviewer found there is no documentation showing the enrollee is taking medication to treat this. The reviewer 
found there is no documentation to support when the enrollee experiences symptoms. Therefore, the reviewer 
found the sedation services were 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 the sedation services have not been met. Therefore, we decided that the Plan 
does not have to pay for the sedation services (D9222, D9223 x 9) provided on July 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation feature (CPT code E2300) and 
cupholder (K0108). 
 
You asked the Plan to pre-approve the items. You say that the items are necessary. The Plan denied your 
request. The Plan says the items are not covered by Medicare or the Health Plan. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.    
The cup holder is not primarily medical in nature and does not meet the definition of DME. The rules say that a 
power seat elevation feature (E2300) and power standing feature (E2301) are non-covered because they are not 
primarily medical in nature. Therefore, we decided that the Plan does not have to pre-approve a power seat 
elevation feature (CPT code E2300) and cupholder (K0108).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 1, 2021, billed with 
codes 81206 and 81292. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says this claim has not been billed in 
accordance with Medicare billing regulations. 
 The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
April 1, 2021, billed with codes 81206 and 81292.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve retainer crowns - porcelain fused to high noble metal 
(D6750). 
 
You asked the Plan to pre-approve retainer crowns. You say that the enrollee needs this service. 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 
retainer crowns - porcelain fused to high noble metal (D6750).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an oral evaluation (June 28, 2022) provided on June 28, 
2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. 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 June 06, 2022. Therefore, 
we decided that the Plan does not have to pay for an oral evaluation (June 28, 2022) provided on June 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation services (99152) provided on March 7, 
2022. 
 
You asked the Plan to pay for code 99152. 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 supported 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. 
 
In this case, the CPT Code Manual definition of code 99152 is Moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older. 
 
We find that CPT code 99152 is not supported in the medical record. Specifically, the medical record does not 
contain evidence that moderate sedation was performed with the presence of an independent trained observer. 
Based on this information, we decided that Medicare rules for coverage of code 99152 have not been met. 
Therefore, we decided that the Plan does not have to pay for the moderate sedation services (99152) provided 
on March 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service May 23, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that this service was billed correctly. The Plan 
denied your request. The Plan says procedure code 99100 is considered bundled and not separately payable. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service May 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve adjustable angle footplates, a cushioned headrest, 
replacement cover for a back or seat cushion, a manual swingaway mounting hardware for a joystick, calf pads, 
and Flex seating system. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that manual swingaway mounting hardware and adjustable 
footplates are covered when specific criteria are met. 
 
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 these services. Our reviewer says that 
the manual swingaway mounting hardware and adjustable footplates are not medically necessary. Our 
physician reviewer found the enrollee has chronic obstructive pulmonary disease (COPD) with respiratory 
failure and requires a power wheelchair for mobility. The records do not adequately support that the requested 
manual swingaway mounting hardware is medically necessary for the enrollee. The records do not document 
that the footrests included in the approved wheelchair base are inadequate to meet the enrollee's needs; 
therefore, the requested adjustable footplates 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 the manual swingaway mounting hardware and adjustable footplates have not 
been met. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The requested Flex seating system, calf pads, and replacement cushion cover do not serve a purpose that is 
primarily medical in nature and are not covered.  
 
Therefore, we decided that the Plan does not have to pre-approve adjustable angle footplates, a cushioned 
headrest, replacement cover for a back or seat cushion, a manual swingaway mounting hardware for a joystick, 
calf pads, and Flex seating system.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Microsurgical techniques, requiring use of operating 
microscope (list separately in addition to code for primary procedure) (69990). 
 You asked the Plan to pre-approve the surgical procedure. You say that the records provided should support the 
necessity of the requested services. The Plan denied your request. The Plan says none of the approved codes 
are ones that are allowable with CPT 69990. CPT code 69990 is to be used only with specific other CPT codes, 
as specified in Medicare guidelines. 
 
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 
Microsurgical techniques is an add-on code and has not been billed with an appropriate primary procedure 
code. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Microsurgical techniques, requiring use of operating microscope (list 
separately in addition to code for primary procedure) (69990).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the surgical placement of dental implants (D6010). 
 
You asked the Plan to pre-approve dental implants. You say that you need implants because you are unable to 
chew correctly and have few teeth already. You say that the only way to solve your problem is to rebuild the 
jaw bones and insert implants. The Plan denied your request. The Plan says dental implants are not covered 
under your supplemental 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 pre-approve the 
surgical placement of dental implants (D6010).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for implant supported porcelain/ceramic crown (D6065) tooth 
#13 provided on April 7, 2022. 
 
You asked the Plan to pay for dental services. You say that you were told you had coverage for the requested 
procedure. After the procedure was completed, the provider told you this would not be covered. The Plan 
denied your request. The Plan says this service is not covered under your 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 implant supported 
porcelain/ceramic crown (D6065) is not among those covered under this benefit. Therefore, we decided that the 
Plan does not have to pay for implant supported porcelain/ceramic crown (D6065) tooth #13 provided on April 
7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implant supported crowns on tooth #3, 5, 12, 14, 19, 20, 
29, and 30 (D6066), endosteal implants on tooth #5, 12, 14, 20, 29, and 30 (D6010), and custom fabricated 
abutments on tooth #5, 12, 14, and 20 (D6057). 
 
You asked the Plan to pre-approve the dental services. You say that you disagree with the denial of dental 
services. The Plan denied your request.  The Plan says an implant supported crown (D6066) is not covered by your dental benefits. The Plan also says 
that your benefit for endosteal implants (D6010) and custom fabricated abutments (D6057) 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, implant supported crowns are not 
among those covered under this benefit. The record shows your benefit for endosteal implants and custom 
fabricated abutments has been exhausted during this prior authorization request. Therefore, we decided that the 
Plan does not have to pre-approve implant supported crowns on tooth #3, 5, 12, 14, 19, 20, 29, and 30 (D6066), 
endosteal implants on tooth #5, 12, 14, 20, 29, and 30 (D6010), and custom fabricated abutments on tooth #5, 
12, 14, and 20 (D6057).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composite-one surface, posterior (D2391) 
and the resin-based composite-two surfaces, posterior (D2392) provided on June 29, 2022. 
 
You asked the Plan to pay for these dental items. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these items are not covered under your 
contractual policy. 
 
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 items provided are not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the resin-based 
composite-one surface, posterior (D2391) and the resin-based composite-two surfaces, posterior (D2392) 
provided on June 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (83789-59) provided on February 22, 
2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed based 
on the medical documentation. The Plan denied your request. The Plan says the documentation does not 
support payment for the services rendered. 
 
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 the laboratory services 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 laboratory services (83789-59) provided on February 22, 2022.