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

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on March 21, 
2022. 
 
You asked the Plan to pay for an evaluation. You say that this service should be covered. The Plan denied your 
request. The Plan says a limited oral evaluation (D0140) 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 a limited 
oral evaluation (D0140) provided on March 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an unlisted molecular pathology procedure (81479) billed for 
date of service, June 8, 2021. 
 You asked the Plan to pay for the pathology procedure. You say that these services were billed correctly. The 
Plan denied your request. The Plan says they have agreed to pay for some of the lab services, but 81479 
remains denied. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the pathology procedure have been 
met. Specifically, the record shows that the Plan has paid for molecular pathology services (81401, 81403, 
81404, 81405 and 81406) provided on this date. Code 81479 is used to report a pathology panel when no other 
code accurately describes the procedure performed. It is unclear how 81479 is separate from the laboratory 
services which have already been reimbursed by the Plan. Therefore, we decided that the Plan does not have to 
pay for an unlisted molecular pathology procedure (81479) billed for date of service, June 8, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve five physical therapy visits. 
 
You asked the Plan to pre-approve therapy visits. You say that physical therapy is medically necessary. The 
Plan denied your request. The Plan says these services are not medically necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve therapy visits. Our reviewer says that 
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that the enrollee was trained in a home exercise program (HEP) and 
can transition to an independent HEP. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of therapy visits have not been met. Therefore, we decided that the Plan does not 
have to pre-approve five physical therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system identified with code 
E2300, expandable controller identified with code E2377, harness for upgrade to expandable controller 
identified with code E2313, electronic connection between wheelchair controller and two or more power 
seating system motors identified with code E2311, and enhanced steering platform identified with code K0108. 
 
You asked the Plan to pre-approve a power seat elevation system, expandable controller, harness for upgrade to 
expandable controller, electronic connection between wheelchair controller and two or more power seating 
system motors, and enhanced steering platform. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the requested items are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that power wheelchair accessories are only covered 
for certain indications. A power seat elevation feature is non-covered. 
 
We looked at the file and Medicare rules. Review of the file shows that the enrollee has a three to five out of 
five bilateral upper limb strength. This means that the enrollee's upper limb strength and function are adequate 
to be able to control the power options using their own switches which are included in the allowance of the 
power options. The enhanced Steering cannot be approved as it is already included with the requested E2377 
Expandable Controller. These should not be requested separately. 
 
Based on this information, we decided that Medicare rules for coverage of a power seat elevation system, 
expandable controller, harness for upgrade to expandable controller, electronic connection between wheelchair 
controller and two or more power seating system motors, and enhanced steering platform have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system identified with 
code E2300, expandable controller identified with code E2377, harness for upgrade to expandable controller 
identified with code E2313, electronic connection between wheelchair controller and two or more power 
seating system motors identified with code E2311, and enhanced steering platform identified with code K0108
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on 
April 20, 2022. 
 
You asked the Plan to pay for the dental services. You say that you have not been to the dentist in over a year. 
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 February 13, 2020. 
Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) 
provided on April 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services (D2950, D7210, D7140) from March 18, 
2022, to March 22, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration for 
payment. 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 dental services (D2950, D7210, D7140) from March 18, 2022, to March 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 30 units of infectious agent detection by nucleic acid (87798) 
billed for date of service January 7, 2022. 
 
You asked the Plan to pay for procedure code 87798. You say that these services were medically necessary. 
The Plan denied your request. The Plan says they have agreed to pay for the other lab services; however, the 30 
units of code 87798 are not supported in the medical record as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
In this case, the CPT Code Manual definition of code 87798 is infectious agent detection by nucleic acid (DNA 
or RNA), not otherwise specified; amplified probe technique, each organism. 
 
 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 87798. Our reviewer says that the 
documentation does not support the billing of 30 units of 87798. Our reviewer found the medical record 
includes a negative result for a urine pathogen panel. No additional documentation was included to support 
organisms identified, or the need for additional units which exceed the medically unlikely edits amount of 13. 
In this case, the procedure 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 code 87798 have not been met. Therefore, we decided that the Plan 
does not have to pay for 30 units of infectious agent detection by nucleic acid (87798) billed for date of service 
January 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the dental services received on January 11, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you want the Plan to reimburse you 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 dental services received on January 11, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient hospital services for the enrollee. 
 
You asked the Plan to pre-approve inpatient hospital services. You say that these services are medically 
necessary. The Plan denied your request. The Plan says that the procedure is currently approved as an 
ambulatory procedure. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 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 inpatient hospital services. Our 
reviewer says that inpatient hospital services are not medically reasonable and necessary. There are no 
comorbid conditions documented which would reasonably lead to an expectation that medically necessary care 
would span two midnights. The record does not show that it would be anticipated that medically necessary care 
would span a time of greater than two midnights. Our physician reviewer found that the enrollee's condition 
does not meet criteria for coverage of these services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient hospital services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve inpatient hospital services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pontic (D6240) and a retainer crown (D6750), provided by 
a participating provider. 
 
You asked the Plan to pay for a pontic and a retainer crown. You say that these services are medically 
necessary. The Plan denied your request. The Plan says the medical criteria for these services have not been 
met. 
 
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 Plan covers a pontic and a 
retainer crown when the services are medically necessary and reasonable.  
 
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 a pontic and a retainer crown. Our physician 
reviewer found the medical criteria has not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of a pontic and a retainer crown have not been met. Therefore, we decided that the Plan does not have to pay for a pontic (D6240) and a retainer crown (D6750), provided by a participating 
provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for scaling in presence of generalized moderate or severe 
gingival inflammation (D4346), gingival irrigation (D4921 x2), and drugs or medicament (D9630) provided on 
March 29, 2022. 
 
You asked the Plan to pay for scaling in presence of generalized moderate or severe gingival inflammation, 
gingival irrigation, and drugs or medicament. You say that you want the Plan to pay for these services. The 
Plan denied your request. The Plan says the services at issue are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 scaling in 
presence of generalized moderate or severe gingival inflammation (D4346), gingival irrigation (D4921 x2), and 
drugs or medicament (D9630) provided on March 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation teeth cleaning (D1110), and an 
adjunctive pre-diagnostic test (D0431) provided on May 11, 2022. 
 
You asked the Plan to pay for a periodic oral evaluation the dental services. You say that the services should be 
covered. The Plan denied your request. The Plan says your benefit for the teeth cleaning has already been 
exhausted. An adjunctive pre-diagnostic test is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 teeth cleaning was exhausted on dates of service July 28, 2021, and November 3, 
2021. Additionally, an adjunctive pre-diagnostic test is not a covered benefit. Therefore, we decided that the 
Plan does not have to pay for a periodic oral evaluation teeth cleaning (D1110), and an adjunctive pre-
diagnostic test (D0431) provided on May 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on July 25, 2021 billed with 
codes 81321. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the services were not billed correctly. 
 
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 
July 25, 2021 billed with codes 81321.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for endodontic therapy (D3330) provided on May 3, 2022. 
 
You asked the Plan to pay for endodontic therapy. You say that this service was medically necessary. The Plan 
denied your request. The Plan says endodontic therapy (D3330) 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 
endodontic therapy (D3330) provided on May 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for the onlay provided for tooth #2 on 
April 27, 2022. 
 
You asked the Plan to pay an additional amount for the dental services. You say that you want the Plan to pay 
an additional amount for these services. The Plan denied your request. The Plan says the charges were applied 
correctly. 
 Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.  
 
You were assessed the $390 copayment for the onlay. You also elected to have a tooth colored onlay for this 
molar tooth, which carries the $150 charge. In addition, the documentation shows that you agreed to the 
upgrade to a name brand onlay (Cerec) and were informed of the additional charge, up to $325 as described in 
the coverage materials. 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 an additional amount for the onlay provided for tooth 
#2 on April 27, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 93041, 36000, 99070, 64484 and A4649 billed for date 
of service February 9, 2022. 
 
You asked the Plan to pay for codes 93041, 36000, 99070, 64484 and A4649. You say that these services were 
necessary and are supported in the medical record. The Plan denied your request. The Plan says these services 
were not billed in accordance with 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 93041 is a column II code to column I code 64483, which was 
previously paid by the Plan. 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, 93041 is not supported 
for separate payment. 
 
We have also found that procedure codes 36000 and 99070 both have a status indicator of B on the Physician 
Fee Schedule. This means that procedure codes 36000 and 99070 are not separately payable. In addition, code 
A4649 has a status indicator of P on the Physician Fee Schedule. This means that procedure code A4649 is also 
not separately payable. Based on this information, we have decided that Medicare rules for coverage of these 
services have not been met. 
 
In this case, the CPT Code Manual definition of code 64484 is injection(s), anesthetic agent(s) and/or steroid; 
transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, each additional level 
(List separately in addition to code for primary procedure). 
 
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 codes 64484. Our reviewer says that code 64484 is not 
supported by the medical record provided. Our reviewer found that the provided procedure report does not 
include documentation of additional levels which would support add-on code 64484. The operative report 
describes one level (L4-L5), and an additional level cannot be verified. 
 
We looked at this coders review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of codes 93041, 36000, 99070, 64484 and A4649 have not been met. Therefore, 
we decided that the Plan does not have to pay for codes 93041, 36000, 99070, 64484 and A4649 billed for date 
of service February 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for fillings (D2392, D2393) provided on May 4, 2022. 
 
You asked the Plan to pay for the dental services. You say that you told the provider to only do the services that 
would be covered. 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 May 4, 2022. Therefore, 
we decided that the Plan does not have to pay for fillings (D2392, D2393) provided on May 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance (D4910) provided on March 25, 
2022. 
 
You asked the Plan to pay for periodontal maintenance. You say that the service should be covered. The Plan 
denied your request. The Plan says the service at issue is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 
periodontal maintenance (D4910) provided on March 25, 2022.