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

 
We decided that the Plan does not have to pay for the infusion services rendered on July 8, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that the applicable payments made under the prospective 
payment systems are payment in full for all inpatient hospital services.  
 
We looked at the file and Medicare rules. The file shows that the services were rendered while the enrollee was 
under inpatient status. Payment for these services is included in the payment to the facility. Therefore, we 
decided that the Plan does not have to pay for the infusion services rendered on July 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diagnostic casts (D0470), immediate maxillary denture 
(D5130), three simple extractions (D7140 x3), two surgical extractions (D7210 x2), and two alveoloplasties in 
conjunction with extractions (D7311 x2) provided on February 5, 2020. 
 
You asked the Plan to pay for the diagnostic casts, immediate maxillary denture, extractions, and 
alveoloplasties. You say that you used your savings to pay your dental bill off and need your money back. The 
Plan denied your request. The Plan says the claim for reimbursement was not filed within one year of the date 
that the services were received. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the diagnostic casts, immediate maxillary denture, extractions, and 
alveoloplasties was not filed until April 9, 2021. This means that more than one calendar year from the date of 
service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the 
diagnostic casts (D0470), immediate maxillary denture (D5130), three simple extractions (D7140 x3), two 
surgical extractions (D7210 x2), and two alveoloplasties in conjunction with extractions (D7311 x2) provided 
on February 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic radiographic image (D0330) and consultation 
- diagnostic service provided by dentist or physician other than requesting dentist or physician (D9310) 
provided November 30, 2021. 
 
You asked the Plan to pay for the panoramic x-ray and dental consultation. You say that the services were 
necessary and should be covered. The Plan denied your request. The Plan says you have exceeded the 
frequency limit for panoramic x-ray and the dental consultation 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. The Plan covers the panoramic 
x-ray once every three plan years. 
 
We looked at the file and Medicare rules. The Plan provided documentation showing that a panoramic x-ray was previously covered on June 8, 2021. Based on this information, we decided that the Plan's frequency limit 
for coverage of the panoramic x-ray has been exceeded. Though the Plan offers dental benefits in excess of 
Medicare coverage, the dental consultation is not among those covered services.  Therefore, we decided that 
the Plan does not have to pay for the panoramic radiographic image (D0330) and consultation - diagnostic 
service provided by dentist or physician other than requesting dentist or physician (D9310) provided November 
30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the consultation (D9310), and therapeutic parenteral drugs 
(D9612) provided on October 29, 2021, by the out of network provider. 
 
You asked the Plan to pay for the consultation and therapeutic parenteral drugs. You say that you had an 
emergency tooth extraction and tissue sample. You say that your dentist referred you to this provider as an 
emergency. You say that you were unaware that the oral surgeon was out of network. You also say that you 
would like to be reimbursed for these services. The Plan denied your request. The Plan says the services are not 
covered.  
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 consultation and therapeutic 
parenteral drug are not among those covered under this benefit, regardless of the providers network status. 
Therefore, we decided that the Plan does not have to pay for the consultation (D9310), and therapeutic 
parenteral drugs (D9612) provided on October 29, 2021, by the out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided December 1, 
2021. 
 
You asked the Plan to pay for the periodontal maintenance. You say that you need four cleanings per year to 
save your teeth. The Plan denied your request. The Plan says you have exceeded the frequency limit for this 
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. The Plan covers the 
periodontal maintenance three times per plan year.  
 
We looked at the file and Medicare rules. The Plan provided documentation showing that periodontal 
maintenance was previously covered on February 3, 2021, May 5, 2021, and August 11, 2021. Based on this 
information, we decided that the Plan's frequency limit for coverage of the periodontal maintenance has been 
exceeded. Therefore, we decided that the Plan does not have to pay for the periodontal maintenance (D4910) 
provided December 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), and prophylaxis 
(D1110) provided by an out-of-network provider on August 6, 2021. 
 
You asked the Plan to pay for a comprehensive oral evaluation and prophylaxis. You say that you believe that 
this should be covered. The Plan denied your request. The Plan says this claim has been processed 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. The Plan covers a 
comprehensive oral evaluation and prophylaxis.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of a comprehensive oral evaluation and prophylaxis have been met. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), and prophylaxis (D1110) provided by 
an out-of-network provider on August 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete maxillary denture (D5110) and complete 
mandibular denture (D5120) provided on November 4, 2021. 
 
You asked the Plan to pay for the complete maxillary denture and complete mandibular denture. You say that 
when you talked to a Plan representative in the past, you asked what types of dental visits were covered and 
were advised that any dental was covered up to the benefit amount of $2,000 during the 2021 plan year. The 
Plan denied your request. The Plan says these services are not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's 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 
complete maxillary denture (D5110) and complete mandibular denture (D5120) provided on November 4, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the dental services provided on August 11, 2021. 
 
You asked the Plan to pay for the dental services. You say that based on the information your doctor gave to 
you, you accepted their recommendation for these services. You also say that these should be covered. The 
Plan denied your request. The Plan says that the claim was denied correctly. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the file does not include a dental claim nor the Plan's initial denial. 
Without these documents, we cannot determine the specific dental services that were performed and/or denied. 
Therefore, we decided that the Plan has to pay for the dental services provided on August 11, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140), analgesia (D9230), and a 
tooth extraction (D7210) provided by an out-of-network provider on October 5, 2021, to October 8, 2021. 
 
You asked the Plan to pay for a limited oral evaluation, analgesia, and a tooth extraction. You say that you 
would like the Plan to pay for this. The Plan denied your request. The Plan says services provided by an out-of-
network provider 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 Plan's coverage rules apply in this case. The Plan covers a limited oral 
evaluation, analgesia, and a tooth extraction when the services are medically necessary and reasonable.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of a limited oral evaluation, analgesia, and a tooth extraction have not been met.  Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140), analgesia (D9230), and a tooth extraction (D7210) provided by an out-of-network provider on October 5, 2021, to October 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic parenteral drugs (D9612) or pay more for the 
three surgical extractions (D7210 x3) provided on August 5, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the therapeutic parenteral drugs and pay more for the surgical extractions. You 
say that you were never told that the treating provider was not in-network. You also say that you did verify that 
the dental office was in-network prior to your appointment. The Plan denied your request. The Plan says the 
therapeutic parenteral drugs are not covered under your contract. The Plan also says that the cost share for the 
surgical extraction was applied correctly because the service was rendered OON. 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, therapeutic parenteral drugs (D9612) is 
not among those covered under this benefit. You are also responsible for a 50% coinsurance for the extractions, 
plus the difference between the billed amount and allowed amount because these services were received OON. 
Therefore, we decided that the Plan does not have to pay for the therapeutic parenteral drugs (D9612) or pay 
more for the three surgical extractions (D7210 x3) provided on August 5, 2021 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 two periodontal scalings and root planings (D4342 
x2) provided on December 7, 2021. 
 
You asked the Plan to pay more for the scalings and planings. You say that your coverage started in August, 
you had not gotten a service, and should still have a $1,000 coverage. The Plan denied your request. The Plan 
says you pay a 20% coinsurance for Class 2 Basic 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, you are responsible for a 20% 
coinsurance for scalings and root planings. Therefore, we decided that the Plan does not have to pay more for 
the two periodontal scalings and root planings (D4342 x2) provided on December 7, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a crown (D2751), prefabricated post and core in addition to a 
crown (D2954), and endodontic therapy (D3310). 
 
You asked the Plan to pre-approve the crown, prefabricated post and core, and endodontic therapy. You say 
that you want to preserve the tooth because your teeth are currently shifting, and you want to maintain the tooth 
to keep the remaining teeth from shifting. The Plan denied your request. The Plan says that the services are not 
covered under your benefit plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan has submitted an Office Reference Manual (ORM) which includes 
exhibits from numerous dental packages offered by the Plan. The file does not specify which exhibit correctly 
corresponds to the enrollees coverage. Review of the product names for the various dental packages does not 
clearly indicate which package correctly corresponds to the enrollees coverage. As such, we are not able to 
determine which dental plan listed describes the enrollees benefits. Without this information, we find that the 
Plan has not substantiated its denial of the services at issue. Therefore, we decided that the Plan has to pre-
approve a crown (D2751), prefabricated post and core in addition to a crown (D2954), and endodontic therapy 
(D3310).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia for patient of extreme age (CPT code 99100) 
provided on January 15, 2021. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the service is not covered 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. 
 
CPT code 99100, which as a status indicator of 'B' on the CMS Physician Relative Value File and is always 
bundled into payment for other services not specified and no separate payment is made per Medicare. Based on 
this information, we decided that Medicare rules for coverage of the service have not been met. Therefore, we 
decided that the Plan does not have to pay for the anesthesia for patient of extreme age (CPT code 99100) 
provided on January 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a retrograde filling (D3430), and surgical exposure of 
root surface (D3503) to be provided by a participating provider. 
 
You asked the Plan to pre-approve a retrograde filling and surgical exposure of root surface. You say that 
without these services the tooth will have to be extracted, rebuilt, and replace. The Plan denied your request. 
The Plan says the requested dental services 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 pre-approve a 
retrograde filling (D3430), and surgical exposure of root surface (D3503) to be provided by a participating 
provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided by a 
participating provider on December 2, 2021. 
 
You asked the Plan to pay for a comprehensive oral evaluation. You say that you would like the Plan to pay for 
this. The Plan denied your request. The Plan says the benefit limit of D0150 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. The Plan covers one 
comprehensive oral evaluation every three years.   
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 comprehensive oral evaluation have already been met. Therefore, we decided 
that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided by a participating 
provider on December 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system (E2300). 
 
You asked the Plan to pre-approve a power seat elevation system. You say that you believe this is medically 
necessary and you are requesting an appeal regarding a custom power wheelchair The Plan denied your 
request. The Plan says a power seat elevator feature is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
We looked at this the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of A power seat elevation system have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power seat elevation system (E2300).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for a needle electromyography procedure of 2 extremities (95861) 
provided on September 22, 2021. 
 
You asked the Plan to pay for needle electromyography of 2 extremities. You say that you have provided 
records in support of the service at issue. The Plan denied your request. The Plan says that records do not 
support the service 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 95861 is "Needle electromyography; 2 extremities with or without related paraspinal areas." 
 
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 needle electromyography of 2 extremities. Our reviewer says 
that the service at issue meets criteria for reimbursement. Our reviewer found that the technical report and 
graphs support this procedure. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of needle electromyography of 2 extremities have been met. Therefore, we decided 
that the Plan has to pay for a needle electromyography procedure of 2 extremities (95861) provided on 
September 22, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a core build up (D2950) for tooth #9 to be provided by a 
participating provider. 
 
You asked the Plan to pre-approve a core build up. You say that this should be covered with the cast and 
crown. The Plan denied your request. The Plan says D2950 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 Plan's 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 
core build up (D2950) for tooth #9 to be provided by a participating provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services coded 82542 and 83789 and billed with 
the 59-modifier provided on April 2, 2021. 
 
You asked the Plan to pay for the medical services as billed. You say that the documentation submitted 
supports the services as billed. The Plan denied your request. The Plan says these services have been billed 
with an incorrect place of service code. 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, we have confirmed that codes 83789 and 82542 are column II codes to column I code G0480; 
however, these codes were 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 the medical services as billed. Our reviewer says that the 
documentation does not support payment for the services as billed. Our reviewer found these procedures would 
be inclusive to the drug testing procedure. Specifically, validity drug testing is not reported separately from 
billed services. Therefore, the use of the 59 modifiers to bypass the NCCI edit is not supported in this situation. 
 
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 medical services as billed have not been met. Therefore, we decided that the 
Plan does not have to pay for the medical services coded 82542 and 83789 and billed with the 59-modifier 
provided on April 2, 2021.