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

 
We decided that the Plan does not have to pay for the fillings (D2330, D2391) provided on November 1, 2021. 
 
You asked the Plan to pay for the fillings. You say that you always called the Plan to verify your benefits, and 
you were not told at any time that you were only covered for two fillings per year. The Plan denied your 
request. The Plan says you had two previous fillings provided and covered on April 16, 2021. Your dental 
benefit covers a maximum of two fillings per calendar year. Therefore, the fillings provided on November 1, 
2021, exceed the frequency limitations of your benefit and are denied. 
 
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 can cover two 
procedure codes for restorations (fillings) per calendar year. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the fillings are requested in a 
frequency that exceeds what is covered under this benefit. Documentation shows that you had two fillings 
covered by the Plan earlier in the year. Therefore, we decided that the Plan does not have to pay for the fillings 
(D2330, D2391) provided on November 1, 2021.  Your complaint about potential missing information from the Plan regarding your benefits is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for sterile gauze (A6402) provided on June 4, 2021. 
 
You asked the Plan to pay for sterile gauze. You say that this claim was billed correctly and should be paid. 
The Plan denied your request. The Plan says this service is always bundled with another procedure or service 
and is not eligible for separate payment under the physician fee schedule. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We find 
that CPT code A6402 is not supported in the medical record. Specifically, the record indicates that this code 
has been billed by a physician. CPT code A6403 has a status indicator of P. This means that CPT code A6402 
is not separately billable in this case. There is not a payment amount for CPT code A6402 under the Physician 
Fee Schedule. Based on this information, we decided that Medicare rules for coverage of sterile gauze have not 
been met. Therefore, we decided that the Plan does not have to pay for sterile gauze (A6402) provided on June 
4, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 CDx testing provided on July 6, 2021. 
 
You asked the Plan to pay for the Guardant360 CDx testing. You say that the POS rules being cited are only 
applicable to tests paid on the Physician Fee Schedule. The testing at issue is correctly billed with POS 81. The 
Plan denied your request. The Plan says this is not billed with the appropriate POS code. 
 
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. The documentation does not indicate this sample was taken by the 
lab directly. As such, the use of POS code 81 is not supported. Based on this information, we decided that 
Medicare rules for coverage of the Guardant360 CDx testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the Guardant360 CDx testing provided on July 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a shingles vaccine provided on October 10, 2021. 
 
You asked the Plan to pay for the shingles vaccine under Medicare Part B. You say that this vaccine should be 
covered by the Plan. The Plan denied your request. The Plan says this vaccine is not covered under Medicare 
Part B. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the shingles vaccine 
under Medicare Part B. The Plan follows the same rules. This vaccine is preventative and is not covered under 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for a shingles vaccine provided on 
October 10, 2021.  
 
Benefits for the shingles vaccine may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the placement of intra-socket biological dressing to aid in 
hemostasis or clot stabilization (D7922), deep sedation/general anesthesia (D9222 and D9223), and infiltration 
of sustained release therapeutic drug (D9613) provided on October 13, 2021. You asked the Plan to pay for the placement of intra-socket biological dressing, deep sedation/general anesthesia, and infiltration of sustained release therapeutic drug. You say that you would like to be reimbursed for these services. The Plan denied your request. The Plan says these services are not covered benefits for this group. 
 
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 
placement of intra-socket biological dressing to aid in hemostasis or clot stabilization (D7922), deep 
sedation/general anesthesia (D9222 and D9223), and infiltration of sustained release therapeutic drug (D9613) 
provided on October 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) 
provided on November 18, 2021. 
 
You asked the Plan to pay for the problem focused limited oral evaluation. You say that oral exams are covered 
under your benefit. The Plan denied your request. The Plan says this procedure exceeds the frequency 
limitations 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, emergency oral evaluation problem 
focused exams are covered once every 12 months. The record shows that you received a problem focused 
limited oral evaluation (D0140) on June 1, 2021 and your emergency oral evaluation problem focused exams 
benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the problem focused 
limited oral evaluation (D0140) provided on November 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal scalings and root planings (D4341) provided 
on November 4, 2021, and November 8, 2021. 
 
You asked the Plan to pay for the scalings and planings. You say that you would like a review of why none of 
these services were covered. The Plan denied your request. The Plan says this procedure is not a benefit under 
the dental plan. 
 
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 
periodontal scalings and root planings (D4341) provided on November 4, 2021, and November 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the alveoloplasties in conjunction with extractions (D7310) 
and surgical extractions (D7210) provided on October 11, 2021. 
 
You asked the Plan to pay for the alveoloplasties and surgical extractions. You say that you would like to 
appeal these services. The Plan denied your request. The Plan says alveoloplasty in conjunction with 
extractions is not a covered expense under your dental Plan and your extractions benefit limitation has been 
exceeded. The Plan also says that you did not contact the Plan prior to this date of service to verify benefits and 
provider eligibility. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
Though the Plan offers a dental benefit in excess of Medicare coverage, alveoloplasty in conjunction with 
extractions (D7310) is not among those covered under this benefit. The Plan contract says that extractions are 
limited to two procedure codes per calendar year. The record shows that you received three surgical extractions 
(D7210 x3) on March 10, 2021, two of which were covered by the Plan, and your extractions benefit has been 
exhausted. Therefore, we decided that the Plan does not have to pay for the alveoloplasties in conjunction with 
extractions (D7310) and surgical extractions (D7210) provided on October 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core build up (D2950), crown (D2740), and fillings 
(D2331, D2392). 
 
You asked the Plan to pre-approve the dental services. You say that you need this dental work done. You say 
that you have a leak under one of your crowns. You also say that you cannot have surgery until this is fixed. 
The Plan denied your request. The Plan says the requested services are not listed as covered service. The Plan 
also says that you are not enrolled in the optional supplemental dental 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 core build up, crown, and 
fillings are not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pre-approve core build up (D2950), crown (D2740), and fillings (D2331, D2392).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two periodontal scalings and root planings (D4341 x2) 
and additional intraoral periapical x-ray (D0230) provided on July 14, 2021, and August 10, 2021. 
 
You asked the Plan to pay for the scalings and planings and additional intraoral periapical x-ray. You say that 
you would like to appeal these services. The Plan denied your request. The Plan says your intraoral x-rays 
benefit has been satisfied and the frequency limitation has been exceeded. The Plan also says that periodontal 
scaling and root planing is not a covered expense under your dental plan. 
 
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, periodontal scaling and root planing 
(D4341) is not among those covered under this benefit. The contract says that intraoral x-rays are limited to one 
procedure code per calendar year. The record shows that you received a first intraoral periapical x-ray (D0220) 
on July 14, 2021 and your intraoral x-rays benefit has been exhausted. Therefore, we decided that the Plan does 
not have to pay for the two periodontal scalings and root planings (D4341 x2) and additional intraoral 
periapical x-ray (D0230) provided on July 14, 2021, and August 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services specified with procedure code 99053 
provided on July 1, 2021. 
 
You asked the Plan to pay for medical services coded 99053. You say that the services at issue were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met 
because the procedure code at issue is always bundled into the payment for another service or procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
Per the Physician Fee Schedule, CPT code 99053 has a status indicator of B. This means that the payment for 99053 is always bundled into the payment for another service or procedure. Based on this information, we 
decided that Medicare rules for coverage of medical services coded 99053 have not been met. Therefore, we 
decided that the Plan does not have to pay for medical services specified with procedure code 99053 provided 
on July 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation services (99153) provided on August 
30, 2021. 
 
You asked the Plan to pay for the moderate sedation services (99153). You say that it does not make sense that 
CPT code 99152 gets paid and CPT code 99153 does not get paid because of the place of service. You say that 
the doctor is entitled to be reimbursed for the medical care provided to the patient and the denial of payment 
should be reversed. The Plan denied your request. The Plan says CPT code 72275 will be covered and CPT 
code 99153 remains denied as not separately payable when performed by a physician in a facility setting. 
 
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 99153 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; each additional 15 minutes intraservice time (List 
separately in addition to code for primary service). 
 
We find that CPT code 99153 is not supported in the medical record. Specifically, CPT code 99153 is a TC 
only code and the claim indicates that this service was rendered in a facility setting. Payment for CPT code 
99153 is made to the facility and is the responsibility of the facility to pay any physician or vendor.  Based on 
this information, we decided that Medicare rules for coverage of the moderate sedation services (99153) have 
not been met. Therefore, we decided that the Plan does not have to pay for the moderate sedation services 
(99153) provided on August 30, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on July 26, 2021. 
 
You asked the Plan to pay for the testing services. You say that the tests were medically necessary. The Plan 
denied your request. The Plan says the codes cannot be separately reimbursed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We looked at the file and the rules. We find that the testing is not supported in the medical record. The records 
show that testing was ordered for a urinary tract infection. In this case, there are insufficient records to show 
how the testing will impact clinical management above the standard care options. Based on this information, 
we decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided 
that the Plan does not have to pay for the lab testing services provided on July 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a TDAP vaccine provided on October 27, 2021. 
 
You asked the Plan to pay for this vaccine under Medicare Part B. You say that this vaccine was recommended 
to you by the doctors office. The Plan denied your request. The Plan says this was given as a preventative 
vaccine which is not covered under Medicare Part B. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide this vaccine under 
Medicare Part B. The Plan follows the same rules. Records do not show that you have been injured or directly 
exposed to any illness related to this vaccine under Medicare Part B. Therefore, we decided that the Plan does 
not have to pay for a TDAP vaccine provided on October 27, 2021.  
 
Benefits for this vaccine under Medicare Part B. may be available under Medicare Part D. Contact the 
Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two crowns (D2750 x2), two prefabricated posts and 
cores in addition to crown (D2954 x2), endodontic therapy of an anterior tooth (D3310), endodontic therapy of 
a premolar tooth (D3320), and four periodontal scalings and root planings (D4341 x4). 
 
You asked the Plan to pre-approve the crowns, prefabricated posts and cores, endodontic therapies, and 
scalings and planings. You say that someone from the Plan told you that you were covered for these services 
that have been denied. The Plan denied your request. The Plan says these services are not covered under your 
benefit plan. 
 
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 two 
crowns (D2750 x2), two prefabricated posts and cores in addition to crown (D2954 x2), endodontic therapy of 
an anterior tooth (D3310), endodontic therapy of a premolar tooth (D3320), and four periodontal scalings and 
root planings (D4341 x4).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prophylaxis (D1110) provided on November 2, 2021. 
 
You asked the Plan to pay for the dental service. You say that you called customer service. You say you were 
advised you are allowed 3 cleanings and 2 fluoride treatments per year. You also say that you cannot pay this 
bill. The Plan denied your request. The Plan says prophylaxis is covered twice per plan year. The Plan also says 
that the frequency limit has been exceeded. 
 
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 and prophylaxis is covered twice per 
plan year, the frequency limit has been exceeded. The record shows that the Plan paid for prophylaxis that you 
received on February 24, 2021, and June 8, 2021. Therefore, we decided that the Plan does not have to pay for 
the prophylaxis (D1110) provided on November 2, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (G0483) provided January 7, 2021. 
 
You asked the Plan to pay for the lab services. You say that the service was medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed services. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, the place of service detailed 
in the records (11, office setting) does not match the place of service listed on the claim (81, laboratory). 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 (G0483) provided January 7, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services (87496, 87498, 87631, 87798, 87486, 87541, 
87581, and 87640) provided on September 10, 2020. 
 
You asked the Plan to pay for the lab services. You say that these claims were billed appropriately and should 
be paid. The Plan denied your request. The Plan says these services were not billed appropriately; the Place of 
Service code must reflect the location of the patient when the specimen was obtained.  The submitted claim form indicates that the laboratory specimen was obtained in the lab; however, medical documentation indicates that the specimens were obtained in a Skilled Nursing Facility. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that CPT codes 87496, 87498, 87631, 87798, 87486, 87541, 87581, and 87640 are not supported in the 
medical record. Specifically, these services were billed with the laboratory place of service code while the 
records indicate that the member's face-to-face service was rendered in a Skilled Nursing Facility setting. 
There is a more appropriate place of service code for the services billed. 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 the lab services (87496, 87498, 87631, 87798, 87486, 87541, 87581, and 87640) 
provided on September 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an attendant control, safety belt, and calf rest/pad 
replacement. 
 
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. Medicare rules say that an attendant control is non-covered if provided in 
addition to a beneficiary-operated drive control system, a safety belt is included in the basic PWC package, and 
replacement calf pads are not covered when billed with the approved Group 3 PWC. 
We looked at the file and Medicare rules. The requested attendant control is non-covered because the enrollee 
is approved for a beneficiary-operated drive control system. The safety belt is already included in the approved 
Group 3 PWC package. The replacement calf pads cannot be approved with the approved K0861 PWC. Based 
on this information, we decided that Medicare rules for coverage of these services have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an attendant control, safety belt, and calf 
rest/pad replacement.