Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 73565 billed for date of service January 28,
2022.

You asked the Plan to pay for code 73565. You say that you have provided medical records and would like the
claim reconsidered. The Plan denied your request. The Plan says payment for code 73565 is bundled into
payment for code 73564.

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 73565
is a column II code to column I code 73564 with a modifier indicator of 0. This means that there are no
modifiers that would allow for separate payment. The column II code is therefore not payable. Based on the
claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have
to pay for procedure code 73565 billed for date of service January 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit provided on July 19, 2019. 
 
You asked the Plan to pay for the emergency department visit. The Plan denied your request. The Plan says 
Medicare denies a claim for untimely filing if the receipt date applied to the claim exceeds 12 months or 1 
calendar year from the date the services were furnished. The claim was received on May 27, 2022. This is past 
the allowed 12-month timeframe. 
 
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 emergency department visit was not filed until May 27, 2022. 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 an emergency department visit provided on July 19, 2019.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the bone marrow aspirate (CPT code 38220). 
 
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says the clinical value and effectiveness of bone marrow aspirate in the setting of spinal 
fusion surgery have not been demonstrated in the peer-reviewed literature. 
 
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 pre-approve the service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found bone marrow aspirate is experimental. More research is needed to show safety and efficacy. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the bone marrow aspirate (CPT code 38220).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are a fall risk, and you need this to help get back 
to your daily life. The Plan denied your request. The Plan says the criteria for admission to the Acute Inpatient 
Rehabilitation setting have not been met. Your ongoing skilled therapy and nursing needs can be provided at a 
lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found your medical problems are stable and there are no complex nursing or rehabilitation needs. There is no documented need for intensive rehabilitation services and medically necessary care can be 
provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for fluoride varnish (D1208), a periodic oral evaluation 
(D0120), and prophylaxis (D1110), provided by an out-of-network provider on June 13, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you bought this insurance in good faith 
that these services would be covered. 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 fluoride varnish (D1208), a periodic oral 
evaluation (D0120), and prophylaxis (D1110), provided by an out-of-network provider on June 13, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested service will help the enrollee regain 
maximum function. The Plan denied your request. The Plan says the request is not medically necessary, the 
services they need can be provided safely in other settings. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. There is no documented need for intensive rehabilitation services and medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional physical therapy visits. 
 
You asked the Plan to pre-approve the visits. You say that this is needed for pain control, gait improvement, 
ambulation, and strength/stamina to improve functional capacity. The Plan denied your request. The Plan says 
that the documentation does not support the need for a skilled therapist. 
 
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 the visits. Our reviewer says that skilled 
services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. 
The requested additional visits are not medically reasonable or necessary. Our physician reviewer found that 
the additional requested therapy generally is not accepted as specific and effective therapy for the patients hip 
and back condition beyond what was approved by the health plan. The patient has had hip and back pain and 
appears to have lumbar radicular symptoms which would cause referred hip pain from the back. The patient has 
had prior therapy and the documentation does not reveal that the patient's requires the unique skills of a 
professional therapist to safely and effectively provide treatment, that the services can be safely and effectively 
performed only by a therapist, or by or under the supervision of a therapist. The requested services are not part 
of a maintenance program, and the specialized skill, knowledge and judgment of a qualified therapist is not 
required to establish, design and/or deliver a program to maintain the patient's current condition or to prevent or 
slow further deterioration. 
 
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 visits have not been met. Therefore, we decided that the Plan does not have 
to pre-approve additional physical therapy visits.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gemtesa tablets. 
 
You asked the Plan to pre-approve Gemtesa tablets. You say that the enrollee has narrow angle glaucoma, and 
has tried Myrbetriq in the past. You also say that only Myrbetriq or Gemtesa can be used. The Plan denied your 
request. The Plan says Gemtesa is a benefit exclusion under the enrollee's Medicare Advantage plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Gemtesa tablets.  
 
Benefits for Gemtesa tablets 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99135 billed for date of service May 28, 
2021. 
 
You asked the Plan to pay for procedure code 99135. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says procedure code 99135 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 99135 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99135 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99135 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99135 billed for date of service May 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on February 17, 2022 to March 8, 
2022 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the charges. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the 
services provided. 
 
  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 include 
cost-sharing obligations that were agreed to when you signed up for the Plan. Therefore, we decided that the 
Plan does not have to pay more for dental services provided on February 17, 2022 to March 8, 2022
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bone replacement graft on tooth #29 (D7953) provided on 
May 24, 2022. 
 
You asked the Plan to pay for a replacement graft. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says a bone replacement graft (D7953) 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 bone 
replacement graft on tooth #29 (D7953) provided on May 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date of service 
January 19, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service was medically necessary and should be 
paid. The Plan denied your request. The Plan says this code is not separately payable. 
 
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 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 validity testing billed with code 83789 for date of service January 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the four two-dimensional (2D) oral/facial photographic 
images (D0350 x4), cone beam computed tomography (CT) capture and interpretation (D0367), oral hygiene 
instructions (D1330), four gingival irrigations (D4921 x4), four periodontal procedures (D4999 x4), or pay 
more for the periodontal scalings and root planings (D4341) provided on March 1, 2022. 
 
  You asked the Plan to pay for the 2D oral/facial photographic images, cone beam CT capture and 
interpretation, oral hygiene instructions, gingival irrigations, periodontal procedures, and to pay more for the 
scalings and planings. You say that you went to an in-network dentist and believe these services should be 
covered. The Plan denied your request. The Plan says the 2D oral/facial photographic images, cone beam CT 
capture and interpretation, oral hygiene instructions, gingival irrigations, and periodontal procedures are not 
covered benefits under your dental plan. The Plan also says copayments are a contractual obligation and cannot 
be waived. 
 
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 2D oral/facial photographic image 
(D0350), cone beam CT capture and interpretation (D0367), oral hygiene instructions (D1330), gingival 
irrigation (D4921), and unspecified periodontal procedure (D4999) are not among those covered under this 
benefit. The contract also clearly states that you are responsible for a 50% coinsurance for periodontal scalings 
and root planings (D4341). Therefore, we decided that the Plan does not have to pay for the four two-
dimensional (2D) oral/facial photographic images (D0350 x4), cone beam computed tomography (CT) capture 
and interpretation (D0367), oral hygiene instructions (D1330), four gingival irrigations (D4921 x4), four 
periodontal procedures (D4999 x4), or pay more for the periodontal scalings and root planings (D4341) 
provided on March 1, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 97110, 97112, and 97530 provided on 
March 21, 2022. 
 
You asked the Plan to pay for procedure codes 97110, 97112, and 97530. You say that you would like the Plan 
to reconsider their denial of payment. The Plan denied your request. The Plan says the medical records do not 
support the services 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 97110 is Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility. The 
definition of code 97112 is Therapeutic procedure, 1 or more areas, each 15 minutes; neuromuscular 
reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting 
and/or standing activities. The definition of code 97530 is Therapeutic activities, direct (one-on-one) patient 
contact (use of dynamic activities to improve functional performance), each 15 minutes. 
 
We find that CPT code 97110, 97112, and 97530 are not supported in the medical record. Specifically, the 
records do not describe these codes as being provided on this date of service. Based on this information, we 
decided that Medicare rules for coverage of procedure codes 97110, 97112, and 97530 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes 97110, 97112, and 97530 
provided on March 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the lingual frenectomy (code D7962), the 5 tooth 
extractions (code D7140) and the two alveoloplasty services (code D7311) you received from an out-of-
network dentist on May 11, 2022. 
 
You asked the Plan to pay more for the dental services. You say that your plan covers up to $2500 per year for 
dental services, so the Plan needs to reimburse you. The Plan denied your request. The Plan says it has 
reprocessed your claim and paid for these services in accordance with your contract.  In addition, the Plan says 
that after reprocessing, it is still denying payment for the lingual frenectomy (D7962), since you are only 
covered for two oral surgery procedure codes per calendar year. 
 
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. Your Plan contract says that 
for out-of-network dental extractions, you pay 50%. For oral surgery procedures, you also pay 50% for out-of-network services.  However, coverage of oral surgery procedures is limited to two procedure codes per 
calendar year.  You had three oral surgery procedures on this date of service (two alveoloplasties and one 
lingual frenectomy).  The Plan has reprocessed the claim to pay for the two alveoloplasties at 50% as per your 
contract for out-of-network services, but it has appropriately denied the third oral surgery code (D7962 for the 
lingual frenectomy). So, in total, you are responsible for 50% cost sharing for the extractions and the two 
alveoloplasties, and you are responsible for the full amount for the lingual frenectomy.  Therefore, we decided 
that the Plan does not have to pay more for the lingual frenectomy (code D7962), the 5 tooth extractions (code 
D7140) and the two alveoloplasty services (code D7311) you received from an out-of-network dentist on May 
11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for a resin-based composite filling on tooth #30 
(D2393) provided on June 22, 2022. 
 
You asked the Plan to waive the cost share for a filling. You say that this service should be covered. The Plan 
denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 50% coinsurance for a filling. The contract also says that fillings are covered once every 24 months per surface, per 
tooth. White fillings on posterior teeth will be processed as a silver filling and the patient is responsible for up 
to the contracted fee. 
 
The record shows the Plan paid at the least costly treatment option and you are responsible for the difference 
between the codes, which is $50 ($186 allowed amount for D2393 - $136 allowed amount for D2160 = $50). 
You have been asked to pay $68, which is 50% coinsurance of the allowed amount for a filling ($136 allowed 
amount x 50% coinsurance = $68). 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. Therefore, we decided that 
the Plan does not have to waive the cost share for a resin-based composite filling on tooth #30 (D2393) 
provided on June 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for a pontic on tooth #10 (D6241) and implant 
supported crowns on tooth #9 and 11 (D6751) provided on May 31, 2022. 
 
You asked the Plan to waive the cost share for the dental services. You say that you were never told that you 
had to pay 50% and a deductible. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that there is a $50 deductible that applies to comprehensive dental services. The Plan contract says that enrollees must pay 50% 
coinsurance for pontics (D6241), and implant supported crowns (D6751). 
 
You have been asked to pay a total of $944 for the dental services received on May 31, 2022. These 
items/services fall within the dental services benefit category.  
 
Code Allowed Amount Deductible Coinsurance 
D6241 $606 $50 $278 
D6751 $616  $308 
D6751 $616  $308 
Total  $944 
 
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 waive the cost share for a pontic on tooth #10 (D6241) and implant supported crowns 
on tooth #9 and 11 (D6751) provided on May 31, 2022.