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

 
We decided that the Plan does not have to pay more for the resin-based composite (D2392) on tooth #15 
provided on December 15, 2021. 
 
You asked the Plan to pay more for the resin-based composite. You say that the dentist you saw has not used 
silver fillings for over five years. You also say that you would like to appeal this service. The Plan denied your 
request. The Plan says when there are multiple, clinically acceptable treatment options, the Plan will pay for the 
least expensive treatment option. The Plan also says that you are responsible for the difference between the 
allowed amounts. 
 
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 received a resin-based composite 
(D2392) on tooth #15, which is a posterior tooth. The contract clearly states if you receive a white filling 
(resin-based composite) on a posterior tooth, the claim will be processed as a silver filling, and you will be 
responsible for the difference between the allowed amounts. Therefore, we decided that the Plan does not have 
to pay more for the resin-based composite (D2392) on tooth #15 provided on December 15, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound services provided on November 9, 2021, 
billed with code 76981-59-PO. 
 
You asked the Plan to pay for the ultrasound services as billed. You say that this is correctly billed and should 
be paid. The Plan denied your request. The Plan says this can only be paid with modifier -26 as only the PC is 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that Plans may not make payment for physicians for 
the TC of radiology services provided to hospital patients.  
 
We looked at the file and Medicare rules. In this case, the global service was billed, comprising both the PC 
and TC. The enrollee was a hospital outpatient at the time of service. This means that only the PC is payable. 
Based on this information, we decided that Medicare rules for coverage of the ultrasound services as billed have not been met. Therefore, we decided that the Plan does not have to pay for the ultrasound services 
provided on November 9, 2021, billed with code 76981-59-PO.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for admission 
 
You asked the Plan to pay for the admission. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the admission. Our reviewer says that the 
requested admission is not medically reasonable or necessary. Our physician reviewer found that at the time of 
admission, the enrollee required skilled rehab services to improve function due to weakness and 
deconditioning. There were no skilled nursing needs. As of 5/19/22, the enrollee did not require any skilled 
nursing or rehab services on a daily basis. She was not expected to make measurable gains within a reasonable 
and predictable period of time or require skilled therapy to prevent deterioration with mobility or ADLs. The 
enrollee did not require skilled therapy to establish a safe and effective maintenance program. As a practical 
matter, the enrollee did not require any skilled services on an inpatient basis, at a SNF level of care as of 
5/19/22. Custodial services were required. 
 
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 admission have not been met. Therefore, we decided that the Plan does not 
have to pay for admission
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and prophylaxis 
(D1110) provided on September 23, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that you have seen the 
same provider for years and usually have a $3.00 to $5.00 copay. You also say that you believe the services 
denied in error. The Plan denied your request. The Plan says services performed by an OON provider are not 
covered because your healthcare plan does not have OON benefits. The Plan also says that you did not contact 
the Plan prior to the 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 Plans coverage rules apply in this case. 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, you are responsible for 100% of the 
cost for dental services rendered by an OON provider. Therefore, we decided that the Plan does not have to pay 
for the periodic oral evaluation (D0120) and prophylaxis (D1110) provided on September 23, 2021 by an out-
of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional supplies, materials, and clinical staff time 
(99072) provided on December 27, 2021. 
 
  You asked the Plan to pay for the additional supplies, materials, and clinical staff time (99072). You say that 
the testing was supposed to be free of charge and you may receive and unwarranted bill if the Plan does not 
reverse the denial. The Plan denied your request. The Plan says procedure codes 87426 and 99211 have been 
paid. The Plan also says that procedure code 99072 remains denied as bundled services are not eligible for 
separate reimbursement, but you are not responsible for the cost of this service. 
 
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 99072 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99072 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of the additional supplies, materials, and clinical staff time (99072) have not been met, and you are not 
responsible for the cost of this service. Therefore, we decided that the Plan does not have to pay for the 
additional supplies, materials, and clinical staff time (99072) provided on December 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abutment supported porcelain/ceramic crown (D6058) 
and prefabricated abutment  includes modification and placement (D6056) provided January 6, 2022. 
 
You asked the Plan to pay for the abutment supported crown and prefabricated abutment. You say that you feel 
this should be covered because it is a crown. The Plan denied your request. The Plan says these services are not 
covered under your benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the abutment supported porcelain/ceramic crown (D6058) and prefabricated abutment  includes modification and 
placement (D6056) provided January 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the filling (D2335) for tooth # 9 provided on August 18, 2021. 
 
You asked the Plan to pay for the filling for tooth # 9. You say that the fillings were medically necessary. The 
Plan denied your request. The Plan says the claim processed correctly. 
 
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 1 filling is covered per calendar 
year, the frequency limit has been exceeded. The record shows that the Plan paid for the fillings for tooth # 8 
that you received on the date of service in this case. Therefore, we decided that the Plan does not have to pay 
for the filling (D2335) for tooth # 9 provided on August 18, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on April 29, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the billed 
code cannot be verified. 
 
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 87150 is culture, typing; identification by nucleic acid 
(DNA or RNA) probe, amplified probe technique, per culture or isolate, each organism probed. 
 
We find that CPT code 87150 is not supported in the medical record. The file shows that gastrointestinal 
pathogen testing for 22 pathogens were provided. There is a more comprehensive code available that describes 
the services provided. Based on this information, we decided that Medicare rules for coverage have not been 
met. Therefore, we decided that the Plan does not have to pay for the lab services provided on April 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on December 20, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the plan has not received the required clinical records to support the medical necessity of the 
services for the date of service requested. 
 
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 laboratory services provided to the enrollee on December 20, 2021 have been met. The records sent in by the provider are incomplete, as they are 
unsigned and undated. The services cannot be verified in this case. Therefore, we decided that the Plan does not 
have to pay for laboratory services provided to the enrollee on December 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a prosthetic leg with an advanced foot feature and other parts.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says a request for K3 foot does not meet Medicare criteria for being reasonable and necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the treating medical provider documentation does not reveal that the patient is a K3 or above ambulator. The vendor documentation of K3 is noted but this is not corroborated by the physician medical record. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve a prosthetic leg with an advanced foot feature and other parts.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endoskeletal knee-shin system, single axis, fluid swing 
and stance phase control (CPT code L5828), endoskeletal, knee-shin system, stance flexion feature, adjustable 
(CPT code L5845), addition to endoskeletal knee-shin system, fluid stance extension, dampening feature, with 
or without adjustability (CPT code L5848), and addition to lower extremity prosthesis, endoskeletal knee-shin 
system, microprocessor control feature, swing and stance phase, includes electronic sensor(s), any type (CPT 
code L5856). 
 
You asked the Plan to pre-approve the items. You say that the items are necessary. The Plan denied your 
request. The Plan says the computerized knee exceeds your medical need; therefore, this cannot be covered. 
The Plan states there are other knees that can meet your needs and a request for a knee that meets your needs 
and Medicare rules can be reviewed if submitted. 
 
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 items. Our physician reviewer 
found the review indicates that requested K3 microprocessor knee is a C-Leg, coded L5848 + L5845 + L5828 
+ L5856. While your doctor documents that you have K3 potential, the doctor does not give any reason why a 
microprocessor knee is medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the items have not been met. Therefore, we decided that the Plan does not have 
to pre-approve endoskeletal knee-shin system, single axis, fluid swing and stance phase control (CPT code 
L5828), endoskeletal, knee-shin system, stance flexion feature, adjustable (CPT code L5845), addition to 
endoskeletal knee-shin system, fluid stance extension, dampening feature, with or without adjustability (CPT 
code L5848), and addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor 
control feature, swing and stance phase, includes electronic sensor(s), any type (CPT code L5856).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic analysis of a stool sample provided on August 29, 
2021. 
 
You asked the Plan to pay for the stool genetic analysis. You say that this is medically necessary testing. The 
Plan denied your request. The Plan says the claim was reported with a POS code that does not describe the 
location in which the sample was collected. 
 
The Plan must follow Medicare rules. Medicare rules say that 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. Based on this information, we decided that Medicare rules for 
coverage of the stool genetic analysis have not been met. Specifically, this claim was billed with the laboratory 
POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided 
that the Plan does not have to pay for genetic analysis of a stool sample provided on August 29, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Drug Testing provided on January 4, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for Drug Testing. You say that you would like to request reconsideration stating to 
review and approve the request for retroactive authorization of the denied claim. The Plan denied your request. 
The Plan says the provider is out-of-network and it was determined these services were not urgent or emergent. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for Drug Testing provided on January 4, 2022 by an 
out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the simple extraction (D7140) provided on February 16, 
2022. 
 
You asked the Plan to pay for the simple extraction. The Plan denied your request. The Plan says this service 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 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 the simple 
extraction (D7140) provided on February 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided by a participating 
provider on January 11, 2022. 
 
You asked the Plan to pay for a limited oral evaluation. You say that you were told that the exam was free. The 
Plan denied your request. The Plan says the rendered service has been correctly denied. 
 
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 by a participating provider on January 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pontic (D6245), and a retainer crown (D6740) provided by 
a participating provider on December 3, 2021. 
 
You asked the Plan to pay for a pontic and a retainer crown. You say that you would like the Plan to pay for 
this. The Plan denied your request. The Plan says these services have been correctly denied. 
 
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 pontic 
(D6245), and a retainer crown (D6740) provided by a participating provider on December 3, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for genetic testing performed on December 
15, 2021. 
 
You asked the Plan to waive the coinsurance for the genetic testing. You say that the test was not the right one 
and you were not made aware ahead of time. The Plan denied your request. The Plan says the correct 
coinsurance was applied. 
 
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 a 20% 
coinsurance for genetic testing in all service settings.  
 
You have been asked to pay $774.60, which is 20% of the allowed amount for the genetic testing ($3,873.00 
allowed amount x 20% coinsurance = $774.60). The genetic testing falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies 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 coinsurance 
for genetic testing performed on December 15, 2021.  
 
Your complaint about receiving the incorrect test from the provider 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve expandable controller, including all related electronics 
and mounting hardware, upgrade provided at initial issue (CPT code E2377), harness for upgrade to 
expandable controller (CPT code E2313), Q-Logic 3 Ex Joystick (CPT code K0108), electronic connection 
between wheelchair controller and two or more power seating system motors, including all related electronics, 
indicator feature, mechanical function selection switch, and fixed mounting hardware (CPT code E2311), and 
foot plate extensions (CPT code K0108). 
 
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your 
request. The Plan says the DME is not necessary. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the DME have not been met. Upgraded electronics (electronic 
connection, expandable controller and harness) cannot be covered per Medicare rules. They are necessary when 
there is a medical need to control power options though the joystick. The notes do not show a medical need to 
control the power options through the joystick. The power options can be controlled using their own switches. 
These switches can be made any size without asking for a separate request. They can be made from any 
material without asking for a separate request. All of this can be done without the need to use the joystick to 
control the power features. The Q-Logic joystick is already included with the upgraded controller. It cannot be 
requested separately. The foot plate extension do not serve a primary medical purpose. Therefore, we decided 
that the Plan does not have to pre-approve expandable controller, including all related electronics and mounting 
hardware, upgrade provided at initial issue (CPT code E2377), harness for upgrade to expandable controller 
(CPT code E2313), Q-Logic 3 Ex Joystick (CPT code K0108), electronic connection between wheelchair 
controller and two or more power seating system motors, including all related electronics, indicator feature, 
mechanical function selection switch, and fixed mounting hardware (CPT code E2311), and foot plate 
extensions (CPT code K0108).