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

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on September 28, 
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 61783 has been billed without appropriate primary 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, the CPT Code Manual definition of the denied codes is: 
 
61783 - Stereotactic computer-assisted (navigational) procedure; spinal (List separately in addition to code for 
primary procedure) 
 
22899 - Unlisted procedure, spine 
 
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 services.  Our reviewer says that the services at issue in this case were not supported by the medical records. Our 
reviewer found the operative report does not include documentation of an unlisted procedure. Therefore, CPT 
22899 this code cannot be verified. Additionally, CPT 61783 is an add-on code. The documentation does not 
document a primary code to support the reporting of an "add on" code. "Add on" procedure codes should never 
be reported as a stand alone code.  Therefore this procedure would not be covered. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for surgical services provided to the enrollee on September 28, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intravascular ultrasound procedures on arteries and veins 
(37253) provided August 25, 2021. 
You asked the Plan to pay for the intravascular ultrasound procedures. You say that you request review of the 
attached procedure report and the reprocessing of this code for payment. The Plan denied your request. The 
Plan says the service is not supported in the medical records. 
 
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 37253 is intravascular ultrasound (noncoronary vessel) 
during diagnostic evaluation and/or therapeutic intervention, including radiological supervision and 
interpretation; each additional noncoronary vessel. 
 
We find that CPT code 37253 is not supported in the medical record. Specifically, the operative report did not 
include documentation of an intravascular ultrasound (noncoronary vessel) during diagnostic evaluation and/or 
therapeutic intervention, including radiological supervision and interpretation for each additional noncoronary 
vessel. Based on this information, we decided that Medicare rules for coverage of the intravascular ultrasound 
procedures have not been met. Therefore, we decided that the Plan does not have to pay for intravascular 
ultrasound procedures on arteries and veins (37253) provided August 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy-duty walker (E0149). 
 
You asked the Plan to pre-approve a heavy-duty walker. You say that this walker is medically necessary. The 
Plan denied your request. The Plan says you do not meet the coverage criteria for the requested walker, and you 
were previously approved for equipment to meet your needs in the home. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. The medical records show you are less than three hundred pounds and do not meet 
the criteria for the requested walker. In addition, the Plan has approved a standard walker for use in your home.  
Therefore, we decided that the Plan does not have to pre-approve a heavy-duty walker (E0149).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency oral evaluation (D0140) provided on 
December 13, 2021. 
 
You asked the Plan to pay for the dental service. You say that both visits you had in December 2021 should be 
covered. You say that the second exam was necessary since the source of the problem seemed to be where you 
had a root canal previously. The Plan denied your request. The Plan says emergency oral evaluation is covered 
once every 12 months. 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage and emergency oral evaluation is 
covered once every 12 months, the frequency limit has been exceeded. The record shows that the Plan paid for an emergency oral evaluation that you received on December 6, 2021. Therefore, we decided that the Plan does 
not have to pay for the emergency oral evaluation (D0140) provided on December 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an MDS-NGS (myelodysplastic syndromes next 
generation sequencing) panel (81450). 
 
You asked the Plan to pre-approve an MDS-NGS panel. You say that this is medically necessary. The Plan 
denied your request. The Plan says this test has not undergone a technical assessment. 
 
The Plan must follow Medicare rules. Medicare rules say that in order for a next-generation sequencing panel 
to be covered, the test has satisfactorily completed a technical assessment (TA) by MolDX for the stated 
indications of the test. 
 
We looked at the file and Medicare rules. The requested testing has not completed a technical assessment (TA) 
by MolDX. Based on this information, we decided that Medicare rules for coverage of an MDS-NGS panel 
have not been met. Therefore, we decided that the Plan does not have to pre-approve an MDS-NGS 
(myelodysplastic syndromes next generation sequencing) panel (81450).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist office visit provided by a 
network physician on November 3, 2021. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that you should not pay for 
the office visit because the provider does not do much. The Plan denied your request. The Plan says you have 
been asked to pay the correct cost-sharing amount. 
 
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 $30 
copayment for each in-network Medicare covered specialist visit.  
 
You have been asked to pay a $30 copayment for the specialist office visit. The specialist office visit falls 
within the "Physician/Practitioner services, including doctor's office visits" 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 copayment for the specialist office visit provided by a network physician on 
November 3, 2021.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay for the prophylaxis. We decided that the Plan does not have to pay for the 
oral exam.  
You asked the Plan to pay for the dental services. You say that you did not pay for the periodontal maintenance 
in June 2021. You also say that the cleaning should be covered. The Plan denied your request. The Plan says 
payment will be made for oral examinations (except after-hours exams and exams for observation) and 
cleanings (including periodontal cleanings in the presence of inflamed gums or any combination thereof) no 
more than twice in a calendar year. 
 
We decided that the Plan has to pay for the prophylaxis.  
 
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 show that the Plan has paid for a combination of 2 
prophylaxis and/or periodontal maintenance prior to the date of service in this case. Therefore, we decided that 
the Plan has to pay for prophylaxis.  
 
We also decided that the Plan does not have to pay for the oral exam. 
 
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 frequency limit has been exceeded. 
The record shows that payment will be made for oral examinations (except after-hours exams and exams for 
observation) no more than twice in a calendar year. The record also shows that the Plan paid for oral exams that 
you received on a cleaning that you received on February 11, 2021, and June 23, 2021.  Therefore, we decided 
that the Plan does not have to pay for the oral exam. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a new enhanced rollator walker. 
 
You asked the Plan to pre-approve a new enhanced rollator walker. You say that a new enhanced rollator 
walker is necessary as your current walker has a broken wheel and is too short for you. The Plan denied your 
request. The Plan says there is no record of an attempt to have the current walker repaired or that the current 
walker cannot be repaired appropriately by the equipment provider. 
 
 The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. The records show you have a walker for your needs inside the home. There is no 
documentation from the DME provider that you have requested repairs or that the equipment cannot be 
repaired or adjusted. Therefore, we decided that the Plan does not have to pre-approve a new enhanced rollator 
walker.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for speech/hearing therapy (92507) provided on February 23, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for speech/hearing therapy. You say that a claim for the same procedure code 
(92507) and the same rendering provider was partially paid. The Plan denied your request. The Plan says this 
provider is out-of-network with the Plan, and authorization was not obtained prior to the services being 
rendered. The Plan also says that the appellant did not reference a date of service which she alleges was 
previously paid, so they cannot validate. 
 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 speech/hearing therapy (92507) provided on 
February 23, 2021, 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 retainer crown (D6750), pontic (D6240), and stress 
breaker (D6940) provided on November 3, 2021. 
 
You asked the Plan to pay for the dental services. You say that payment should be made as a regular crown. 
The Plan denied your request. The Plan says retainer crown, pontic, and stress breaker are not listed as covered 
services. 
 
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 retainer crowns, pontics, and stress 
breaker are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the retainer crown (D6750), pontic (D6240), and stress breaker (D6940) provided on November 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) 
provided August 25, 2021. 
 
You asked the Plan to pay for the problem focused oral exam. You say that you do not feel you received this 
service and should not be charged for it. The Plan denied your request. The Plan says the coinsurance has been 
applied correctly. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the problem 
focused oral exam with 50% coinsurance. 
 
We looked at the file and Medicare rules. In this case you were billed for a problem focused exam. You have 
been asked to pay $28 coinsurance ($56 allowed amount x 50% coinsurance = $28). The problem focused 
exam is a Class 2 Basic Service. This means you have been asked to pay the correct amount based on you 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation - problem focused 
(D0140) provided August 25, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that you were approved for a total left 
shoulder arthroplasty and will need inpatient admission after surgery. The Plan denied your request. The Plan 
says there is no documentation provided to support the expectation you will require a greater than 2 midnight 
stay. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.   
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case. Our physician reviewer found you are approved for a total left shoulder arthroplasty. The record does not 
document that the treating physician has a reasonable expectation of a length of stay spanning 2 or more 
midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fluoride treatment (code D1206) you received on 
November 29, 2021. 
 
You asked the Plan to pay for the fluoride treatment. You say that the dentist told you that your teeth were in 
poor condition and that's why you needed to fluoride treatment. The Plan denied your request. The Plan says 
fluoride treatments are not covered under 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. The Plan's contract says that 
only those dental services specifically listed in the supplemental benefits chart are covered. Fluoride treatments 
are not listed as a covered in this chart. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the fluoride treatment is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the fluoride 
treatment (code D1206) you received on November 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for the comprehensive oral evaluation 
(D0150), prophylaxis (D1110), and complete series x-ray (D0210) provided on January 3, 2022 by the out of 
network dentist. 
 
You asked the Plan to pay an additional amount for the dental services. You say that the complete series x-ray 
should be covered. You also say that the provider did not advise that they did not participate with your 
insurance plan. The Plan denied your request. The Plan says complete series x-ray is not a covered service. The 
Plan also says there is a 50% coinsurance for covered dental services received out of network. 
 
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 and the oral evaluation and cleaning are 
listed as covered, there is a 50% coinsurance when you receive these services out of network. Additionally, 
complete series x-ray is not among those covered under this benefit. Therefore, we decided that the Plan does 
not have to pay an additional amount for the comprehensive oral evaluation (D0150), prophylaxis (D1110), and 
complete series x-ray (D0210) provided on January 3, 2022 by the out of network dentist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for dental services you received on November 2, 2021. 
 
You asked the Plan to pay more for the dental services. You say that your provider directory lists the dental 
group that you went to as a participating group with the Plan. You said that you were using the information that 
you were sent and were never told that the provider was out-of-network. You would like this claim processed 
as in-network. The Plan denied your request. The Plan says it does not list provider groups as participating 
providers in its directory.  Rather, the Plan lists individual providers with their group name underneath in the 
directory.  The specific provider you saw was not a network dentist on the date of service in question.  The 
Provider directory specifically states that this particular provider was not going to be a network provider until 
2022.  The Plan says that based on this information, you were charged appropriately for these dental 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. In this case, the provider you 
saw was out-of-network with the Plan no the date of service in question. According to your dental benefit, 
basic dental services are covered with a $100 annual deductible, and then 20% coinsurance of the covered plan allowance thereafter. The covered plan allowance for the services you received is $116. After the $100 
deductible, that left a remaining $16 towards the covered plan allowance for this service.  The Plan reimbursed 
you 80% of this remainder, a total of $12.80.  Because you used an out-of-network provider, they are not 
obligated to limiting their billing to the covered plan allowance.  That is why the amount you were charged by 
the dentist was higher than $116. Based on the Plan's contract language, you have been paid appropriately for 
the dental services you received. Therefore, we decided that the Plan does not have to pay more for dental 
services you received on November 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the partial upper denture (D5211) and partial lower denture 
(D5214) provided on September 23, 2020. 
 
You asked the Plan to pay for the dental services. You say that you received prior authorization for upper and 
lower partial dentures. You say that the provider failed to confirm the benefit information. You also say that 
you were not notified that there would be out of pocket costs. The Plan denied your request. The Plan says the 
annual maximum benefit of $2,000 has been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage and dentures are listed as covered, the 
annual maximum benefit of $2,000 has been exceeded. 
 Date of Service Plan Paid 
6/16/2020 $201.26 
6/17/2020 $610.25 
6/24/2020 $810.70 
9/8/2020 $377.77 
TOTAL: $2,000 
 
Additionally, the prior authorization letter clearly states that payment for covered services is also based on the 
benefit limits and maximum annual benefit included in your dental benefit. Therefore, we decided that the Plan 
does not have to pay for the partial upper denture (D5211) and partial lower denture (D5214) provided on 
September 23, 2020.