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

 
We decided that the Plan does not have to pay for the anesthesia services coded 00541 provided on October 19, 2021. 
 
You asked the Plan to pay for the anesthesia services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation. 
 
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 00541 is anesthesia for thoracotomy procedures 
involving lungs, pleura, diaphragm, and mediastinum (including surgical thoracoscopy); utilizing 1 lung 
ventilation. 
 
We find that CPT code 00541 is not supported in the medical record. Specifically, the medical records 
submitted do not include an anesthesia record for the billed date of service. Based on this information, we 
decided that Medicare rules for coverage of the anesthesia services have not been met. Therefore, we decided 
that the Plan does not have to pay for the anesthesia services coded 00541 provided on October 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a white glass with metal crown for teeth #7-9. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the x-rays of the tooth do not show a cavity under the old cap. 
 
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 services 
when the services are medically necessary and reasonable.  
 
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 medically reasonable or necessary. Our physician reviewer found a review of the 
documentation did not reveal the reason for the replacement of the crowns. The radiographs submitted were 
inadequate and according to the rules of coverage crowns are covered once in a 5 year period per tooth. The 
crowns in place are less that the 5 year time period allows. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a white glass with metal crown for teeth #7-9.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dermatology consult for the purpose of permanent hair 
removal. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is considered cosmetic for transgender care purposes. 
 
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 record indicates that the enrollee is transitioning from male to female and has gender dysphoria. The 
record provided does not support the medical necessity of the requested procedure as defined by Medicare 
rules. The record does not indicate why the requested service is medically necessary at this time instead of 
standard treatments. The elements of the coverage criteria are not satisfied. 
 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 dermatology consult for the purpose of permanent hair removal.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periapical dental x-rays you received on November 11, 2021. 
 
You asked the Plan to pay for the periapical x-rays. You say that you believe that x-rays are covered under your 
dental plan.  You also said that you cannot afford these x-rays. The Plan denied your request. The Plan says 
these x-rays are not covered 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. This dental benefit includes 
coverage only for bitewing, panoramic, or complete series dental x-rays.  There is no coverage for periapical x-
rays. 
 
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 periapical dental x-rays you received on 
November 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for electrodes (A4556) provided February 10, 2021. 
 
You asked the Plan to pay for the electrodes. You say that the item was medically necessary. 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 must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code A4556 has a status indicator of P on the Physician Fee Schedule. This means that CPT 
code A4556 is not separately payable. Based on this information, we decided that Medicare rules for coverage of the electrodes have not been met. Therefore, we decided that the Plan does not have to pay for electrodes 
(A4556) provided February 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on 
December 15, 2021. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you disagree with the $35 
copayment. The Plan denied your request. The Plan says you have been charged 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 $35 
copayment for a specialist office visit.  
 
The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay a 
$35 copayment for a specialist office visit. A specialist office visit falls within the Physician/Practitioner 
Services, Including Doctors 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 a specialist office visit provided on December 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom knee brace. 
 
You asked the Plan to pre-approve the brace. You say that this is medically necessary. The Plan denied your 
request. The Plan says you refused off-the-shelf braces, even when you were told that these braces would 
benefit you. 
 
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 brace. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the documentation does not reveal objective physical exam evidence of knee instability. There is no 
evidence of recent injury or surgery to the knees. The patient is documented to be wheelchair bound and it is 
not clear if she ambulates. There are no deformities, muscle mass deficits or other indications on a knee exam 
that require a custom orthosis for the knees. 
 
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 brace have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a custom knee brace.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a transthoracic echocardiogram (TTE) with 
doppler provided on December 1, 2021. 
 
You asked the Plan to waive the deductible for the TTE with doppler. You say that you switched to a new plan 
and you do not know why your deductible was reset. The Plan denied your request. The Plan says the correct 
amount was applied to your deductible. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is $750 deductible which applies to certain items and services.  
 
The item or service you asked the Plan to waive the deductible for falls within Outpatient Diagnostic Tests and 
Therapeutic Services and Supplies the benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is $750 deductible which applies to certain items and services. Please note 
that when enrolling in a new plan, the deductible for that new plan will apply. This cost sharing is a contractual 
obligation that had not been met at the time the TTE with doppler was received on December 1, 2021. 
Therefore, we decided that the Plan does not have to waive the deductible for a transthoracic echocardiogram 
(TTE) with doppler provided on December 1, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation provided on 
January 7, 2022. 
 
You asked the Plan to waive the copayment for ambulance transportation. You say that you thought everything 
related to COVID-19 was fully covered including the ambulance. You say that you feel it should pay for 
this because they paid your whole claim for the hospital stay. The Plan denied your request. The Plan says 
coinsurance is correct. 
 
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 $250 
copayment per one-way trip for ambulance services and non-emergency ambulance services.  
 
  You have been asked to pay $250 copayment for ambulance transportation. Ambulance transportation falls 
within the "Ambulance 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 copayment for 
ambulance transportation provided on January 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2750) for tooth #30 provided by a 
participating provider. 
 
You asked the Plan to pre-approve a crown. You say that this crown is medically necessary. The Plan denied 
your request. The Plan says the benefit limit for D2750 has already been met and exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers one crown per 
tooth every five years. 
 
We looked at the file and Medicare rules. Evidence was provided to show that a crown was provided for tooth 
#30 on August 28, 2018. Based on this information, we decided that the Plan's rules for coverage of a crown 
have not been met. Therefore, we decided that the Plan does not have to pre-approve a crown (D2750) for tooth 
#30 provided by a participating provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the manual therapy provided on July 27, 2021, and August 9, 2021. 
 
You asked the Plan to pay for manual therapy. You say that this service was medically necessary for your 
quality of life. The Plan denied your request. The Plan says that the manual therapy remains denied as not a 
covered chiropractic service. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the manual therapy provided on July 27, 2021, and August 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fixed partial denture sectioning (D9120) provided 
January 6, 2022. 
 
You asked the Plan to pay for the fixed partial denture sectioning. You say that to save money, your dentist 
reconfigured your denture so that it would still work. The Plan denied your request. The Plan says this service 
is not covered under your benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
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 fixed 
partial denture sectioning (D9120) provided January 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an interlaminar epidural injection for the enrollee. 
 
You asked the Plan to pre-approve the injection. You say that the enrollee experiences significant pain and a 
significantly reduced qualify of life. The Plan denied your request. The Plan says the clinical documentation 
did not show narrowing of the spine.  
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 injection. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found a vertebral fracture is not an indication for an epidural steroid injection. The steroid may lead to further 
loss of bony matrix. The request is not medically reasonable or necessary. There are other evidence based 
procedures that are available for this patient. 
 
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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an interlaminar epidural injection for the enrollee.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services (99285) provided to the enrollee 
on January 25, 2022. 
 
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 a different code was added because it more accurately describes the services rendered. 
 
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 relevant codes are: 
 
CPT 99284: 
 
Emergency department visit for the evaluation and management of a patient, which requires these 3 key 
components: A detailed history; A detailed examination; and Medical decision making of moderate 
complexity. Counseling and/or coordination of care with other physicians, other qualified health care 
professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or 
family's needs. Usually, the presenting problem(s) are of high severity, and require urgent evaluation by the 
physician, or other qualified health care professionals but do not pose an immediate significant threat to life or 
physiologic function. 
 CPT 99285: 
 
Emergency department visit for the evaluation and management of a patient, which requires these 3 key 
components within the constraints imposed by the urgency of the patient's clinical condition and/or mental 
status: A comprehensive history; A comprehensive examination; and Medical decision making of high 
complexity. Counseling and/or coordination of care with other physicians, other qualified health care 
professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or 
family's needs. Usually, the presenting problem(s) are of high severity and pose an immediate significant threat 
to life or physiologic function. 
 
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 enrollee presented to the 
emergency department with abdominal pain. The last bowel movement was two days prior, without passing 
gas. The labs and computed tomography (CT) were done without remarkable findings. The enrollee was given 
an enema which relieved the symptoms. The CPT code that was used in this case - 99285 - describes a high 
severity which was not described in the documentation. A more appropriate CPT based on the provided 
documentation is 99284.  
 
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 emergency room services (99285) provided to the enrollee on January 25, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Computed tomography scan coded as 70491 and the 
Computed tomography scan coded as 70460 provided on December 9, 2021. 
 
You asked the Plan to pay for codes 70491 and 70460. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70491 
is a column II code to column I code 70498. We have also confirmed that code 70460 is a column II code to 
column I code 0042T. These claims have not been billed with an appropriate modifier to bypass the edits. 
Based on the claims submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan 
does not have to pay for the Computed tomography scan coded as 70491 and the Computed tomography scan 
coded as 70460 provided on December 9, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on December 16, 
2021. 
 
You asked the Plan to pay for the services. You say that this was incorrectly reimbursed because of the payer's 
payment policy. The Plan denied your request. The Plan says there was a lack of supporting documentation 
from the non-participating provider. 
 
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 33208 is "Insertion of new or replacement of permanent 
pacemaker with transvenous electrode(s); atrial and ventricular." 
 
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 medical records attached 
accurately describe the process of a temporary replacement of a single chamber cardiac electrode. The 
procedure code for that would be CPT 33210. 
 
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 December 16, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services (73030) provided September 13, 2021. 
 
You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 73030 is not supported in the medical record. Specifically, the TC modifier was 
inappropriately billed for a radiology service provided to an enrollee that is in a facility setting. Based on this 
information, we decided that Medicare rules for coverage of the radiology services have not been met. 
Therefore, we decided that the Plan does not have to pay for radiology services (73030) provided September 
13, 2021.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture services (97811, 97810) provided October 1, 
2021. 
 
You asked the Plan to pay for the acupuncture services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that acupuncture treatments may be provided by a 
physician in accordance with state requirements, or by physician assistants, nurse practitioners/clinical nurse 
specialists, and auxiliary personnel if they meet certain licensure requirements. Auxiliary personnel furnishing 
acupuncture must be under the appropriate level of supervision of a physician, physician assistant, or nurse practitioner/clinical nurse specialist.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the record does not show that the service was 
provided by a physician, physician assistant, or nurse practitioner or under the supervision of one. Therefore, 
we decided that the Plan does not have to pay for acupuncture services (97811, 97810) provided October 1, 
2021.