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

 
We decided that the Plan does not have to pay for the physical performance test (97750) provided on October 
25, 2021. 
 
You asked the Plan to pay for the physical performance test (97750). You say that the records prove the 
medical necessity for the services provided and the claim should be reprocessed for payment. The Plan denied 
your request. The Plan says the documentation received does not indicate the appropriate use of the -59 
modifier as it does not include the specific test performed, and a separate measurement report, as required by 
the LCD. 
 
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 97750 is a column II code to column I code 97530; however, 97750 
was billed with a modifier.  
 
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 physical performance test (97750). Our reviewer says 
that modifier -59 is used to distinguish a different session, patient encounter, procedure or surgery, anatomical 
site, or separate injury. Our reviewer found that the documentation doesn't support the use of modifier -59 with 
CPT code 99750. 
 
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 physical performance test (97750) have not been met. Therefore, we decided 
that the Plan does not have to pay for the physical performance test (97750) provided on October 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extractions, erupted tooth or exposed root (elevation 
and/or forceps removal) (D7140) and extractions, erupted tooth requiring removal of bone and/or sectioning of 
tooth and including elevation of mucoperiosteal flap if indicated (D7210) provided November 8, 2021. 
 
You asked the Plan to pay for the tooth extractions. You say that the extractions became necessary during your 
routine cleaning. The Plan denied your request. The Plan says extractions 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
extractions, erupted tooth or exposed root (elevation and/or forceps removal) (D7140) and extractions, erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210) provided November 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the adjunctive pre-diagnostic test (D0431), gingival 
irrigation (D4921), localized delivery of antimicrobial agents (D4381) and drugs dispensed in the office for 
home use (D9630) provided on November 9, 2021. 
 
You asked the Plan to pay for the dental services. You say that you are being billed more than you expected for 
these services. The Plan denied your request. The Plan says these services are not covered by your dental 
benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
adjunctive pre-diagnostic test (D0431), gingival irrigation (D4921), localized delivery of antimicrobial agents 
(D4381) and drugs dispensed in the office for home use (D9630) provided on November 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown (D2740), and core buildup (D2950), provided on 
November 29, 2021, by an out-of-network provider. 
 
You asked the Plan to pay for the crown and core buildup. You say that the services should be covered. The 
Plan denied your request. The Plan says this service was performed by a non-participating provider. You are 
responsible for any difference between the Maximum Allowable Fee and the amount the provider bills you for 
the 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 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 crown 
(D2740), and core buildup (D2950), provided on November 29, 2021, by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implant supported porcelain/ceramic crown (D6065) 
and prefabricated abutment - includes modification and placement (D6056). 
 
You asked the Plan to pre-approve the implant supported crown and prefabricated abutment. You say that these 
services are medically necessary. The Plan denied your request. The Plan says implant 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 pre-approve 
implant supported porcelain/ceramic crown (D6065) and prefabricated abutment - includes modification and 
placement (D6056).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyeglasses (V2020, V2100, V2799) purchased on 
November 8, 2021, by an out-of-network provider. 
 
You asked the Plan to pay for the eyeglasses. You say that member services directed you to use this provider. 
The Plan denied your request. The Plan says the provider in this case is not part of the Plan's network. The Plan 
also states that the call logs have been reviewed. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services up to $100 when they are received from an in-network provider. 
 
We looked at the file and the Plan's rules. The provider in this case is not part of the Plans network. Based on 
this information, we decided that the Plan's rules for coverage of the eyeglasses have not been met. Therefore, 
we decided that the Plan does not have to pay for the eyeglasses (V2020, V2100, V2799) purchased on 
November 8, 2021, by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on December 30, 2021. 
 
You asked the Plan to pay for the services provided. You say that the exam was required to be seen by the 
provider. The Plan denied your request. The Plan says the service is non-covered. 
 
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.  
 
We looked at the file and the rules. The office visit, when provided by a chiropractor, is not a covered service. 
Based on this information, we decided that the Medicare rules for coverage have not been met. Therefore, we 
decided that the Plan does not have to pay for the office visit provided on December 30, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that records do not show that doctors expect that the enrollee will 
get better with LTACH care. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. The enrollee 
is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the 
LTACH that are not available at the acute care hospital where she is currently receiving care. There are no 
services available at the LTACH that the enrollee requires that are not available at the health care setting being 
offered by the health plan. Our physician reviewer found that the enrollee's condition does not meet Medicare 
criteria for LTACH services. 
 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital discharge day management rendered on January 
13, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 99239 is not supported. 
 
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 99239 is hospital discharge day management; more than 
30 minutes. We find that CPT code 99239 is not supported in the medical record. Specifically, there is no 
documentation of more than 30 minutes of hospital discharge day management. Based on this information, we 
decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the 
Plan does not have to pay for the hospital discharge day management rendered on January 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on January 19, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that services that do not contribute meaningfully to the 
treatment of an illness or injury or the functioning of a malformed body member are not covered. 
 
We looked at the file and Medicare rules. The file shows that you received laboratory services for pre-
employment. These services were not rendered for the treatment of an illness or injury. Based on this 
information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we 
decided that the Plan does not have to pay for the laboratory services rendered on January 19, 2022.  
 
Benefits for these services 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator. 
 
You asked the Plan to pre-approve a portable ventilator. You say that the records provided support the need for 
a portable ventilator. The Plan denied your request. The Plan says the Medicare criteria for coverage of lung 
devices has not been met. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 a portable ventilator. Our reviewer says 
that a home ventilator is not medically necessary. Our physician reviewer found the enrollee experienced chest 
pain after endoscopy, and then after IV morphine became hypotensive requiring pressors. A subsequent arterial 
blood gas (ABG)reportedly showed a partial pressure of carbon dioxide (PaCO2) of 68, but full information 
was not provided. It is not clear whether the ABG was done while the enrollee was still affected by morphine. Forced expiratory volume (FEV1) and forced vital capacity (FVC) show severe obstruction, but full data was 
not provided. The enrollee may benefit from bilevel positive airway pressure (BiPAP) during sleep if chronic 
carbon dioxide (CO2) retention is confirmed. The order dated April 7, 2022, is for BiPAP with average 
volume-assured pressure support (AVAPS) and backup rate, not for a ventilator. Medicare does not pay for a 
home ventilator when used as BiPAP. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup (D2950) and crown (D2740) provided on 
September 30, 2021. 
 
You asked the Plan to pay for the dental services. You say that you were assured by a Plan representative that 
your dental care would be covered prior to services. The Plan denied your request. The Plan says these services 
are not covered by your dental benefit. The Plan also says that in your calls to the Plan, you indicated that you 
were not sure which services you were going to need and prior authorizations for specific services were not 
discussed. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the core 
buildup (D2950) and crown (D2740) provided on September 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services you received on August 3, 2021, and October 
12, 2021. 
 
You asked the Plan to pay for the dental services. You say that you were never told that you had to use a 
network dentist. The Plan denied your request. The Plan says dental services with an out-of-network provider 
are not covered. 
 
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 out-of-network dental services you 
received are not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pay for dental services you received on August 3, 2021, and October 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for unspecified preventative procedure (D1999), and a maxillary 
denture (D5110) by a participating provider on April 21, 2021, to June 1, 2021. 
 
You asked the Plan to pay for unspecified preventative procedure (D1999), and a maxillary denture. You say 
that you would like the Plan to pay for this. The Plan denied your request. The Plan says D1999 is not a 
covered dental benefit. The Plan says that the members maximum benefit allowance amount of $1,000 has 
already been met. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum 
benefit allowance of $1,000. The Plan does not cover D1999. 
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of unspecified preventative procedure (D1999), and a maxillary denture have not been met. 
Therefore, we decided that the Plan does not have to pay for unspecified preventative procedure (D1999), and a 
maxillary denture (D5110) by a participating provider on April 21, 2021, to June 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral imaging provided by a contracted provider on 
January 7, 2022. 
 
You asked the Plan to pay for intraoral imaging. You say that you believe this should all be covered. The Plan 
denied your request. The Plan says the benefit limit for intraoral imaging has already 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. The Plan covers intraoral 
imaging once per calendar year.  
 
We looked at the file and Medicare rules. Evidence was provided to show that multiple intraoral images were 
taken on January 7, 2022. Based on this information, we decided that the Plan's rules for coverage of intraoral 
imaging have not been met. Therefore, we decided that the Plan does not have to pay for intraoral imaging 
provided by a participating provider on January 7, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care (99233) provided on October 
26, 2021. 
 
You asked the Plan to pay for the subsequent hospital care. You say that you would like reconsideration based 
on the records submitted. The Plan denied your request. The Plan says the member was enrolled in hospice. 
 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the subsequent hospital care (99233) provided on October 26, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2740), a core build-up (D2950), and 
gingivectomy (D4211) provided by a participating provider on March 24, 2021. 
 
You asked the Plan to pay for a crown, a core build-up, and gingivectomy. You say that you would like this 
claim reprocessed and paid. The Plan denied your request. The Plan says the rendered dental services are not 
covered dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a crown 
(D2740), a core build-up (D2950), and gingivectomy (D4211) provided by a participating provider on March 24, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on September 9, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed and 
approved for payment based on the medical documentation provided The Plan denied your request. The Plan 
says the claim has denied correctly based on Medicare billing regulations. 
 
  The Plan must follow Medicare rules. Medicare rules say that if the specimen was stored for more than 30 
calendar days before testing, the specimen is considered to have been archived and the date of service of the 
test/service must be the date the specimen was obtained from storage 
 
We looked at the file and Medicare rules. In this case, the specimen that testing was performed on had been in 
storage since January 31, 2020. The specimen is said to have been received on September 1, 2021. The 
specimen was in storage for more than 30 days. Therefore, the date of service that should have been billed 
would have been September 1, 2021, not September 9, 2021. Based on this information, we decided that 
Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pay for the laboratory services provided on September 9, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hot or cold packs therapy (97010) provided on November 26, 2021. 
 
You asked the Plan to pay for hot or cold packs therapy. You say that there was prior authorization for the 
physical therapy services. The Plan denied your request. The Plan says payment for this service is always 
bundled into the payment for another 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 97010 has a status indicator of B on the Physician Fee Schedule. This means that CPT code 97010 is not separately payable. Based on this information, we decided that Medicare rules for coverage of hot or cold packs therapy have not been met. Therefore, we decided that the Plan does not have to pay for hot or cold packs therapy (97010) provided on November 26, 2021.