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

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service April 28, 
2022. 
 
You asked the Plan to pay for procedure code 99100. The Plan denied your request. The Plan says procedure 
code 99100 is considered bundled and not separately payable. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service April 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on September 
28, 2021, and April 21, 2022. 
 
You asked the Plan to pay for the periodontal maintenance. You say that you were unaware this service was not 
covered under your plan. You also say that you would like this service to be covered as a one-time exception. 
The Plan denied your request. The Plan says this service is not covered. The Plan also says that an optional 
supplemental dental benefit is offered under your plan which provides coverage for this service, but you were 
not enrolled in this optional benefit on these dates of service. 
 
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 
periodontal maintenance (D4910) provided on September 28, 2021, and April 21, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 63102 and 63103 billed for date of service 
March 4, 2022. 
 
You asked the Plan to pay for procedure code 63102 and 63103. The Plan denied your request. The Plan says 
the number of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 63102 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code [insert code at issue] have not been met. 
 
Medicare rules also say that providers must report services correctly. Providers must report services with the 
appropriate CPT code. In this case, we have confirmed that code 63103 is an add-on code. While code 63102 is 
an appropriate primary code, it is not payable in this case, and therefore add-on code 63103 is also not payable. 
Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 63102 and 63103 billed for date of service March 4, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for DME and supplies provided on February 
23, 2022. 
 
You asked the Plan to waive the coinsurance for DME and supplies. You say that you are unsure if you 
received all the equipment or if something was missing because the package was open upon arrival. You say 
that the box only contained bandages, which you did not use because the box was opened. The Plan denied 
your request. The Plan says the coinsurance applied 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 20% 
coinsurance for Medicare-covered durable medical equipment.  
 
 
  You have been asked to pay a coinsurance of $562.80, which is 20% of the allowed amount for durable 
medical equipment and supplies ($2,814 x 20% = $562.80). Durable medical equipment and supplies falls 
within the Durable Medical Equipment (DME) And Related 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 DME and supplies provided on February 23, 2022.  
 
Your complaint about the package being opened upon arrival 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an endodontic therapy (D3310) of tooth #7 and 
treatment of root canal obstruction (D3331) for tooth #7 to be rendered by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the endodontic therapy of an anterior tooth (D3310) for tooth #7 and 
treatment of root canal obstruction (D3331) for tooth #7. You say that you were advised that this office 
accepted your insurance, and had the procedures performed. You also say that you found out after the services 
were provided that the services needed to be approved because the treating provider was OON. The Plan 
denied your request. The Plan says dental services from an out-of-network provider are not covered by your 
supplemental 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. 
 
You are requesting dental services from an OON provider. Though the Plan offers a dental benefit in excess of 
Medicare coverage, the requested items or services are not covered under this benefit when received from an 
OON provider. Therefore, we decided that the Plan does not have to pre-approve an endodontic therapy 
(D3310) of tooth #7 and treatment of root canal obstruction (D3331) for tooth #7 to be rendered by an out-of-
network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cone beam CT capture (D0340) provided by a contracted 
provider on May 20, 2022. 
 
You asked the Plan to pay for a cone beam CT capture. You say that this dental work was medically necessary. 
The Plan denied your request. The Plan says the rendered dental work is not a covered benefit. 
 
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 cone 
beam CT capture (D0340) provided by a participating provider on May 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the rebase of a complete maxillary denture (D5710) provided 
on May 9, 2022. 
 
You asked the Plan to pay for the rebase of a complete maxillary denture. You say that full coverage for this 
service should be $786.00. The Plan denied your request. The Plan says this service is not a covered benefit 
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 rebase 
of a complete maxillary denture (D5710) provided on May 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the validity testing provided on April 18, 2022. 
 
You asked the Plan to pay for the testing services. You say that the lab tests for prescribed drugs and drugs of 
abuse. The Plan denied your request. The Plan says the testing is not separately reportable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 We looked at the file and Medicare rules. We find that the testing described by billed code 83789 is considered 
specimen validity testing which is not separately payable. Based on this information, we decided that Medicare 
rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have 
to pay for the validity testing provided on April 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gingival irrigation (D4921) provided by a participating 
provider. 
 
You asked the Plan to pre-approve gingival irrigation. You say that these services are medically necessary. The 
Plan denied your request. The Plan says the requested dental service is not a covered benefit. 
 
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 
gingival irrigation (D4921) provided by a participating provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on March 17, 2022. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the code cannot 
be separately reimbursed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 We looked at the file and Medicare rules. We find that the testing described by billed code 83789 is considered 
specimen validity testing which is not separately payable. Based on this information, we decided that Medicare 
rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have 
to pay for the lab testing services provided on March 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic x-ray (D0330) and a root canal on tooth #30 
(D3330) provided on May 17, 2022. 
 
You asked the Plan to pay for the dental services. You say that your regular dentist was closed, and that you 
were in severe pain. The Plan denied your request. The Plan says the dental services were received from an out-
of-network provider and are not covered by your supplemental 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 record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a panoramic x-ray (D0330) and a root canal on tooth #30 (D3330) provided on May 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on April 29, 
2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says your benefit for the requested item or service 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service March 2, 2022. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on 
April 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on April 
18, 2022. 
 
You asked the Plan to pay for the dental services. You say that your crown broke, and you saw a new dentist. 
The Plan denied your request. The Plan says your benefit for the requested item or service 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service November 10, 2021. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) 
provided on April 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone replacement graft (D4263) and guided tissue 
regenerate (D4266). 
 
You asked the Plan to pre-approve these services. You say that these services are necessary. The Plan denied 
your request. The Plan says that these services 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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
bone replacement graft (D4263) and guided tissue regenerate (D4266).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dental crown for tooth #22 (D2740) 
 
You asked the Plan to pre-approve the dental crown. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says The x-rays do not show the tooth to have 
decay or loss due to fracture involving more than 50% of the biting edge of the tooth or tooth surfaces. Wear on 
the tooth is not considered an approvable criteria for a crown based on your plan. These are clinical 
requirements for a crown benefit. There is no clinical evidence to support medical necessity. 
 
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 dental 
crown 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 dental crown. Our physician 
reviewer found that the documentation provided does not meet the criteria for coverage for a crown restoration 
for tooth #22. 
 
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 dental crown have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a dental crown for tooth #22 (D2740)
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown on tooth #30 (D2740) and core build up on tooth 
#30 (D2950) provided on April 26, 2022. 
 
You asked the Plan to pay for a crown and core build up. You say that your plan allows for these services, and 
they should be covered. The Plan denied your request. The Plan says your annual benefit maximum has been 
met. 
 
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 have coverage up to $550 for covered dental services.   
 
The record shows your annual dental benefit has been exhausted. A crown and core build up falls within the 
Dental Services benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to pay for a crown on tooth #30 (D2740) and core build 
up on tooth #30 (D2950) provided on April 26, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for unspecified adjunctive procedures (D9999 x 2) provided on June 29, 
2021. 
 
You asked the Plan to pay for adjunctive procedures. You say that it was your understanding that you would be 
reimbursed for these services. The Plan denied your request. The Plan says that this provider has opted out of 
Medicare and is not eligible for payment. 
 
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. The Plan did not provide enough information allowing us to confirm the 
providers national provider identifier (NPI). 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare plans may not pay for services given 
by a physician or other practitioner who has opted out of Medicare. The rules also say that a Medicare plan 
must pay for emergency or urgently needed services given by a physician or practitioner who has not signed a 
private contract with the enrollee. 
  
We are unable to confirm if the provider you received services from has opted out of Medicare, as the address 
location provided in the record is different than the one listed on the Medicare opt out website. We were also 
unable to confirm the providers NPI based on the information provided by the Plan. Therefore, we decided 
that the Plan has to pay for unspecified adjunctive procedures (D9999 x 2) provided on June 29, 2021.  
 
 
 
 
 
 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 49320 billed for date of service August 11, 
2021. 
 
You asked the Plan to pay for procedure code 49320. You say that you believe this claim was filed timely and 
should be paid. The Plan denied your request. The Plan says this code was billed incorrectly. 
 
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 49320 is a column II code to column I code 49324 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 49320 billed for date of service August 11, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 83789 billed for date of service April 14, 
2022. 
 You asked the Plan to pay for procedure code 83789. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 83789 is bundled into payment for code 80307 and 
G0481. 
 
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 83789 
is a column II code to column I codes 80307 and G0481. This claim has not been billed with an appropriate 
modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 83789 billed for date of service 
April 14, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that you are requesting inpatient rehabilitation services.
The Plan denied your request. The Plan says rules for IRF care have not been met.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found there are no complex nursing or rehabilitation needs. While you have a need for
physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation program.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the surgical extraction (D7210) provided on May 2, 
2022. 
 
You asked the Plan to pay more for the surgical extraction. You say that you did not get credit for this service. 
The Plan denied your request. The Plan says this claim processed correctly. 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 a 50% 
coinsurance for surgical extractions received in-network. Therefore, we decided that the Plan does not have to 
pay more for the surgical extraction (D7210) provided on May 2, 2022.