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

 
We decided that the Plan does not have to pay for the genetic testing provided on October 20, 2021, billed with 
codes 81479, 81406, 81226, 81225, 81401, 81227, 81230, 81231, 81400, 81241, 81291, and 81240. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says this claim has not been billed in 
accordance with Medicare billing regulations. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
October 20, 2021, billed with codes 81479, 81406, 81226, 81225, 81401, 81227, 81230, 81231, 81400, 81241, 
81291, and 81240.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids you purchased on May 12, 2022. 
 
You asked the Plan to pay for the hearing aids. You say that you were referred to this provider, so these hearing 
aids should be covered. The Plan denied your request. The Plan says you only have a $250 benefit for hearing 
aids, and that has already been accounted for.  You are not entitled to additional coverage. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only up to $250 every 24 months.  Because the hearing aids you purchased were well above this 
amount, you are responsible for the difference in cost. 
 Therefore, we decided that the Plan does not have to pay for the hearing aids you purchased on May 12, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services (90832). 
 
You asked the Plan to pay for psychotherapy services. You say that you would like this claim reprocessed 
based on the medical records. The Plan denied your request. The Plan says the criteria for coverage have not 
been met. 
 
The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of psychotherapy services have not been met. Specifically, the record does not include documentation of a consultation or an attempt to consult the enrollee's primary/attending physician as required by Medicare 
rules. Therefore, we decided that the Plan does not have to pay for psychotherapy services (90832).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the trigeminal and greater occipital nerve blocks provided on 
April 26, 2022. 
 
You asked the Plan to pay for the trigeminal and greater occipital nerve blocks. You say that these services 
were medically necessary. The Plan denied your request. The Plan says the trigeminal and greater occipital 
nerve blocks provided for the treatment of chronic migraine is not considered medically necessary and 
reasonable. The clinical value and effectiveness of nerve blocks in the setting of chronic migraine bridge pain 
treatment with initiation of Botox has not been demonstrated in the peer-reviewed literature. 
 
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 pay for the trigeminal and greater occipital nerve 
blocks. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the use of a combination of trigeminal and occipital nerve 
blocks to control migraine headaches is not evidence-based. The procedures were not medically reasonable and 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the trigeminal and greater occipital nerve blocks have not been met. Therefore, 
we decided that the Plan does not have to pay for the trigeminal and greater occipital nerve blocks provided on 
April 26, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provide on January 
29, 2022, to February 11, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you do not feel that you 
need to pay this much for inpatient hospital care The Plan denied your request. The Plan says this cost sharing 
was charged correctly. 
 
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 $395 
copayment per day for days 1 to 5 for inpatient hospital care. This inpatient hospital stay lasted 13 days, 
resulting in a copayment amount of $1,975.00 ($395 per day for 5 days = $1,9750.00). 
 
You have been asked to pay $1,975.00 copayment for inpatient hospital care. This item/service falls within the 
inpatient hospital care 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 inpatient 
hospital care provide on January 29, 2022, to February 11, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from March 10, 2022, to April 8, 2022. 
 You asked the Plan to pay for SNF care. You say that this was medically necessary. The Plan denied your 
request. The Plan says there was no daily skilled nurse or therapist need. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee did not qualify for SNF coverage. The enrollee did not have 
documented skilled nursing needs. The enrollee did not have documented skilled therapy needs. Daily skilled 
services were not required to establish a maintenance program or to prevent deterioration of the enrollees 
condition. The enrollees care needs could, as a practical matter, be provided at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) services provided to the enrollee from March 10, 2022, to April 8, 
2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient services provided from May 10, 2021, through 
May 26, 2021. 
 
You asked the Plan to pay for the outpatient services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says this claim was received past the allowed 
12-month timeframe. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the outpatient services was not filed until June 9, 2022. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for the outpatient services provided from May 10, 2021, through May 26, 2021.
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 December 
16, 2021. 
 
You asked the Plan to pay for procedure code 99100. You say that you would like this claim reprocessed and 
approved for payment. 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 December 16, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crutch substitute, lower leg platform, with or without 
wheels, each (E0118) provided to the enrollee on December 15, 2021. 
 
You asked the Plan to pay for the item. You say that this should be paid for. The Plan denied your request. The 
Plan says Medicare says services must be medically necessary as documented in recent notes by the physician, 
ordered by the patients physician who has knowledge of the patient, and verified as delivered to the member 
by proof of delivery. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. Medicare rules say that durable medical equipment (DME) supplies must be 
provided with a proof of delivery. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of a crutch substitute, lower leg platform, 
with or without wheels, each (E0118) provided to the enrollee on December 15, 2021 have been met. The 
required documentation pertaining to the proof of delivery of these supplies was not provided. Additionally, a 
valid order was not provided. Therefore, we decided that the Plan does not have to pay for a crutch substitute, 
lower leg platform, with or without wheels, each (E0118) provided to the enrollee on December 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve complete maxillary and mandibular denture (D5110 and 
D5120). 
 
You asked the Plan to pre-approve the dental services. You say that the dentures you received did not fit after 
multiple adjustments. 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 January 27, 2022. 
Therefore, we decided that the Plan does not have to pre-approve complete maxillary and mandibular denture 
(D5110 and D5120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for an extraction of tooth #10 (D7111) provided on April 
18, 2022. 
 
You asked the Plan to pay more for an extraction. You say that an extraction should be covered at 50%. The 
Plan denied your request. The Plan says this cost sharing was charged correctly. 
 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 50% 
coinsurance for simple extractions.  
 
You have been asked to pay $60, which is 50% coinsurance of the allowed amount for an extraction ($120 
allowed amount x 50% coinsurance = $60). This item/service 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 more for an extraction of tooth #10 (D7111) provided on April 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the problem focused limited oral evaluation (D0140), 
crown (D2740), and core buildup, including any pins when required (D2950) provided on June 14, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay more for the dental services. You say that you were referred to this OON dentist by 
another dentist, and you would like these services to be covered by the Plan. The Plan denied your request. The 
Plan says you are responsible for any charged amount above the Plans cost-sharing amount when your 
services are received from an out-of-network provider. 
 
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 have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 more for the problem focused limited oral evaluation 
(D0140), crown (D2740), and core buildup, including any pins when required (D2950) provided on June 14, 
2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a prophylaxis (D1110) provided on June 1, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you were told the dental procedure would 
be covered. The Plan denied your request. The Plan says you are responsible for any charged amount above the 
Plans cost-sharing amount when your services are received from an out-of-network provider. 
 
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 have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 more for a prophylaxis (D1110) provided on June 1, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bone replacement graft (D7953) provided on May 23, 
2022. 
 
You asked the Plan to pay for the dental service. You say that this was a mandatory dental procedure. You say 
that this service had to be done in connection to a partial denture. The Plan denied your request. The Plan says 
the bone replacement graft is not listed as a covered 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 bone replacement graft is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the bone 
replacement graft (D7953) provided on May 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for procedure code 83789 billed for date of service February 21, 
2022. 
 
You asked the Plan to pay for procedure code 83789. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 83789 is bundled into payment for code 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 code G0481. This claim has not been billed with an appropriate modifier to 
bypass the edit. The -59 modifier is not supported as a separate and distinct procedural service. 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 February 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), prophylaxis (D1110), 
and fluoride varnish (D1206) provided on May 4, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were unaware that you had maxed out your 
dental benefits. The Plan denied your request. The Plan says your annual dental maximum benefit 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 this benefit includes 
coverage up to $3,000 for routine dental services. The contract says that you are responsible for any amount 
above the coverage benefit limit. 
 
The record shows your annual dental maximum benefit has been met. You are responsible for any amount 
above the coverage benefit limit. These items/services fall 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 periodic oral evaluation (D0120), prophylaxis (D1110), and fluoride varnish 
(D1206) provided on May 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for extractions of tooth #8, 9, 11, 12, 13, and 14 (D7111) 
provided on June 9, 2022. 
 
You asked the Plan to pay for extractions. You say that these services should be covered at 50%. The Plan 
denied your request. The Plan says this cost sharing was charged correctly. 
 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 50% 
coinsurance for in-network simple extractions.  
 
You have been asked to pay $60, which is 50% coinsurance of the allowed amount for each extraction ($120 
allowed amount x 50% coinsurance = $60). You have been asked to pay a total of $360 ($60 coinsurance x 6 
extractions = $360). This item/service 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 extractions of tooth #8, 9, 11, 12, 13, and 14 (D7111) provided on June 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a full mouth debridement to enable a comprehensive oral 
evaluation and diagnosis (D4355) provided on September 4, 2020. 
 
You asked the Plan to pay for a full mouth debridement to enable a comprehensive oral evaluation and 
diagnosis (D4355). You say that you receive financial help from the government and are requesting 
reconsideration of the denied services. The Plan denied your request. The Plan says this service is not covered 
by the Plan's 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. 
 
 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 full 
mouth debridement to enable a comprehensive oral evaluation and diagnosis (D4355) provided on September 
4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the retainer crowns (D6740 x 2), and pontic (D6245) 
provided on July 21, 2022. 
 
You asked the Plan to pay for the dental services. You say that you need a bridge instead of implants. You say 
that your body rejects materials used in an implant. You say that your plan would cover one half of the cost of 
an implant. You also say that you would like the same coverage for the bridge. The Plan denied your request. 
The Plan says the retainer crowns are not listed as covered dental services. The Plan also says the pontic is not 
listed as a covered dental 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 retainer crowns and pontic are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
retainer crowns (D6740 x 2), and pontic (D6245) provided on July 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scalings and root planings (D4341) for the 
upper left and upper right quadrants. 
 
You asked the Plan to pre-approve the 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 benefits for the requested service were exhausted on date of service April 4, 2022. Therefore, we 
decided that the Plan does not have to pre-approve periodontal scalings and root planings (D4341) for the upper 
left and upper right quadrants.