Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation - problem focused (D0140) 
provided on January 19, 2022. 
 
You asked the Plan to pay for a limited oral evaluation - problem focused. You say that you were referred to 
this provider for a root canal. The Plan denied your request. The Plan says there is a claim on file that supports 
the member receiving the same services from another dentist on January 14, 2022, and a payment was on that 
claim on January 26, 2022. 
 
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 contract states that 
limited oral evaluation  problem focused is limited to 1 per year. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, a limited oral evaluation - problem 
focused (D0140) are limited to one per year under this benefit. Therefore, we decided that the Plan does not 
have to pay for a limited oral evaluation - problem focused (D0140) provided on January 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implantable neurostimulator electrode, each (L8680). 
 
You asked the Plan to pre-approve Implantable neurostimulator electrode. You say that the enrollee has 
attempted multiple other treatment options with very limited success. The Plan denied your request. The Plan 
says this service is not covered by Medicare.  
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, L8680 may be used by hospitals and ambulatory surgical centers (ASCs) for reporting outpatient 
services to non-Medicare payers. Medicare does not allow separate payment for implanted neurostimulator 
devices in an ASC. Rather, the surgical procedure codes are considered to be device-intensive procedures and, 
as such, reimbursement for the implants is included in the payment for the surgical procedure. Based on this 
information, we decided that Medicare rules for coverage of Implantable neurostimulator electrode have not 
been met. Therefore, we decided that the Plan does not have to pre-approve implantable neurostimulator 
electrode, each (L8680).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve abutment supported cast metal crown (dental code 
D6063) and implant supported porcelain/ceramic crown (dental code D6065) for teeth #27, #28, #29, #30, and 
#31. 
 
You asked the Plan to pre-approve abutment supported cast metal crown and implant supported 
porcelain/ceramic crown. You say that you understand that these services are not covered, but you would like 
to see if the Plan would approve them. The Plan denied your request. The Plan says the services requested 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 pre-approve 
abutment supported cast metal crown (dental code D6063) and implant supported porcelain/ceramic crown 
(dental code D6065) for teeth #27, #28, #29, #30, and #31.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental fillings (D2335) provided on March 28, 2022. 
 
You asked the Plan to pay for the dental fillings. You say that the services should be covered as they were 
medically necessary. The Plan denied your request. The Plan says the services denied correctly as they do not 
fall within your dental coverage. 
 
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 dental 
fillings (D2335) provided on March 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided by 
network provider on February 7, 2022. 
 
You asked the Plan to pay for the comprehensive oral evaluation (D150). You say that your last visit was 
January 4, 2021, and your recent visit was February 7, 2022, which is more than one year. The Plan denied 
your request. The Plan says the service exceeded the frequency limitation in the benefit 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 Plan also has a maximum benefit 
of one comprehensive oral evaluation every three plan years. The requested comprehensive oral evaluation is 
not covered because the Plan paid for a comprehensive oral evaluation on January 4, 2021, which exhausted 
your benefit. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation 
(D0150) provided by network provider on February 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core build up on tooth #3 (D2950). 
 
You asked the Plan to pre-approve core build up. You say that you previously received a temporary setting on 
tooth #3 and are being denied a permanent setting. The Plan denied your request. The Plan says this service is 
covered by the Plan's dental benefits; however, your benefit for one procedure per tooth every five years has 
been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers one core build 
up (D2950) per tooth every five years. 
 
We looked at this case file, the Plans rules, and Medicare rules. The record shows the Plan paid for core build 
up provided on November 30, 2020; therefore, the benefit for core build up has been exhausted. Therefore, we 
decided that the Plan does not have to pre-approve core build up on tooth #3 (D2950).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93042 billed for date of service July 29, 2021. 
 You asked the Plan to pay for procedure code 93042. You say that the medical records support payment of the 
claim as originally billed. The Plan denied your request. The Plan says payment for code 93042 is bundled into 
payment for code 93010. 
 
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 93042 
is a column II code to column I code 93010. 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 93042 billed for date of service July 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cone beam CT capture (D0367) provided by a participating 
provider on February 22, 2022. 
 
You asked the Plan to pay for a cone beam CT capture. You say that you would not have had this done if you 
knew it was not covered. The Plan denied your request. The Plan says cone beam CT capture is not a covered 
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 a cone 
beam CT capture (D0367) provided by a participating provider on February 22, 2022.  
 
This appeal does not include a comprehensive oral evaluation (D0150), or a panoramic radiographic image 
(D0330). D0150 and D0330 have been processed and paid.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the guided tissue regeneration (D4266 x2), the bone 
replacement graft (D7953 x 2), and the consultation (D9310) provided by a network provider on February 10, 
2022. 
 
You asked the Plan to pay for the guided tissue regeneration (D4266 x2), the bone replacement graft (D7953 
x2), and the consultation (D9310). You say that you fell, and your bottom teeth were knocked out. You say you 
were unable to eat your food, and you are unable to afford the out-of-pocket amount. The Plan denied your 
request. The Plan says the services are not covered 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 guided tissue regeneration (D4266 
x2), the bone replacement graft (D7953 x 2), and the consultation (D9310) are not among those covered under 
this benefit. Therefore, we decided that the Plan does not have to pay for the guided tissue regeneration (D4266 
x2), the bone replacement graft (D7953 x 2), and the consultation (D9310) provided by a network provider on 
February 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the replace broken teeth - per tooth (D5640) provided March 
8, 2021. 
 
You asked the Plan to pay for the replacement of broken teeth in a denture. You say that it was necessary for 
the enrollee's health to have the broken teeth fixed. The Plan denied your request. The Plan says this service is 
not covered under the enrollee's 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 
replace broken teeth - per tooth (D5640) provided March 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing (G0480) provided on February 14, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for drug testing. You say that you were not aware authorization was required. The 
Plan denied your request. The Plan says out-of-network services require authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for drug testing (G0480) provided on February 14, 
2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the monitored anesthesia care (01992-QZ,QS,P3), completed 
on November 4, 2021. 
 
You asked the Plan to pay for the monitored anesthesia care. You say that the service was medically necessary. 
The Plan denied your request. The Plan says the service was not medically necessary. 
 
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 monitored anesthesia care. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there was no documentation that monitored anesthesia care was performed by the CRNA and the enrollee only received local anesthesia. 
 
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 monitored anesthesia care have not been met. Therefore, we decided that the 
Plan does not have to pay for the monitored anesthesia care (01992-QZ,QS,P3), completed on November 4, 
2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department evaluation and management 
services (99284) provided on January 29, 2022. 
 
You asked the Plan to pay for the emergency department evaluation and management services. You say that 
you would like this claim reprocessed based on the medical records. The Plan denied your request. The Plan 
says this claim is a duplicate service provided by another provider of the same specialty under the same billing 
group.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Medicare rules say that if more than one 
evaluation and management (face-to-face) service is provided on the same day to the same patient by the same 
physician or more than one physician in the same specialty in the same group, only one evaluation and 
management service may be reported unless the evaluation and management services are for unrelated 
problems. 
 
In this case, the CPT Code Manual definition of code 99284 is 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. 
 
We looked at the file and Medicare rules. In this case, two evaluation and management services were billed on 
the same date of service by providers with the same specialty. One of these claims was paid while the second 
will be treated as a duplicate based on Medicare rules and denied. Based on this information, we decided that 
Medicare rules for coverage of the emergency department evaluation and management services have not been 
met. Therefore, we decided that the Plan does not have to pay for the emergency department evaluation and 
management services (99284) provided on January 29, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care (99309) provided on 
June 18, 2021. 
 
You asked the Plan to pay for the nursing facility care. You say that the services were rendered to the enrollee 
in good faith. The Plan denied your request. The Plan says the enrollees claim would be covered under 
Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the 
last day of the month in which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage before rendering services and to know proper billing procedures for a Medicare 
Advantage member on 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 nursing facility care (99309) provided on June 
18, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa (J7323). 
 
You asked the Plan to pre-approve Euflexxa. You say that the injections are 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 Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
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 Euflexxa. Our reviewer says that 
Euflexxa is not medically necessary. Our physician reviewer found the provided records do not document that 
the corticosteroid injections were ineffective in treating the patient's pain.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa (J7323).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the Transcutaneous Electrical Nerve Stimulators (TENS) supply 
(A4595), provided on February 18, 2022. 
 
You asked the Plan to pay for the TENS supply. You say that the items are medically necessary. The Plan 
denied your request. The Plan says that the items are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 TENS supply. Our reviewer says that the 
requested items are considered medically reasonable and necessary in this case. Our physician reviewer found 
the enrollee has chronic neck pain and meets LCD criteria for coverage of this item. 
 
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 TENS supply have been met. Therefore, we decided that the Plan has to pay 
for the Transcutaneous Electrical Nerve Stimulators (TENS) supply (A4595), provided on February 18, 2022.  
 
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: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient care provided on August 20 to August 25, 2020, billed with 
DRG 207 and primary diagnosis code J96.22. 
 
You asked the Plan to pay for inpatient care. You say that you have provided medical records to support the 
billing of the services at issue. The Plan denied your request. The Plan says that rules for payment have not 
been met because DRG 189 would be more appropriate billed in this case. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 207, defined as "RESPIRATORY SYSTEM 
DIAGNOSIS WITH VENTILATOR SUPPORT GREATER THAN 96 HOURS." 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 inpatient care. Our reviewer says that the services billed with DRG 
207 meet criteria for payment. Our physician reviewer found that the available medical records supported the 
use of DRG 207. DRG 207 is better supported by the available records than the Plan's suggested alternative, 
DRG 189. The available records support diagnosis code J96.22. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do substantiate the DRG as billed. Therefore, we decided that the Plan has to pay for inpatient 
care provided on August 20 to August 25, 2020, billed with DRG 207 and primary diagnosis code J96.22.  
 
 
 
 
 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pathology services provided from January 26, 2022, to 
January 27, 2022. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the claim was 
billed with an inappropriate place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. We looked at the file and the rules. The claim at issue lists a place of service as an outpatient hospital. The 
records show that the enrollee was an inpatient at the time the services were provided. Based on this 
information, we decided that Medicare rules for coverage of the services provided have not been met. 
Therefore, we decided that the Plan does not have to pay for the pathology services provided from January 26, 
2022, to January 27, 2022.