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

 
We decided that the Plan does not have to waive the coinsurance for resin-based composite fillings on tooth #4 
and 5 (D2391) provided on May 17, 2022. 
 
You asked the Plan to waive the coinsurance for the fillings. You say that these services should be paid in full. 
The Plan denied your request. The Plan says you have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 50% 
coinsurance for an in-network filling.  
 
You have been asked to pay $37.50, which is 50% coinsurance of the allowed amount for each filling ($77 
allowed amount x 50% coinsurance = $38.50. You have been asked to pay a total of $77 ($38.50 coinsurance x 
2 fillings = $77). A filling 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 waive the coinsurance for resin-based composite fillings on tooth #4 and 5 (D2391) provided on May 17, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), an intraoral series 
of radiographic images (D0210), and teeth cleaning (D1110) provided by an out-of-network provider on April 
11, 2022. 
 
You asked the Plan to pay for the dental services. You say that these services should be covered. 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 comprehensive oral evaluation (D0150), an intraoral series of radiographic images (D0210), and 
teeth cleaning (D1110) provided by an out-of-network provider on April 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prosthetic foot (L5981, L5986) and heel (L5990) 
components. 
 
You asked the Plan to pre-approve prosthetic components. You say that the enrollee is unable to complete 
activities of daily living in the prosthetic device's current state. The Plan denied your request. The Plan says the 
denial of authorization for these components is correct, because the enrollee already has a prosthetic foot that is 
still under warranty and a user-adjustable heel height feature is not covered by Medicare.  
The Plan must follow Medicare rules. Medicare rules say that prosthetic components that are part of an 
artificial limb may be replaced due to a change in the patients physiological condition, an irreparable change 
in the condition of the component, or the required repairs would be more than 60 percent of the cost of a 
replacement device. Medicare rules say that a user-adjustable heel height feature is not covered. 
 
We looked at the file and Medicare rules. The enrollee already has a prosthetic foot that is currently under 
warranty, and the record does not note that the enrollees physiological condition or the condition of the current 
prosthetic components meet any of the criteria for replacement at this time. Additionally, the requested user-
adjustable heel height feature is not covered by Medicare. Based on this information, we decided that Medicare 
rules for coverage of prosthetic components have not been met. Therefore, we decided that the Plan does not 
have to pre-approve prosthetic foot (L5981, L5986) and heel (L5990) components.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene panel testing provided on July 6, 2021. 
 
You asked the Plan to pay for the testing services. You say that the test was ordered to determine the best 
course of treatment. The Plan denied your request. The Plan says a claim using individual codes for gene 
panels is considered incorrect coding. 
 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 the hereditary cancer panel was not billed with a singular code as required. 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 gene panel testing provided on July 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 93312, 93613, 93620 and 76000 billed on 
September 7, 2021. 
 
You asked the Plan to pay for procedure codes 76000, 93312, 93613 and 93620. You say that there is an 
approved authorization for the denied services and the procedures were rendered. You say that the claim should 
be reviewed, and payment made. The Plan denied your request. The Plan says procedure code 93650 was 
approved and procedure codes 93312, 93613 and 93620 are not supported by the medical records submitted. 
The Plan also says procedure code 76000 is considered inclusive to 93650. 
 
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 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 procedure codes 93312, 93613 and 93620. Our reviewer says 
that the documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer 
found that the procedure report does not include enough documentation to confirm these procedures were 
performed. 
 
In this case, we have confirmed that code 76000 is a column II code to column I code 96350; however, 76000 
was billed with a modifier. Our reviewer says that the medical record does not support a fluoroscopy was 
performed as a separate procedure from the intracardiac catheter ablation. Therefore, CPT code 76000 would 
not be reported in addition to CPT code 93650. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 93312, 93613, 93620 and 76000 have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 93312, 93613, 93620 and 76000 billed on 
September 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for alveoloplasty (D7310), and deep sedation/general anesthesia 
(D9222, D9223) provided from September 1, 2021, through October 27, 2021. 
 
You asked the Plan to pay for alveoloplasty, and deep sedation/general anesthesia. You say that the services 
were medically necessary. The Plan denied your request. The Plan says the services at issue 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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
alveoloplasty (D7310), and deep sedation/general anesthesia (D9222, D9223) provided from September 1, 
2021, through October 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the panoramic radiographic image (D0330) provided 
April 15, 2021. 
 
You asked the Plan to pre-approve the panoramic x-ray. You say that the dentist provided covered services. 
The Plan denied your request. The Plan says this benefit does not list panoramic x-rays as a covered service. 
Additionally, the Plan says they have no record of being contacted prior to the services being rendered to verify 
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 the 
panoramic radiographic image (D0330) provided April 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for incomplete endodontic therapy (D3332) and an unspecified 
endodontic procedure (D3999) provided on February 2, 2022. 
 
You asked the Plan to pay for incomplete endodontic therapy and an unspecified endodontic procedure. You 
say that the services should be covered. The Plan denied your request. The Plan says the services at issue 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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
incomplete endodontic therapy (D3332) and an unspecified endodontic procedure (D3999) provided on 
February 2, 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 15, 
2022. 
 
You asked the Plan to pay for code 83789. You say that these services were reported correctly and are 
supported in the medical records. The Plan denied your request. The Plan says the payment for 83789 is included in the payment for code 80307 and/or G0481. Although 83789 was billed with a modifier for separate 
payment, the medical records do not support that this modifier was used appropriately as the documentation 
does not show that 83789 was separate and distinct from these other procedures. 
 
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 80307 and/or G0481; however, 83789 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 code 83789. Our reviewer says that the use of the 59 
modifier is not supported in this case. Our reviewer found the laboratory report describes a urine drug screen. 
In this case, specimen validity would be inclusive to codes 80307 and G0481. Providers performing validity 
testing on urine specimens utilized for drug testing shall not separately bill the validity testing. For example, if 
a laboratory performs a urinary pH, specific gravity, creatinine, nitrates, oxidants, or other tests to confirm that 
a urine specimen is not adulterated, this testing is not separately billed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 83789 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 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81025, 80307) billed for date of service June 
22, 2021. 
 
You asked the Plan to pay for lab services. You say that these services were reported appropriately and are 
supported in the records provided. The Plan denied your request. The Plan says there is insufficient 
documentation to support these services. 
 
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 80307 is drug test(s), presumptive, any number of drug 
classes, any number of devices or procedures; by instrument chemistry analyzers (e.g., utilizing immunoassay), 
chromatography, and mass spectrometry either with or without chromatography, includes sample validation 
when performed, per date of service. The CPT Code Manual definition of code 81025 is urine pregnancy test, 
by visual color comparison methods.  
 
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 lab services. Our reviewer says that these services are not supported as billed. Our reviewer found the laboratory report does not include documentation of a urine 
pregnancy test by visual color comparison method, and the record does not include 22 or more drug classes. 
These services cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for lab services (81025, 80307) billed for date of service June 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 7, 2022 billed with 
code 81292. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are not separately payable. 
 
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. While this is a single procedural code that is being denied, there were other codes that were billed 
on the claim as well. 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 March 7, 2022 billed with code 81292.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an adjunctive pre-diagnostic test (D0431) provided on April 
21, 2022. 
 
You asked the Plan to pay for an adjunctive pre-diagnostic test. You say that the service should be covered. 
The Plan denied your request. The Plan says the service at issue 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 an 
adjunctive pre-diagnostic test (D0431) provided on April 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for extractions (D7140 x 10), and the Plan 
does not have to pay for alveoloplasty (D7310, 7320) and the removal of torus mandibularis (D7473) provided 
on March 1, 2022. You asked the Plan to waive the coinsurance for extractions and to pay for alveoloplasty and removal. You say 
that you were told all your dental work would be covered. The Plan denied your request. The Plan says you 
have been charged the correct cost sharing amount for the extractions. The Plan also says that alveoloplasty 
(D7310, 7320) and the removal of torus mandibularis (D7473) are not covered by your dental benefits. 
 
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 each in-network extraction.  
 
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, alveoloplasty (D7310, 7320) and the 
removal of torus mandibularis (D7473) are not among those covered under this benefit.    
 
You have been asked to pay 50% coinsurance for extractions. Extractions 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.  
 
Code Allowed Amount Not Covered 
Amount 
50 % Coinsurance Total 
Responsibility  
D7473 $758 $758  $758 
D7473 $758 $758  $758 
D7310 $100 $100  $100 
D7320 $152 $152  $152 
D7140 $99  $49.50 $49.50 
D7140 $99  $49.50 $49.50 
D7140 $99  $49.50 $49.50 
D7140 $99  $49.50 $49.50 
D7140 $99  $49.50 $49.50 
D7140 $99  $49.50 $49.50 
D7140 $99  $49.50 $49.50 
D7140 $99  $49.50 $49.50 
D7140 $99  $49.50 $49.50 
D7140 $99  $49.50 $49.50 
Total    $2,263 
 
Therefore, we decided that the Plan does not have to waive the coinsurance for extractions (D7140 x 10), and 
the Plan does not have to pay for alveoloplasty (D7310, 7320) and the removal of torus mandibularis (D7473) 
provided on March 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periapical x-rays (D0220, D0230) provided on December 13, 
2021. 
 
You asked the Plan to pay for x-rays. You say that you disagree with the denial of dental services. The Plan 
denied your request. The Plan says periapical x-rays (D0220, D0230) are not covered by your 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 periapical 
x-rays (D0220, D0230) provided on December 13, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 95908, 95886, 95955 and 95937 billed on 
September 2, 2021. 
 
You asked the Plan to pay for procedure codes 95908, 95886, 95955 and 95937. The Plan denied your request. 
The Plan says procedure code G0453 was approved. The Plan also says procedure codes 95908, 95886, 95955 
and 95937 are not supported by the medical records submitted. 
  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 procedure codes 95908, 95886, 95955 and 95937 is nerve 
conduction studies; 3-4 studies. The CPT Code Manual definition of code 95886 is needle electromyography, 
each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and 
latency/velocity study; complete, five or more muscles studied, innervated by three or more nerves or four or 
more spinal levels (List separately in addition to code for primary procedure). The CPT Code Manual 
definition of code 95955 is electroencephalogram (EEG) during nonintracranial surgery (eg, carotid surgery). 
The CPT Code Manual definition of code 95937 is neuromuscular junction testing (repetitive stimulation, 
paired stimuli), each nerve, any 1 method. 
 
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 procedure codes 95908, 95886, 95955 and 95937. Our 
reviewer says that the documentation submitted was reviewed and does not meet the criteria for coverage. Our 
reviewer found that the technical report describes pedicle screw stimulation, which would not be reported with 
nerve conduction studies. The technical report also describes train of four testing as performed, which would 
not be reported with neuromuscular junction testing. Therefore, procedure codes 95908 and 95937 cannot be 
verified. Per the description of CPT code 95886, this procedure is done with nerve conduction studies. Since 
nerve conduction studies were not documented as performed, this procedure code cannot be verified. In 
addition, the technical report did not include documentation of an EEG so this procedure cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 95908, 95886, 95955 and 95937 have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 95908, 95886, 95955 and 95937 billed on 
September 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound care supplies provided on January 18, 2022, by an 
out-of-network (OON) provider. 
 
 You asked the Plan to pay for the wound care supplies. You say that the supplies are a separately billable 
expense that does not require separate authorization.  The Plan denied your request. The Plan says no prior 
authorization was obtained. 
 
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 did not pre-approve the 
wound care supplies. We found no exception that would require the Plan to pay for the wound care supplies. 
The records provided for review do not show that the wound care supplies were urgent or emergent. Therefore, 
we decided that the Plan does not have to pay for the wound care supplies provided on January 18, 2022, by an 
out-of-network (OON) provider.