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

 
We decided that the Plan does not have to pay for imaging services provided on June 7, 2022. 
 
You asked the Plan to pay for imaging services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed code. 
 
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 74420-26-59 is Urography, retrograde, with or without 
KUB. 
 
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 imaging services provided. Our reviewer says that the 
documentation does not support the billed code. Our reviewer found that the documentation does not state that 
the ureters and kidneys were injected with contrast and imaged, observing retrograde flow. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of imaging services provided have not been met. Therefore, we decided that the 
Plan does not have to pay for imaging services provided on June 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture treatments (97813, 97814) provided from 
March 8, 2022, through May 3, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services are not payable as they were not 
provided on the basis of a covered diagnosis. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met.   
Specifically, the acupuncture services in this case were not provided on the basis of a diagnosis for chronic low 
back pain. Therefore, we decided that the Plan does not have to pay for the acupuncture treatments (97813, 
97814) provided from March 8, 2022, through May 3, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for codes 88185, 88184, 86800, 88187, 86431, 86376, 86235, 86225, 
86200, 86147, 86146, 86037, 86038, and 83516 provided on August 17, 2021. 
 
You asked the Plan to pay for codes 88185, 88184, 86800, 88187, 86431, 86376, 86235, 86225, 86200, 86147, 
86146, 86037, 86038, and 83516. You say that you disagree with the Plan's denial. The Plan denied your 
request. The Plan says that this charge is a duplicate. 
 
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. Review of the file shows that the Plan states that this is a duplicate. However, 
the documentation did not include remittances of the two claims, showing one being paid and one as a 
duplicate. No other denial rationale was provided. The Plan did not substantiate their denial. Therefore, we 
decided that the Plan has to pay for codes 88185, 88184, 86800, 88187, 86431, 86376, 86235, 86225, 86200, 
86147, 86146, 86037, 86038, and 83516 provided on August 17, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pneumatic compression device to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve pneumatic compression device. You say that you are requesting 
reconsideration. The Plan denied your request. The Plan says the enrollee must receive their care from a 
network provider (for more information about this, see Section 2 in Chapter 3). In most cases, care the enrollee 
receives from an out-of-network provider (a provider who is not part of the plans network) will not be 
covered. This means the enrollee will have to pay the provider in full for the services furnished. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
pneumatic compression device to be provided 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 limited oral evaluation (D0140) provided on December 5, 
2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. 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 August 15, 2022. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on 
December 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 99217, 99219, and 99226 provided on May 20, 2022, 
to May 23, 2022. 
 
You asked the Plan to pay for codes 99217, 99219, and 99226. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services billed are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 99217, 99219, and 99226 are not supported in the medical record. Specifically, these 
observation care evaluation and management codes require a designation of observation status. The medical 
records submitted do not indicate that the enrollee's status is designated or admitted for observation. This 
means the validity and accuracy of the billed services cannot be verified. Based on this information, we decided 
that Medicare rules for coverage of codes 99217, 99219, and 99226 have not been met.  Therefore, we decided that the Plan does not have to pay for codes 99217, 99219, and 99226 provided on May 
20, 2022, to May 23, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgery provided on June 30, 2022. 
 
You asked the Plan to pay for surgery. You say that you are requesting reconsideration. The Plan denied your 
request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for surgery provided on 
June 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient visit provided on December 01, 2022. 
 
You asked the Plan to pay for outpatient visit. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for outpatient visit provided 
on December 01, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a prophylaxis - adult (D1110) provided on October 17, 2022. 
 
You asked the Plan to pay for the dental services. You say that you paid extra to have this cleaning covered. 
You also say that you had three cleanings covered last year, so this should also be paid in full. 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 prophylaxis - adult was exhausted on dates of service February 9, 2022, and June 16, 
2022. Therefore, we decided that the Plan does not have to pay for a prophylaxis - adult (D1110) provided on 
October 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99203) provided on October 21, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit (99203) provided on October 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for limited oral evaluation (D0140) provided on September 28, 
2022. 
 
You asked the Plan to pay for the dental services. You say that this should be covered because this was your 
first exam in years. 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. This benefit includes the 
requested limited oral evaluation (D0140) but is limited to one procedure per plan year 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows you received D0140 on September 28, 2022, and a covered D0140 on October 6, 2022. The Plan 
received the claim for the October visit prior to receiving the claim for the September visit. Therefore, your 
benefit was  exhausted on date of service October 6, 2022. Therefore, we decided that the Plan does not have to 
pay for limited oral evaluation (D0140) provided on September 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pre-diagnostic test (D0431) and a pontic (D6245) for tooth 
#29 provided on November 23, 2022. 
 
You asked the Plan to pay for the dental services. You say that the dental services were medically necessary. 
The Plan denied your request. The Plan says the denial of payment for these services is correct, because the 
pre-diagnostic test and pontics are not covered by the 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 a pre-
diagnostic test (D0431) and a pontic (D6245) for tooth #29 provided on November 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prefabricated abutments (D6056) and abutments support 
to metal crowns (D6059) for tooth #30 and #31. 
 
You asked the Plan to pre-approve the dental services. You say that only 2 were approved and all 4 implants 
should be approved. The Plan denied your request. The Plan says your benefit for the requested items or 
services 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 the Plan approved 2 implant services on January 23, 2023; therefore, your benefit for the requested items 
or services was exhausted on the date of approval of January 23, 2023. Therefore, we decided that the Plan 
does not have to pre-approve prefabricated abutments (D6056) and abutments support to metal crowns (D6059) 
for tooth #30 and #31.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on March 09, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the records provided support medical 
necessity. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the laboratory services 
provided on March 09, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an endosteal implant, custom fabricated abutment, and 
metal-ceramic crown restoration (D6059, D6057, D6010). 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they do 
not fall within 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 pre-approve an 
endosteal implant, custom fabricated abutment, and metal-ceramic crown restoration (D6059, D6057, D6010).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive oral evaluation (D0150) and intraoral-
comprehensive series of radiographic images (D0210) provided on November 22, 2022. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. 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 September 16, 2022. 
Therefore, we decided that the Plan does not have to pay for comprehensive oral evaluation (D0150) and 
intraoral-comprehensive series of radiographic images (D0210) provided on November 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for dental services provided on November 23, 2023. 
 
You asked the Plan to pay more for the dental services. You say that both services you received show as 
covered under your insurance, so you would like the billed amount to be paid in full. 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 the Plan paid $196 on date of service March 17, 2022, $298 on date of service July 21, 2022, and $6.00 
on date of service November 23, 2022 ($196 + $298 + $6 = $500). Therefore, your annual maximum of $500 
was exhausted on November 23, 2022. Therefore, we decided that the Plan does not have to pay more for 
dental services provided on November 23, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing coded G0483 provided on October 10, 2022. 
 
You asked the Plan to pay for the drug testing. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services billed are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code G0483 is drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or 
more drug class(es), including metabolite(s) if performed. 
 We find that CPT code G0483 is not supported in the medical record. Specifically, the documentation does not 
support a detail physician order for 22 or more drug classes or a laboratory requisition for the billed test. The 
submitted documentation did not itemize what all tests are included in this panel. Based on this information, we 
decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the drug testing coded G0483 provided on October 10, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional trips for routine transportation beyond the 
Plan's 48-trip limit. 
 
You asked the Plan to pre-approve additional routine transportation. You say that you need transportation to 
dialysis appointments. The Plan denied your request. The Plan says you have exhausted your routine 
transportation benefit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 48 trips per year.  
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional trips for routine transportation beyond the Plan's 
48-trip limit.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup (D2950) for tooth #30 provided on 
November 3, 2022. 
 
You asked the Plan to pay for the dental service. You say that the core buildup was required and necessary for 
your crown. The Plan denied your request. The Plan says the denial of payment for this service is correct, 
because the core buildup is not covered by the 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 item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the core 
buildup (D2950) for tooth #30 provided on November 3, 2022.