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

 
We decided that the Plan does not have to pay for the crown (D2740) provided on January 5, 2022. 
 
You asked the Plan to pay for the crown. You say that you were initially told that this service would only cost 
you $25.00. You also say that when you went back after your crown was delivered, the provider wanted to 
charge you $630.00. The Plan denied your request. The Plan says this service is not a covered expense under 
your dental plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the crown 
(D2740) provided on January 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2740) provided by a participating provider on 
December 21, 2021. 
 
You asked the Plan to pay for a crown. You say that you would like the Plan to reprocess and pay this. The 
Plan denied your request. The Plan says D2740 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 crown 
(D2740) provided by a participating provider on December 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the retreatment of previous root canal therapy (D3347) 
provided on October 6, 2021. 
 
You asked the Plan to pay for the retreatment of previous root canal therapy. You say that this service is 
covered at a 50% coinsurance by your plan, and you are not sure why it was denied. The Plan denied your 
request. The Plan says this service is not a covered benefit under your dental plan. The Plan also says that you 
signed a treatment plan on September 23, 2021 accepting responsibility for the cost of this service shown as 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 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. This service is only covered under the dental plan, and you 
were not enrolled in the dental plan on this date of service. Therefore, we decided that the Plan does 
not have to pay for the retreatment of previous root canal therapy (D3347) provided on October 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the periodic oral evaluation (D0120) and prophylaxis 
(D1110) provided on January 6, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the periodic oral evaluation and prophylaxis. You say that you did not 
realize this treating provider was OON. You also say that you usually pay the dentist and then get reimbursed. 
The Plan denied your request. The Plan says the treating provider is not contracted with the Plan. The Plan also 
says that you must receive services at a participating provider. 
 
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 
covered when they are received OON. Therefore, we decided that the Plan does not have to pre-approve the 
periodic oral evaluation (D0120) and prophylaxis (D1110) provided on January 6, 2022 by an out-of-network 
(OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mandibular partial denture (D5214) provided on January 
4, 2022. 
 
You asked the Plan to pay for the mandibular partial denture. You say that you would like to appeal this 
service. The Plan denied your request. The Plan says this service is not a covered expense under your dental 
plan. The Plan also says that you did not contact the Plan prior to the date of service to verify benefits and 
provider eligibility. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 the 
mandibular partial denture (D5214) provided on January 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140), periapical x-ray 
(D0220), and filling (D2335) for tooth # 26 provided on November 17, 2021. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered. The Plan denied 
your request. The Plan says limited oral evaluation and periapical x-ray are not listed as covered service. The 
Plan says that 1 filling is covered per year. The Plan also says that the frequency limit has been exceeded. 
 
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 limited oral evaluation and 
periapical x-ray are not among those covered under this benefit. Additionally, the frequency limit of 1 filling 
per year has been exceeded. The record shows that the Plan paid for the filling for tooth # 25 that you received 
on the date of service in this case. Therefore, we decided that the Plan does not have to pay for the limited oral 
evaluation (D0140), periapical x-ray (D0220), and filling (D2335) for tooth # 26 provided on November 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an addition, endoskeletal system, below knee, alignable 
system (L5910).  
You asked the Plan to pre-approve an addition, endoskeletal system, below knee, alignable system. You say 
that you meet Medicare criteria for a new prosthetic leg because your leg changed, and it is out of your weight 
range. You also say you need your new prosthetic leg and foot so you can continue to be active. The Plan 
denied your request. The Plan says your needs can be met with a socket replacement using same components. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that the requested item was approved September 2021. Specifically, the medical records 
provided do not show that the item is damaged beyond repair and cannot be re-used for approved socket. 
Therefore, we decided that the Plan does not have to pre-approve an addition, endoskeletal system, below knee, 
alignable system (L5910).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care services provided from March 10, 2021, to 
March 18, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the billed 
codes cannot be verified. 
 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 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. We find that CPT code 99291 is not supported in 
the medical record. Specifically, the records do not indicate the amount of time spent with the enrollee for the 
services 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 critical care 
services provided from March 10, 2021, to March 18, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the rhythm electrocardiogram services coded as 93042 
provided on July 15, 2021. 
 
You asked the Plan to pay for the rhythm electrocardiogram services. You say that you would like this claim 
reprocessed and approved for payment based on the medical records. The Plan denied your request. The Plan 
says this claim was not billed with an appropriate modifier as required by Medicare rules. 
 
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 the rhythm electrocardiogram services coded as 93042 provided 
on July 15, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy (PT) services provided on September 
21, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the PT services. You say that this facility is the only PT that is specialized in 
Ehlers-Danlos syndrome near me, and you have been seen by this facility for the last 6 years. The Plan denied 
your request. The Plan says this claim processed correctly. 
 
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 
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 the physical therapy (PT) services provided on 
September 21, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Chiropractic services provided on December 22, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for Chiropractic services. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says prior authorization is required for an out-of-network 
visit. 
 
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 Chiropractic services provided on December 22, 
2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve crowns (D2752) for tooth #'s 4, 5, 14, and 15 and core buildups, 
including any pins when required (D2950) for tooth #'s 4, 5, 14, and 15. 
 
You asked the Plan to pre-approve the crowns and core buildups. The Plan denied your request. The Plan says 
that medical necessity for the crowns and core buildups have not been met. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the crowns 
and core buildups when the services are medically necessary and reasonable. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the crowns and core buildups. Our 
reviewer says that the documentation supports the need for core buildup (D2950) and crown restorations 
(D2752) for teeth #'s 4, 5, 14, and 15. Our physician reviewer found the restorations in tooth #'s 4, 5, 14, and 15 
appear defective with recurrent caries. Our reviewer found that due to the size of these restorations, weakened 
tooth structure would result upon removal of the restorations along with the recurrent caries. Our physician 
reviewer also found that core buildup and crown restorations are medically reasonable and necessary for good 
long-term function. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the crowns and core buildups have been met. Therefore, we decided that the 
Plan has to pre-approve crowns (D2752) for tooth #'s 4, 5, 14, and 15 and core buildups, including any pins 
when required (D2950) for tooth #'s 4, 5, 14, and 15.  
 
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 mass spectrometry rendered on July 14, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says procedure code 83789 is not separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically
appropriate NCCI modifier is used to report the reason it should be paid as well.
The provider submitted a claim for procedure codes 83789 (mass spectrometry) and 80307 (presumptive drug
testing). Code 83789 is a column II code with a modifier indicator of 1 when billed with column I code 80307.
Code 83789 was not billed with an appropriate modifier to allow for separate payment. The -59 modifier is not
supported as a separate and distinct procedural service. Therefore, we decided that the Plan does not have to
pay for the mass spectrometry rendered on July 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the charge for services provided between 10:00 PM and 8:00 
AM at 24-hour facility billed with code 99053 in addition to hospital physician services provided on October 
29, 2021. 
 
You asked the Plan to pay for the charge for services provided between 10:00 PM and 8:00 AM. You say that 
the rendered services should be paid. The Plan denied your request. The Plan says all payable services were 
approved for payment; however, code 99053 is 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 CPT code. 
 
We find that CPT code 99053 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99053 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of the charge for services provided between 10:00 PM and 8:00 AM have not been met. Therefore, we decided 
that the Plan does not have to pay for the charge for services provided between 10:00 PM and 8:00 AM at 24-
hour facility billed with code 99053 in addition to hospital physician services provided on October 29, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Mass spectrometry and tandem mass spectrometry (MS, 
MS/MS), analyte not elsewhere specified; qualitative, each specimen (83789) provided October 28, 2021, 
You asked the Plan to pay for the laboratory services. You say that please review the attached documents and 
reprocess the claim per the benefits of the Plan. The Plan denied your request. The Plan says the records do not 
support the service billed. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. The submitted claim form indicates the laboratory specimen was 
obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates 
that the specimen was obtained in Off Campus-Outpatient Hospital POS 19 Based on this information, we 
decided that Medicare rules for coverage of the laboratory services have not been met. Specifically, this claim 
was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory 
setting. Therefore, we decided that the Plan does not have to pay for Mass spectrometry and tandem mass 
spectrometry (MS, MS/MS), analyte not elsewhere specified; qualitative, each specimen (83789) provided 
October 28, 2021,
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Methylenetetrahydrofolate Reductase (MTHFR) 
Thermolabile Variant, DNA Analysis (81291) provided on October 26, 2021 by an out-of-network (OON) 
provider.  
You asked the Plan to pay for the laboratory services. You say that you request for reconsideration of the 
original determination and cover the Genesight Psychotropic test as medically necessary The Plan denied your 
request. The Plan says genetic testing for MTHFR Gene is experimental and investigational for the reason 
given by provider. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered. 
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay 
for Methylenetetrahydrofolate Reductase (MTHFR) Thermolabile Variant, DNA Analysis (81291) provided on 
October 26, 2021 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from May 3, 2022, forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from May 3, 2022, forward. You say that the 
services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue are 
not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric care from May 3, 
2022, forward. Our reviewer says that the enrollee does not meet the criteria for acute inpatient mental health 
treatment beyond the date in question of May 3, 2022, forward. Our physician reviewer found the enrollee did 
not require inpatient mental health treatment beyond May 3, 2022, as she was not a danger to herself or others 
and did not have any delusions, auditory or visual hallucinations. It did not appear that active treatment was 
taking place beyond the date in question. It did not appear that the services for the dates in question were 
reasonably expected or medically necessary to improve the enrollees condition or for the purpose of diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care from May 3, 2022, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from May 3, 2022, 
forward.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services rendered on May 6, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 29823 is 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 29823 is arthroscopy, shoulder, surgical; debridement, 
extensive, 3 or more discrete structures (eg, humeral bone, humeral articular cartilage, glenoid bone, glenoid 
articular cartilage, biceps tendon, biceps anchor complex, labrum, articular capsule, articular side of the rotator cuff, bursal side of the rotator cuff, subacromial bursa, foreign body[ies]). 
 
We find that CPT code 29823 is not supported in the medical record. Specifically, the documentation does not 
meet the guidelines for a surgical shoulder arthroscopy with extensive debridement. Based on this information, 
we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that 
the Plan does not have to pay for the surgical services rendered on May 6, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital discharge day management (99239) provided on 
April 29, 2021. 
 
You asked the Plan to pay for hospital discharge day management. You say that this service is supported as 
billed. The Plan denied your request. The Plan says this service is not supported as billed. 
 
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 99239 is hospital discharge day management; more than 
30 minutes. 
 
We find that CPT code 99239 is not supported in the medical record. Specifically, the medical record does not 
show that this service was provided for more than 30 minutes on the date in question. Based on this 
information, we decided that Medicare rules for coverage of hospital discharge day management have not been 
met. Therefore, we decided that the Plan does not have to pay for hospital discharge day management (99239) 
provided on April 29, 2021.