Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99291, 99292, & 99239 billed for date of 
service May 21, 2022. 
 
You asked the Plan to pay for procedure codes 99291, 99292, & 99239. You say that the services were 
medically necessary. The Plan denied your request. The Plan says payment for codes 99291, 99292, & 99239 
are bundled into payment for code 32554. 
 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 codes 
99291, 99292, & 99239 are column II codes to column I code 32554. 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 codes 99291, 99292, & 99239 
billed for date of service May 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial observation care provided on June 13, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for initial observation care. You say that this internal medicine provider performed 
this service at the hospital. The Plan denied your request. The Plan says the services were billed by and 
rendered by non-participating providers. The Plan also says that these services were not approved in advance. 
 
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 initial observation care provided on June 13, 2022, 
by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided on June 22, 2022. 
 
You asked the Plan to pay for the self-administered drugs. You say that the tests and medications during your 
hospital stay should have been covered. The Plan denied your request. The Plan says this service is not covered 
by Medicare or your healthcare plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
provided on June 22, 2022.  
 
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the detailed and extensive oral evaluation (D0160), deep 
sedation/general anesthesia services (D9222 and D9223), and panoramic x-ray (D0330) provided from May 31, 
2022, to June 20, 2022.  
You asked the Plan to pay for the detailed and extensive oral evaluation, deep sedation/general anesthesia 
services, and panoramic x-ray. You say that you are not satisfied with the first part of the procedure. You also 
say that only the wisdom teeth were paid for. The Plan denied your request. The Plan says the detailed and 
extensive oral evaluation and deep sedation/general anesthesia services are not covered benefits. The Plan also 
says that the maximum limit has been reached for the panoramic x-ray. 
 
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, detailed and extensive oral evaluation 
(D0160) and deep sedation/general anesthesia services (D9222 and D9223) are not among those covered under 
this benefit. The contract clearly states that you are allowed up to 1 panoramic radiographic image or complete 
series of intraoral radiographic images including a pair of bitewing X-Rays, every three years, but not both. 
The record shows that you received a panoramic x-ray (D0330) on May 23, 2022, and this benefit has been 
exhausted. Therefore, we decided that the Plan does not have to pay for the detailed and extensive oral 
evaluation (D0160), deep sedation/general anesthesia services (D9222 and D9223), and panoramic x-ray 
(D0330) provided from May 31, 2022, to June 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on June 23, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you are appealing the claim payment denial. 
The Plan denied your request. The Plan says the services were provided out-of-network and were not approved 
in advanced. 
 
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 laboratory services provided on June 23, 2022, by 
an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve personal care services (T1019). 
 
You asked the Plan to pre-approve personal care services. You say that you need this looked into as soon as 
possible. The Plan denied your request. The Plan says personal care services is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
 
 
 
 
 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of personal care services have not been met. Specifically, we find that the services at issue in this case 
are considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve personal 
care services (T1019).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve full mouth debridement and application of desensitizing 
resin (D9911, D4355) 
 
You asked the Plan to pre-approve the full mouth debridement and application of desensitizing resin. 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 and the benefit limit has 
exhausted for D4355. 
 
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 full 
mouth debridement and application of desensitizing resin (D9911, D4355)
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76376 billed for date of service June 18, 
2022. 
 
You asked the Plan to pay for procedure code 76376. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code 76376 is bundled into payment for code 78226.  
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 76376 
is a column II code to column I code 78226. 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 76376 billed for date of service June 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the implant /abutment supported removable denture for 
upper and lower arches (D6111, D6110). 
 
You asked the Plan to pre-approve the dental services. You say that your previous dentures were done poorly. 
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 16, 2019. 
Therefore, we decided that the Plan does not have to pre-approve the implant /abutment supported removable 
denture for upper and lower arches (D6111, D6110).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99360 billed for date of service May 6, 2022. 
 
You asked the Plan to pay for procedure code 99360. You say that the service at issue was a medical necessity 
for the enrollee. The Plan denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99360 has a Status Indicator of X on the Physician Fee Schedule. This means that 
procedure code 99360 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure code 99360 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99360 billed for date of service May 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical extraction (D7210) provided on June 8, 2022. 
 
You asked the Plan to pay for the extraction. 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 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 
surgical extraction (D7210) provided on June 8, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 43260 billed for date of service October 15, 
2021. 
 
You asked the Plan to pay for procedure code 43260. You say that these services were necessary and should be 
paid. The Plan denied your request. The Plan says the payment for code 43260 is included in the payment for 
43262. 
 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 43262 
is a column II code to column I code 43260 with a modifier indicator of 0. The column II code is therefore not 
payable. 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 43260 billed for date of service October 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the hip replacement recovery kit (E1399) 
purchased March 25, 2022. 
 
You asked the Plan to reimburse you for the hip replacement recover kit. You say that you feel the 
reimbursement should be processed. You needed a toilet seat right away and could not wait. You did not 
realize this was a covered benefit until after you purchased it. The Plan denied your request. The Plan says the 
purchase of durable medical equipment needs to be through a contracted provider. The elevated toilet seat is 
being approved for reimbursement as a one-time exception. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 The hip replacement recovery kit consists of a sock aid, 2 reachers, a dressing stick, a bath sponge and a 
shoehorn. These items at issue in this appeal do not serve a purpose that is primarily medical in nature. These 
are self hep items. These items are available to the general public and would be helpful even to those who are 
not sick or injured. Therefore, we decided that the Plan does not have to reimburse you for the hip replacement 
recovery kit (E1399) purchased March 25, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a mammography provided on January 19, 
2022. 
 
You asked the Plan to waive the copayment for a mammography. You say that due to your history of breast 
cancer, you have a mammogram every six months because something was seen on your right breast. You say 
that these tests are medically necessary, and you are appealing the cost-share applied. The Plan denied your 
request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay up to a 
$175 copayment for each Medicare-covered outpatient diagnostic procedure and test in an outpatient facility.  
 
 
  You have been asked to pay $114.84, which is less than the maximum $175 copayment for a mammography. 
This item/service falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for a mammography provided on January 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on April 25, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. 
 The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related laboratory 
testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on April 
25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on April 11, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on April 
11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says this type of procedure is not covered because it is still considered experimental and 
investigational. 
 
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 pre-approve the device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that this device is experimental. More research is needed. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Vertiflex device for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided June 22, 
2022. 
 
You asked the Plan to pay for the periodontal maintenance. You say that you feel there is no difference 
between this service and a covered regular cleaning. The Plan denied your request. The Plan says this service is 
not covered under your 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 
periodontal maintenance (D4910) provided June 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and a cone beam 
CT capture (D0367) provided by an out-of-network provider on June 22, 2022. 
 
You asked the Plan to pay for the dental services. You say that you have never seen an oral surgeon before. The 
Plan denied your request. The Plan says your benefit for D0150 has already been exhausted. D0367 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, certain limitations apply. The record 
shows your benefit for D0150 was exhausted on date of service September 29, 2021. D0367 is not a covered 
dental benefit. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation 
(D0150) and a cone beam CT capture (D0367) provided by an out-of-network provider on June 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an endosteal implant on tooth #19 (D6010) and non-
intravenous sedation (D9248) provided on April 19, 2022. 
 
You asked the Plan to pay for an implant and sedation. You say that you disagree with the denial of dental 
services. The Plan denied your request. The Plan says an endosteal implant (D6010) and non-intravenous 
sedation (D9248) are not covered by your routine 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 an 
endosteal implant on tooth #19 (D6010) and non-intravenous sedation (D9248) provided on April 19, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an MRI provided on May 15, 2022. 
 
You asked the Plan to waive the copayment for an MRI. You say that the second MRI was not authorized by 
you or your provider, and you would like charges to be removed. The Plan denied your request. The Plan says 
this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200 
copayment per visit for other outpatient diagnostic tests, including magnetic resonance imaging (MRI).  
 
You have been asked to pay $190.17, which is less than the standard $200 copayment for an MRI. This 
item/service falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for an MRI provided on May 15, 2022.