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

 
We decided that the Plan does not have to pay more for emergency dental services provided on November 30, 
2022. 
 
You asked the Plan to pay more for the dental services. You say that this should be covered. The Plan denied 
your request. The Plan says you are responsible for any charged amount above the Plans cost-sharing amount 
when your services are received from an out-of-network provider. 
 
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. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for emergency dental services provided on 
November 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the specialist visits to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the specialist visits. You say that you do not agree with the denial of these 
services. The Plan denied your request. The Plan says you must receive your care from a network provider. 
 
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 
the specialist visits to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve deep gum and root cleaning, all four quadrants (D4341). 
 
You asked the Plan to pre-approve dental services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says that D4341 is denied because it is not medically necessary and does not 
meet criteria. 
 
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 dental 
services 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 dental services. Our physician reviewer 
found the documentation provided meets the criteria for coverage for periodontal scaling and root planing 
(D4341) in four quadrants. 
 
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 dental services have been met. Therefore, we decided that the Plan has to pre-
approve deep gum and root cleaning, all four quadrants (D4341).  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code J3490 provided on August 30, 2022. 
 
You asked the Plan to pay for procedure code J3490. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the Medicare Fee Schedule Data Base (MFSDB) 
provides the postoperative periods that apply to each surgical procedure. If there is an indicator of 000, postoperative visits beyond the day of the procedure are not included in the payment amount for the surgery. 
 
We looked at the file and Medicare rules. The record shows that the enrollee had the sacroiliac joint injection 
(27096) performed on August 30, 2022. The MFSDB shows that the postoperative period for this code is the 
day of surgery/procedure. The enrollee received the Bupivacaine (J3490) injection on August 30, 2022, which 
is the same day the initial procedure was rendered. Therefore, we decided that the Plan does not have to pay for 
procedure code J3490 provided on August 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on December 05, 2022. 
 
You asked the Plan to pay for the office visit. 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 office visit provided 
on December 05, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a custom fabricated abutment (D6057) and an abutment 
supported to a crown (D6060) for tooth #12 provided on December 12, 2022. 
 
You asked the Plan to pay for the dental services. You say that crowns are a covered service, and it does not 
explain that a crown for an implant is not covered. The Plan denied your request. The Plan says the denial of 
payment for these services is correct, because implants and related services 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 custom 
fabricated abutment (D6057) and an abutment supported to a crown (D6060) for tooth #12 provided on 
December 12, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for radiology services provided on October 6, 2022, through October 7, 
2022. 
 
You asked the Plan to pay for the CT scan. You say that the services were medically necessary. The Plan 
denied your request. The Plan says that this is not a covered service. 
 
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. specifically, the Plan has not forwarded sufficient information to support their 
denial. The Plan has not forwarded a claim to indicate the specific services that were billed or provided any 
explanation as to why these services do not meet Medicare coverage criteria. It is the burden of the Health Plan 
to substantiate their denial with evidence. In this case, the Plans denial has not been substantiated, so we must 
find in your favor.  
 
 Therefore, we decided that the Plan has to pay for radiology services provided on October 6, 2022, through 
October 7, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on February 1, 2022, to November 
1, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were not aware that the dental provider was 
not in network. 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 dental services provided on February 1, 2022, to November 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oral hygiene instructions (D1330) provided on December 7, 
2022. 
 
You asked the Plan to pay for the oral hygiene instructions, and bitewings - four radiographic images. You say 
that you are unable to pay for the treatments and wish the Plan to make an exception to help pay for the dental 
services. The Plan denied your request. The Plan says the oral hygiene instructions is not covered under the 
benefit package. 
 
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 hygiene instructions (D1330) is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the oral 
hygiene instructions (D1330) provided on December 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraspinal chiropractic manipulative treatment (98943) 
provided on December 19, 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. Additionally, the rules say that extraspinal 
chiropractic manipulative treatment is not a covered benefit.  
 
The records show that the service at issue is not a Medicare-covered benefit. Therefore, we decided that the 
Plan does not have to pay for the extraspinal chiropractic manipulative treatment (98943) provided on 
December 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics (L3000). 
 
You asked the Plan to pay for foot orthotics. You say that the services should be covered as you disagree with 
the denial. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
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 you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pay for foot orthotics (L3000).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bone replacement graft (D7953), biologic materials to aid in 
soft and osseus tissue regeneration (D4265) and drugs or medicaments, dispensed in the office for home use 
(D9630) provided on July 21, 2022. 
 
You asked the Plan to pay for bone replacement graft, biologic materials and drugs or medicaments for home 
use. You say that this should be covered. The Plan denied your request. The Plan says these are not covered 
services. 
 
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 bone 
replacement graft (D7953), biologic materials to aid in soft and osseus tissue regeneration (D4265) and drugs 
or medicaments, dispensed in the office for home use (D9630) provided on July 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for fixed partial denture sectioning (D9120) provided on 
September 26, 2022. 
 
You asked the Plan to pay for the fixed partial denture sectioning. You say that would like an explanation what 
the additional work was and why it has been declined to pay for. The Plan denied your request. The Plan says 
this service is not covered under the benefit package. 
 
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 fixed 
partial denture sectioning (D9120) provided on September 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
December 5, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service December 5, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on August 18, 2022, billed 
with procedure codes 78812, 70490, and 71250. 
 
You asked the Plan to pay for the medical services. You say that the claim should be paid as billed The Plan 
denied your request. The Plan says some of the billed services were approved on the appeal; however, 
procedure codes 78812, 70490, and 71250 remain 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, we have confirmed that code 70490 is a column II code to column I code 78812, however, 70490 
was billed with a modifier. Also, we have confirmed that code 71250 is a column II code to column I code 
78812, however, 71250 was billed with a modifier. In this case, the CPT Code Manual definition of code 
78812 is Positron emission tomography (PET) imaging; skull base to mid-thigh. 
 
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 the medical services. Our reviewer says that the 
documentation does not support procedure codes 78812, 70490, and 71250.  Our reviewer found that the 
procedure report does not include documentation to support the date of service.  Although, date released and 
addended is documented, the actual date of service cannot be verified. In terms of CPT 70490, the radiology 
report does not support modifier -59 distinct procedural service from CPT 78812 to bypass NCCI edit, and 
therefore cannot be verified. In terms of CPT 71250, the radiology service provided on the thorax would be 
included in CPT 78812 when supported.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the medical services have not been met. Therefore, we decided that the Plan 
does not have to pay for the medical services provided on August 18, 2022, billed with procedure codes 78812, 
70490, and 71250.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for limited oral evaluation (D0140) provided on October 17, 
2022. 
 
You asked the Plan to pay for limited oral evaluation. You say that this should be covered. The Plan denied 
your request. The Plan says this is not a covered service. 
 
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 limited 
oral evaluation (D0140) provided on October 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation, intraoral x-ray, bitewing x-ray, 
and cleaning (D0120, D0274, D0220, D1110) provided on December 14, 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 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 periodic oral evaluation, intraoral x-ray, bitewing x-ray, and cleaning (D0120, D0274, D0220, 
D1110) provided on December 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 17250 billed for date of service June 21, 
2022. 
 
You asked the Plan to pay for procedure code 17250. The Plan denied your request. The Plan says payment for 
code 17250 is bundled into payment for code 11043. 
 
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 17250 is a column II code to column I code 11043. Code 17250 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 17250 
billed for date of service June 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the resin-based composite (D2392) for 
tooth #21 and to pay for the unspecified restorative procedure (D2999) for tooth #21 provided on June 29, 
2022. 
 
You asked the Plan to waive the coinsurance for the resin-based composite and to pay for the unspecified 
restorative procedure. You say that the provider charged you more then what they were suppose to. The Plan 
denied your request. The Plan says the proper cost share was applied to the resin-based composite. Also, the 
denial of payment for the unspecified restorative procedure is correct because it 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. 
 The total allowed amount for the resin-based composite was $124.65 with a coinsurance amount of $31.16 
($124.65 allowed x 25% coinsurance). This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. The unspecified restorative procedure is not covered under the Plans dental benefit. 
Therefore, we decided that the Plan does not have to waive the coinsurance for the resin-based composite 
(D2392) for tooth #21 and to pay for the unspecified restorative procedure (D2999) for tooth #21 provided on 
June 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the house/extended care facility call (D9410) provided on 
December 9, 2022. 
 
You asked the Plan to pay for the dental service. You say that you have always been covered for cleanings at 
the nursing home and have never been charged. The Plan denied your request. The Plan says the denial of 
payment for this service is correct, because the house/extended care facility call 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 
house/extended care facility call (D9410) provided on December 9, 2022.