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

 
We decided that the Plan does not have to pay for fixed partial denture sectioning (D9120), extraction (D7140) 
tooth #16 and filling (D2331) tooth #26 provided on September 10, 2021, to September 16, 2021. 
 
You asked the Plan to pay for fixed partial denture sectioning (D9120), extraction (D7140) tooth #16 and 
filling (D2331) tooth #26. You say that the dental procedures had to be done before your cancer treatment. The 
Plan denied your request. The Plan says the member did not contact the Plan 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. Supplemental dental services 
benefit includes restorations (fillings) two procedure codes per calendar year and extractions (pulling teeth) two 
procedure codes per calendar year. 
 
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. The fixed partial denture sectioning (D9120) is not a covered service. 
On September 10, 2021, you received covered dental extractions for tooth #3 and #18 and September 16, 2021, 
you received covered dental fillings for tooth #7 and #8. Therefore, these benefits were exhausted. Therefore, 
we decided that the Plan does not have to pay for fixed partial denture sectioning (D9120), extraction (D7140) 
tooth #16 and filling (D2331) tooth #26 provided on September 10, 2021, to September 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for massage therapy (97124) provided on March 29, 2022, to 
April 28, 2022. 
 
You asked the Plan to pay for massage therapy. You say that you saw chiropractic care listed in alternative 
therapy coverage in your policy and believed that the therapeutic massage was related to the chiropractic 
services. You were not advised by your provider that the care might not be covered. The Plan denied your 
request. The Plan says the service reported is not a covered service. 
 
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore, 
we decided that the Plan does not have to pay for massage therapy (97124) provided on March 29, 2022, to 
April 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chiropractic services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve chiropractic services. You say that you need chiropractic care. The Plan 
denied your request. The Plan says the service can be provided by an in-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 
chiropractic services to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care services provided on February 1, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for wound care services. You say that you would like to appeal the denial of the 
claim. The Plan denied your request. The Plan says the provider is out-of-network and authorization is required 
prior to 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 wound care services provided on February 1, 
2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair and tub transfer bench. 
 
You asked the Plan to pre-approve a shower chair and tub transfer bench. You say that this is necessary for the 
enrollee's condition. The Plan denied your request. The Plan says these items are not covered by Medicare or 
the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair and tub transfer bench.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic radiographic image (D0330) provided by a 
participating provider on May 17, 2022. 
 
You asked the Plan to pay for a panoramic radiographic image. You say that you should have been told that 
this would not be covered. The Plan denied your request. The Plan says the rendered dental work is not a 
covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a 
panoramic radiographic image (D0330) provided by a participating provider on May 17, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgery services coded 20900 and 23474 provided on 
December 16, 2021. 
 
You asked the Plan to pay for the surgery services as billed. You say that you would like this claim reprocessed 
based on the operative report submitted. The Plan denied your request. The Plan says these services are not 
supported in the record as they were 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 20900 is bone graft, any donor area; minor or small (eg, dowel or button). The CPT Code Manual definition of code 23474 is revision of total shoulder arthroplasty, 
including allograft when performed; humeral and glenoid component. 
 
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 surgery services as billed. Our reviewer says that the 
documentation does not support the codes as billed. Our reviewer found that for CPT 20900, the operative 
report does not include documentation of bone graft, any donor area. This procedure was not documented in the 
report and cannot be verified. In addition, for CPT code 23474 the operative report describes a total shoulder 
revision, however procedure report does not include enough documentation to confirm modifier 22.  To be 
reimbursed for increased procedural services, documentation should be detailed to confirm procedure was 
complicated, complex, difficult or took significantly more time than usually required by the provider to 
complete the procedure.  Work is substantially greater than typically required. Operative report documents 
"Due to complexity of this revision procedure, including the complexity of removal of a well-fixed implant 
avoiding the need for humeral osteotomy or fracture of the humerus, revision work of the axillary nerve, 
removing it from the scar with extensive scar requiring extensive dissection and extra workup comes to 
approximately 150% to 200% of more work than a standard revision procedure".  Modifier 22 is not supported 
due to lack of documentation. 
 
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 surgery services as billed have not been met. Therefore, we decided that the 
Plan does not have to pay for the surgery services coded 20900 and 23474 provided on December 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for endodontic therapy (D3320), intraoral imaging (D0220), a 
cone beam CT capture (D0364), and a limited oral evaluation (D0140), provided by a participating provider on 
April 27, 2022. 
 
You asked the Plan to pay for the dental services. You say that you believe the Plan should be paying for this. 
The Plan denied your request. The Plan says your maximum dental allowance 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 maximum dental benefit was exhausted on date of service April 27, 2022. Therefore, we decided that the Plan does not have to pay for endodontic therapy (D3320), intraoral imaging (D0220), a cone beam CT 
capture (D0364), and a limited oral evaluation (D0140), provided by a participating provider on April 27, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy visits provided on March 
25, 2022, to April 5, 2022. 
 
You asked the Plan to waive the copayment for physical therapy visits. You say that you had these visits in 
your home so they should be covered. The Plan denied your request. The Plan says the copayments applied are 
correct. 
 
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 $40 
copayment per day for Medicare-covered physical therapy services.  
 
You have been asked to pay $160 ($40 x 4 visits) copayment for physical therapy visits. Physical therapy visits 
fall within the Outpatient Rehabilitation Services benefit category. This means that you have been asked to pay 
the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for physical therapy visits provided on March 25, 2022, to April 5, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve the crown for tooth #5 (CPT code D2740). 
 
You asked the Plan to pre-approve the dental services. You say that the service is necessary. The Plan denied 
your request. The Plan says that based on the documentation provided, it demonstrates sub-crestal decay. The 
Plan states that based on the standard of care, education, literature, and practice - this finding results in a poor 
long-term prognosis for this tooth and therefore, the requested service is denied. 
 
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 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 the dental services. Our physician 
reviewer found the documentation provided meets the criteria for coverage for a replacement crown for tooth 
#5. 
 
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 dental services have been met. Therefore, we decided that the Plan has to 
pre-approve the crown for tooth #5 (CPT code D2740).  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit and laboratory procedure to be provided 
by an OON provider. 
 
You asked the Plan to pre-approve an office visit and laboratory procedure. You say that per the doctor-patient 
continuity, doctor-patient familiarity, confidence, and final visit for your release from the series of treatments 
you prefer to see this physician. The Plan denied your request. The Plan says services are available with in-
network providers. 
 
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 
an office visit and laboratory procedure to be provided by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) and a panoramic 
radiographic imaging (D0330), provided by a participating provider on March 24, 2022. 
 
You asked the Plan to pay for the dental services. You say that these services were medically necessary. 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 December 7, 2021. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) and a panoramic 
radiographic imaging (D0330), provided by a participating provider on March 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on July 13, 2021, billed with 
codes 81407, 81408 and 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that the claim should be paid. The Plan denied 
your request. The Plan says the panel should be billed with one code. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
July 13, 2021, billed with codes 81407, 81408 and 81479.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a radiographic survey of the whole mouth and a 
comprehensive oral evaluation. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. 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 July 9, 2021. Therefore, 
we decided that the Plan does not have to pay for a radiographic survey of the whole mouth and a 
comprehensive oral evaluation.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87481, 87640, 87653, 87798, 87801, and 
87641 billed for date of service October 22, 2021. 
 
You asked the Plan to pay for procedure code 87481, 87640, 87653, 87798, 87801, and 87641. You say that 
you disagree with the Plan's denial. The Plan denied your request. The Plan says payment for certain codes are 
bundled into payment for other codes billed on the claim. 
 
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 87481 
is a column II code to column I codes 87150 and 87801. We have confirmed that code 87640 is a column II 
code to column I codes 87150, 87641, and 87801. We have confirmed that code 87653 is a column II code to 
column I codes 87150 and 87801. We have confirmed that code 87798 is a column II code to column I codes 
87801 and 87150. We have confirmed that code 87641 is a column II code to column I codes 87150 and 87801. 
This claim has not been billed with an appropriate modifier to bypass the edit. The submitted medical records 
do not contain sufficient information to support multiple organisms to support code 87801. In addition, the 
documentation did not include a lab oratory report or laboratory results for this test. Therefore, code 87801 
cannot be verified. 
 
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 87481, 87640, 87653, 87798, 87801, and 87641 billed for date of 
service October 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on June 21, 2021. 
 
You asked the Plan to pay for laboratory services. You say that the test is medically necessary because the 
enrollees condition could worsen and irrevocably compromise their health in the absence of these results. The 
Plan denied your request. The Plan says this service is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
 We looked at the file and Medicare rules. The next generation sequence testing (NGS) testing panel performed 
included testing for the FANCC gene. Testing for this gene is not a Medicare benefit and is statutorily excluded 
service. In addition to single gene testing, panels that include the FANCC gene are statutorily excluded service. 
Based on this information, we decided that Medicare rules for coverage of laboratory services have not been 
met. Therefore, we decided that the Plan does not have to pay for laboratory services provided on June 21, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown - porcelain/ceramic (D2740) provided March 3, 
2022. 
 
You asked the Plan to pay for the crown. You say that this service is necessary due to a fall. 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 crown 
- porcelain/ceramic (D2740) provided March 3, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of the thoracic and lumbar 
spine. 
 
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your 
request. The Plan says that there is no evidence of six weeks of back exercises. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
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 MRI. Our reviewer says that the 
requested MRI is medically reasonable and necessary. Our physician reviewer found that the enrollee 
completed a full six week course of physical therapy in May 2021, and has continued home exercises since 
then. His symptoms persist. Having completed physical therapy and having continued the home exercise 
program, he qualifies for magnetic resonance imaging of the thoracic and lumbar spine. 
 
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 MRI have been met. Therefore, we decided that the Plan has to pre-approve 
magnetic resonance imaging (MRI) of the thoracic and lumbar spine.  
 
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.