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

 
We decided that the Plan does not have to pay for procedure code 11044 billed for date of service December 
22, 2021. 
 You asked the Plan to pay for procedure code 11044. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 11044 is bundled into payment for code 27091. 
 
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 11044 
is a column II code to column I code 27091. This claim has not been billed with an appropriate modifier to 
bypass the edit. The -59 modifier is not supported as a separate and distinct procedural service. 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 11044 billed for date of service December 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine cytopathology (88120) provided January 5, 2022. 
 
You asked the Plan to pay for the urine cytopathology. You say that this service was medically necessary. The 
Plan denied your request. The Plan says this test is not covered for the enrollees diagnoses. 
 
The Plan must follow Medicare rules. Medicare rules say that this assay is performed on urine specimens from 
persons with hematuria suspected of having bladder cancer as an aid for initial diagnosis of bladder carcinoma 
and subsequent monitoring for tumor recurrence in patient previously diagnosed with bladder cancer. 
 
We looked at the file and Medicare rules. There is no indication from the provided records that the enrollee has 
hematuria. Based on this information, we decided that Medicare rules for coverage of the urine cytopathology 
have not been met. Therefore, we decided that the Plan does not have to pay for the urine cytopathology 
(88120) provided January 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for orthoses (L3762, L0650) provided April 12, 2022 . 
 
You asked the Plan to pay for the orthoses. You say that the items were medically necessary. The Plan denied 
your request. The Plan says the records do not support the billed items. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. There is no record of a face to face encounter. There is no evaluation and management notes 
detailing the need for these items. The record shows that the Plan made several attempts to obtain the necessary 
documentation without success. Therefore, we decided that the Plan does not have to pay for orthoses (L3762, 
L0650) provided April 12, 2022 .
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal scaling and root planing (D4342) provided on 
April 12, 2022, and periodontal scaling and root planing (D4342) and topical fluoride varnish (D1206) 
provided on April 19, 2022. 
 
You asked the Plan to pay for periodontal scaling and fluoride varnish. You say that you disagree with the 
denial of dental services. The Plan denied your request. The Plan says periodontal scaling and root planing 
(D4342) and topical fluoride varnish (D1206) are not covered by your dental benefits. 
 Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
periodontal scaling and root planing (D4342) provided on April 12, 2022, and periodontal scaling and root 
planing (D4342) and topical fluoride varnish (D1206) provided on April 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 26, 2022, billed 
with codes 88346 and 88350. 
 
You asked the Plan to pay for the laboratory services billed. 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 providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We looked at the file and the rules. The claim shows that the testing at issue was billed with codes 88346 and 88350. We find that the testing was not billed with the appropriate code per the guidelines. Based on this 
information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the 
Plan does not have to pay for the laboratory services provided on January 26, 2022, billed with codes 88346 
and 88350.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown on tooth #7, 8, and 9 (D2740), core build up on 
tooth #7, 8, and 9 (D2950), application of desensitizing treatment on tooth #7, 8, and 9 (D9911), and pulp caps 
on tooth #7, 8, and 9 (D3120) provided on May 9, 2022. 
 
You asked the Plan to pay for the dental services. You say that these services were necessary after a fall. The 
Plan denied your request. The Plan says a crown (D2740), core build up (D2950), application of desensitizing 
treatment (D9911), and pulp caps (D3120) 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 a crown 
on tooth #7, 8, and 9 (D2740), core build up on tooth #7, 8, and 9 (D2950), application of desensitizing 
treatment on tooth #7, 8, and 9 (D9911), and pulp caps on tooth #7, 8, and 9 (D3120) provided on May 9, 2022.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pay for therapy services (97535) provided July 18, 2020. 
 
You asked the Plan to pay for the therapy services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says that the appeal was filed untimely. 
 
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. The plan did not fully articulate the reason for the denial. Therefore, we decided 
that the Plan has to pay for therapy services (97535) provided July 18, 2020.  
 
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 periodic oral evaluation and removal of plaque (D0120, 
D1110) provided on April 19, 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 Plan's 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 periodic oral evaluation and removal of plaque (D0120, D1110) provided on April 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for endodontic therapy and a prefabricated post and core 
(D3330, D2954) provided on April 15, 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 Plan's 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 endodontic therapy and a prefabricated post and core (D3330, D2954) provided on April 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140), panoramic x-ray (D0330), 
an intraoral x-ray (D0220), and a resin-based composite filling on tooth #7 (D2335) provided on April 19, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says the dental services were received from an out-of-network provider 
and are not covered by the enrollees supplemental benefits. 
 
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. 
 
The record shows the requested dental services were received 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 limited oral evaluation (D0140), panoramic x-ray (D0330), an intraoral x-ray (D0220), and a 
resin-based composite filling on tooth #7 (D2335) provided on April 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral complete x-ray series (D0210) provided on May 
12, 2022. 
 
You asked the Plan to pay for x-rays. You say that you were assured the x-rays were covered. The Plan denied 
your request. The Plan says intraoral complete x-ray series (D0210) is not covered by your supplemental 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 
intraoral complete x-ray series (D0210) provided on May 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on July 22, 2021 billed with 
codes 81238, 81220, 81226, 81335, 81230, 81227, 81355, 81241, 81291, and 81240. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as billed. 
 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 22, 2021 billed with codes 81238, 81220, 81226, 81335, 81230, 81227, 81355, 81241, 81291, and 81240.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic x-ray (D0330) and a diagnostic consultation 
(D9310) provided on April 6, 2022. 
 
You asked the Plan to pay for a panoramic x-ray (D0330) and a diagnostic consultation (D9310). You say that 
this should have been paid because you were not informed that this was not covered. The Plan denied your 
request. The Plan says a panoramic x-rays (D0330) and diagnostic consultation (D9310) are not covered 
benefits. 
 
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 
panoramic x-ray (D0330) and a diagnostic consultation (D9310) provided on April 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) and a tooth extraction 
(D7140), provided by an out-of-network provider on April 21, 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 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 Plan's 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 limited oral evaluation (D0140) and a tooth extraction (D7140), provided by an out-of-network 
provider on April 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for an extraction (D7140) and inhalation of nitrous 
oxide/analgesia (D9230) provided on February 10, 2022. 
 
You asked the Plan to pay more for the dental services. You say that the summary of benefits specifically says 
that extractions and anesthesia are covered at 100% by the Plan for an out-of-network dentist. The Plan denied 
your request. The Plan says you are responsible for the difference between the billed charges and the Plan paid 
amount when visiting an out-of-network dentist. 
 
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. 
 
You have been asked to pay the difference between the out-of-network provider's charges and the Plan's 
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 an extraction (D7140) and inhalation of 
nitrous oxide/analgesia (D9230) provided on February 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve deep sedation/general anesthesia (D9223, D9222). 
 
You asked the Plan to pre-approve deep sedation/general anesthesia (D9223, D9222). You say that you would 
like to appeal the denial because you believe you need the sedation service because there are more than 4 
extractions. The Plan denied your request. The Plan says the services requested have been denied by the plan as 
not covered in accordance to the members EOC, as they 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 pre-approve deep 
sedation/general anesthesia (D9223, D9222).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repeat radiofrequency ablation (RFA). 
 
You asked the Plan to pre-approve repeat RFA. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that thermal radiofrequency destruction of cervical, 
thoracic, or lumbar paravertebral facet joint (medial branch) nerves are considered medically reasonable and 
necessary for patients who meet specific coverage criteria. 
 
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 repeat RFA. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the requirement for repeating the RFA is 
six months of pain relief. The request is made at only 5 months and therefore, the request does not meet criteria 
and is considered not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of repeat RFA have not been met. Therefore, we decided that the Plan does not 
have to pre-approve repeat radiofrequency ablation (RFA).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of a spinal cord stimulator implant. 
 
You asked the Plan to pre-approve insertion of a spinal cord stimulator implant. You say that the services are 
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 
has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that no payment may be made for the implantation of 
dorsal column or depth brain stimulators or services and supplies related to such implantation, unless specific 
criteria are met. 
 
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 insertion of a spinal cord stimulator implant. Our reviewer says that the services are not medically necessary. Our physician reviewer found there is 
no documentation of a surgical consult for back pain. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of insertion of a spinal cord stimulator implant have not been met. Therefore, we 
decided that the Plan does not have to pre-approve insertion of a spinal cord stimulator implant.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided by a 
participating provider on March 31, 2022. 
 
You asked the Plan to pay for the dental services. You say that you recently moved and had to get a new 
dentist. 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 February 24, 2022. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) 
provided by a participating provider on March 31, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a vacuum erection device (L7900) provided April 6, 2022. 
 
You asked the Plan to pay for the vacuum erection device. You say that this device was medically necessary. 
The Plan denied your request. The Plan says this is not a covered item. 
 
The Plan must follow Medicare rules. Medicare rules say that vacuum erection devices (L7900) and related 
accessories (L7902) are statutorily non-covered. 
 
We looked at the file and Medicare rules. This equipment is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the vacuum erection device have not been met. Therefore, we 
decided that the Plan does not have to pay for a vacuum erection device (L7900) provided April 6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xT Panel testing provided March 1, 2022. 
 
You asked the Plan to pay for the Tempus xT Panel testing. You say that this test was medically necessary. The 
Plan denied your request. The Plan says this test is not FDA-approved. Additionally, the Plan states that 
multiple genes were billed individually rather than under a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers FDA-approved NGS 
testing, when the test is FDA approved. 
 
We looked at the file and Medicare rules. Research shows that the Tempus xT tesing is not FDA approved. 
Based on this information, we decided that Medicare rules for coverage of the Tempus xT Panel testing have 
not been met. Therefore, we decided that the Plan does not have to pay for the Tempus xT Panel testing 
provided March 1, 2022.