Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrodiagnostic testing provided during intraoperative 
neuromonitoring (IONM) provided on March 10, 2021, billed with codes 95908 and 95885. 
 
You asked the Plan to pay for the services as billed. You say that this was correctly coded as should be paid. 
The Plan denied your request. The Plan says codes 95908 and 95885 are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 95908 is nerve conduction studies; 3-4 studies. The 
description of code 95885 is needle electromyography, each extremity, with related paraspinal areas, when 
performed, done with nerve conduction, amplitude and latency/velocity study; limited (List separately in 
addition to code for primary procedure). 
 
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 services as billed. Our reviewer says that the billed codes are not supported by the record. Our reviewer found the technical report describes pedicle screw 
stimulation. CPT code 95908 is incorrect code to report for this service, as nerve conduction studies measure 
amplitude and latency/velocity. The services described by code 95885 are performed with nerve conduction 
studies. As the nerve conduction studies cannot be verified, this procedure would not be covered. 
 
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 services as billed have not been met. Therefore, we decided that the Plan 
does not have to pay for the electrodiagnostic testing provided during intraoperative neuromonitoring (IONM) 
provided on March 10, 2021, billed with codes 95908 and 95885.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the provisional splinting (D4321) provided on December 8, 2021. 
 
You asked the Plan to pay for the provisional splinting. You say that you informed the dentist to not complete 
any service that is not covered under your dental plan. You also say that you should not be held responsible for 
this bill. The Plan denied your request. The Plan says that this service is not a covered benefit. 
 
Medicare generally does not cover dental services. Medicare rules say that the health plan must provide you 
with a clear and accurate description of the Original Medicare and/or mandatory/optional supplemental benefits 
offered under your plan contract including applicable conditions and limitations and any other conditions 
associated with the use or receipt of the benefits. 
 
We looked at the file and Medicare rules. The record shows that you received a provisional splinting which is 
considered to be a periodontal service. The 2021 Evidence of coverage lists periodontics as a covered benefit. 
The contract does not clearly state which periodontic services are covered under the Plan. You reasonably 
believed the provisional splinting would be covered because it is a periodontic benefit. Based on this 
information, we decided that the Plan's rules for coverage of the provisional splinting have been met. 
Therefore, we decided that the Plan has to pay for the provisional splinting (D4321) provided on December 8, 2021.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for  the inpatient hospital and surgery services provided on 
October 5, 2021 to October 10, 2021 by out-of-network (OON) providers. 
 
You asked the Plan to pay for the inpatient hospital and surgery services. You say that you would like 
reconsideration because these services were medically necessary and should be covered. The Plan denied your 
request. The Plan says these claims were denied correctly. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested providers in this case are not network providers 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. Additionally, you have been asked to pay a 30% coinsurance for the inpatient services provided from October 
5, 2021, through October 10, 2021. This is the correct coinsurance based on your contract with the Plan. 
Therefore, we decided that the Plan does not have to pay for  the inpatient hospital and surgery services 
provided on October 5, 2021 to October 10, 2021 by out-of-network (OON) providers.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a fixed bridge comprised of a pontic (D6245) for tooth #14 and 
retainer crowns (D6740) for teeth #13 and #15. 
 
You asked the Plan to pre-approve a fixed bridge. You say that this bridge is necessary. The Plan denied your 
request. The Plan says that this service is not medically necessary because there is no indication as to why a 
removable prosthesis cannot be used. 
 
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 a fixed bridge 
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 a fixed bridge. Our reviewer says that 
the requested service is appropriate in this case. Our physician reviewer found that the documentation indicates 
that tooth #14 is the only tooth missing in the oral cavity. Good bilateral mastication would be achieved with 
the replacement of this tooth. A removable partial denture to replace a single tooth is not the recommended 
treatment. It is the opinion of our reviewer that a fixed bridge is medically reasonable and necessary to achieve 
good bilateral masticatory function. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of a fixed bridge have been met. Therefore, we decided that the Plan has to pre-
approve a fixed bridge comprised of a pontic (D6245) for tooth #14 and retainer crowns (D6740) for teeth #13 
and #15.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor, and related supplies 
provided on September 28, 2021. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the billed code 
cannot be verified. 
 
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 valid proof of delivery for the supplies provided in this case. 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 the continuous glucose monitor, and related supplies provided on 
September 28, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service August 13, 
2021. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service August 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prophylaxis - adult (D1110) provided October 28, 2021. 
 
You asked the Plan to pay for the dental cleaning. You say that you have money remaining in your dental 
allowance that you feel should apply towards this claim. The Plan denied your request. The Plan says you have 
exceeded the frequency limit for this service. 
 
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 
cleaning twice per plan year. 
 
We looked at the file and Medicare rules. The Plan provided documentation showing that a dental cleaning was 
previously covered on March 4, 2021, and June 24, 2021. Based on this information, we decided that the Plan's frequency limit for coverage of the dental cleaning has been exceeded. Therefore, we decided that the Plan 
does not have to pay for the prophylaxis - adult (D1110) provided October 28, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional imaging services provided to the enrollee on 
March 14, 2020. 
 
You asked the Plan to pay for the services. You say that this was denied as duplicate in error. The Plan denied 
your request. The Plan says the documentation received does not indicate that two studies were performed for 
this date of service. 
 
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 74174 is "Computed tomographic angiography, abdomen 
and pelvis, with contrast material(s), including non-contrast images, if performed, and image postprocessing." 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the report shows a single unit  
cPT 74174  was done on 3/14/20, and read by the doctor. This should remain denied as a duplicate charge. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for additional imaging services provided to the enrollee on March 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), bitewing x-rays 
(D0274), and prophylaxis (D1110) provided on January 13, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the comprehensive oral evaluation, bitewing x-rays, and prophylaxis. You say 
that you would like this claim to be reconsidered for payment based on the prior 2021 plan year benefits for 
using an OON dental provider. The Plan denied your request. The Plan says services performed by an OON 
provider are not covered because your healthcare plan does not have OON benefits. The Plan also says that you 
did not contact the Plan prior to the service date to verify benefits or provider status. 
 
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, you are responsible for 100% of the 
cost for dental services rendered by an OON provider. Therefore, we decided that the Plan does not have to pay 
for the comprehensive oral evaluation (D0150), bitewing x-rays (D0274), and prophylaxis (D1110) provided 
on January 13, 2022 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
May 19, 2021, through May 21, 2021. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you do not make 
enough money to pay this, and this should be paid by the Plan. The Plan denied your request. The Plan says the 
copayment applied 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 $300 
copayment per day for days 1-5 for in-network, Medicare-covered inpatient hospital stays.  
  You have been asked to pay a $600 copayment for the inpatient hospital stay. ($300/day x 2 days = $600). The 
inpatient hospital stay falls within the "Inpatient hospital care" 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 the inpatient hospital stay provided from May 19, 2021, through May 21, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on November 4, 2021. 
 
You asked the Plan to pay for the services provided. You say that hematuria is the reason for the testing. The 
Plan denied your request. The Plan says the testing is not covered for screening. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 We looked at the file and Medicare rules. The file shows that fluorescence in situ hybridization (FISH) testing 
was provided due to hematuria. There are no medical records to show that the treating physician ordered the 
testing to rule out bladder cancer due to hematuria. Based on this information, we decided that the Medicare 
rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the lab 
testing services provided on November 4, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting 
on December 9, 2021. 
 
You asked the Plan to pay for the self-administered drugs. You say that the drugs you received should be 
covered. The Plan denied your request. The Plan says the drugs you received are considered self-administered. 
The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan 
also says the drugs you received are not covered under Medicare Part B. 
 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 in an outpatient setting on December 9, 2021.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transport chair, adult size, patient weight capacity up 
to and including 300 pounds (E1038). 
 
You asked the Plan to pre-approve a transport chair. You say that the transport chair is needed to transport the 
enrollee back and forth to the doctor's office. The Plan denied your request. The Plan says the enrollee does not 
meet the criteria for a transport chair. Transport chairs are not approved for use outside the home. 
 
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 a transport chair. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case.  
 Our physician reviewer found the records indicate the enrollee is ambulating 50 feet with a single point cane 
with contact guard assistance. Records do not document the enrollee has a mobility limitation that significantly 
impairs his ability to participate in one or more mobility-related activities of daily living such as toileting, 
feeding, dressing, grooming, and bathing in customary locations in the home and the mobility limitation cannot 
be sufficiently resolved by the use of an appropriately fitted cane or walker. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a transport chair have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a transport chair, adult size, patient weight capacity up to and including 300 pounds 
(E1038).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service October 15, 
2021. 
 You asked the Plan to pay for procedure code 70496. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service October 15, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composite (D2335) provided on November 
30, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the resin-based composite. You say that $219 of this bill should be paid. You 
also say that you were under the Plan when you had the $219 done and would like to know why it was not paid. 
The Plan denied your request. The Plan says this service is not a covered benefit under your dental plan. The 
Plan also says that you were not enrolled in the Plan's dental rider on this date of 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 the resin-
based composite (D2335) provided on November 30, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and 
first intraoral periapical x-ray (D0220) provided on December 7, 2021. 
 
You asked the Plan to pay for the problem focused limited oral evaluation and first intraoral periapical x-ray. 
You say that you contacted the Plan on January 3, 2022 and were told that you had coverage for these services. 
The Plan denied your request. The Plan says these services are not covered benefits under your dental plan. The 
Plan also says that you did not contact the Plan prior to receiving these services. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
problem focused limited oral evaluation (D0140) and first intraoral periapical x-ray (D0220) provided on 
December 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the implant supported crown (D6065) provided on 
September 30, 2021. 
 
You asked the Plan to pay for the dental service. You say that something should be paid toward this crown 
since something is paid on regular crowns. You also say that you have used very little of your yearly benefit 
maximum. The Plan denied your request. The Plan says implant supported crown is not listed as 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 Plans coverage rules apply in this case. 
 
 
 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the implant supported crown is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
implant supported crown (D6065) provided on September 30, 2021.