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

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on March 
23, 2022. 
 
You asked the Plan to pay for a comprehensive oral evaluation. You say that you went to this provider who you 
have used in the past and has been easy to work with and fair on pricing. The Plan denied your request. The 
Plan says the denial of payment for this service is correct, because one comprehensive oral evaluation is 
covered every 3 years and you previously received an exam on June 30, 2021. 
 
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 one 
comprehensive oral evaluation once every three years.  
 
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 
comprehensive oral evaluation (D0150) provided on March 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the female external urinary collection device, pouch (A4328) 
purchased January 4, 2022. 
 
You asked the Plan to pay for the female external urinary collection device. You say that the enrollee has 
incontinence and the PureWick system is a must for her care. The Plan denied your request. The Plan says the 
durable medical equipment was purchased from a provider who is not certified for Medicare. If you go to a 
provider who is not eligible to participate in Medicare, you will be responsible for the full cost of the services 
you receive. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the female external urinary collection 
device, pouch (A4328) purchased January 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an adjunctive pre-diagnostic test (code D0431) provided on 
April 7, 2022. 
 
You asked the Plan to pay for the diagnostic test. You say that this was a routine dental checkup and services 
should be covered. The Plan denied your request. The Plan says this service is not included on the covered code 
list and therefore, is not covered. 
 
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 
adjunctive pre-diagnostic test (code D0431) provided on April 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve therapeutic CGM. You say that your blood sugars have been better with 
continuous glucose monitor use. The Plan denied your request. The Plan says you do not meet the Medicare 
criteria for a continuous glucose monitor. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan.   
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of therapeutic CGM have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the requested Intracept procedure is 
medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this is considered 
experimental/investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee is a 72-year-old who is being treated for lumbar spondylosis; chronic 
pain syndrome; spinal stenosis of the lumbar region without neurogenic claudication. In this case, there 
were/are multiple plausible pathologic sources of significant pain generation. Overall, documentation was/is 
lacking regarding reasonably detailed and/or evidenced findings supportive of the spinal vertebral bodies as 
being the overwhelming primary generators of the enrollees chronic persistent pain. Documentation does not 
support actual formal surgical ablation of pre-designated basivertebral nerves as being medically necessary 
and/or reasonable at this time. There is no compelling rationale presented or extenuating circumstances noted 
to support the medical necessity of this request as an exception. Therefore, the requested Intracept intraosseous basivertebral nerve ablation at L5-S1, in this case, is 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 the Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve biologic materials (code D4265). 
 
You asked the Plan to pre-approve biologic materials. You say that this services is necessary to fix your 
denture. The Plan denied your request. The Plan says this service is not covered under your benefit 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 pre-approve 
biologic materials to aid in soft and osseous tissue regeneration (code D4265).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup (code D2950) provided on December 2, 2021. 
 
You asked the Plan to pay for the core buildup. The Plan denied your request. The Plan says there is no 
coverage for core build up under the benefit plan. 
 
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 core 
buildup, including pins (code D2950) provided on December 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller with accessories (E2311, 
E2376, E2313, E2377). 
 
You asked the Plan to pre-approve an expandable controller with accessories. You say that this device is 
medically necessary. The Plan denied your request. The Plan says the requested expandable controller is not 
medically reasonable per Medicare rules.  
The Plan follows Medicare rules. Medicare rules say that an expandable controller is subject to the criteria 
listed in the Medicare rules section. 
 
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 an expandable controller with 
accessories. Our reviewer says that the requested expandable controller is not medically reasonable and 
necessary. Our physician reviewer found the record from your provider does not document significant right 
upper extremity weakness and the record from the vendor is non-specific. You were managing with a cane and 
walker previously. There is insufficient evidence that you require an expandable controller because the 
evidence does not demonstrate that you lack the capacity to operate a power wheelchair with standard switches.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an expandable controller with accessories have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an expandable controller with accessories (E2311, E2376, 
E2313, E2377).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychiatric diagnostic evaluation (90792) and advance 
care planning (99497) provided on December 22, 2021. 
  You asked the Plan to pay for the psychiatric diagnostic evaluation (90792) and advance care planning (99497). 
You say that the physician provided medically necessary services that met recognized standards of healthcare 
and the claim should be processed for payment. The Plan denied your request. The Plan says CPT code 90792 
is not considered and evaluation and management service to be billed with modifier 25. The Plan also says CPT 
code 99497 is considered bundled and not separately payable. 
 
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 90792 is psychiatric diagnostic evaluation with medical 
services. The CPT Code Manual definition of code 99497 is advance care planning including the explanation 
and discussion of advance directives such as standard forms (with completion of such forms, when performed), 
by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, 
family member(s), and/or surrogate. 
 
We find that CPT codes 90792 and 99497 are not supported in the medical record. Specifically, procedure code 
90792 is not considered and evaluation and management code to be billed with modifier 25. In addition, we 
have confirmed that code 99497 is a column II code to column I code 90792 with a modifier indicator of 0. The 
column II code is therefore not payable. Based on this information, we decided that Medicare rules for 
coverage of the psychiatric diagnostic evaluation (90792) and advance care planning (99497) have not been 
met. Therefore, we decided that the Plan does not have to pay for the psychiatric diagnostic evaluation (90792) 
and advance care planning (99497) provided on December 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic x-ray (D0330) and two-dimensional (2D) 
oral/facial photographic images (D0350) provided on February 16, 2022. 
 
You asked the Plan to pay for the panoramic x-ray and 2D oral/facial photographic images. You say that you 
do not think you should have been charged. The Plan denied your request. The Plan says your calendar year 
maximum benefit has been met. 
 
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 Plan offers a $1,500 combined 
allowance for supplemental preventive and comprehensive dental services every year. The contract says you 
are responsible for any amount over and above the allowance amount. The record shows that you met the 
annual maximum benefit while processing this claim for February 16, 2022, and your annual maximum benefit 
has been exhausted. Therefore, we decided that the Plan does not have to pay for the panoramic x-ray (D0330) 
and two-dimensional (2D) oral/facial photographic images (D0350) provided on February 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on January 14, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that all ESRD-related laboratory services are included in 
the ESRD PPS base rate and must be reported by the ESRD facility and are not separately paid. 
 
We looked at the file and Medicare rules. The file shows that the laboratory services were rendered for end-
stage renal disease (ESRD). Payment is included in the payment to the ESRD facility. Therefore, we decided 
that the Plan does not have to pay for the laboratory services rendered on January 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on March 29, 2021, to March 30, 2021. 
 
You asked the Plan to pay for the dental services. You say that you were in pain and needed this dental work. 
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 dental services provided on March 29, 2021, to March 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional payment for the crown - porcelain fused to high 
noble metal (D2750) provided April 12, 2022. 
 
You asked the Plan to provide additional payment for the crown. You say that this dental work was necessary 
to prevent a root canal later. The Plan denied your request. The Plan says your remaining dental allowance was 
applied to this claim, and no further payment is due. 
 
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 crown up 
to a $1,500 allowance every year.  
 
We looked at the file and Medicare rules. The Plan provided documentation showing that at the time of the 
service you had $1,070 remaining in your dental allowance. This amount was applied to your claim. You have 
been asked to pay the remaining amount above this allowance. 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 provide additional 
payment for the crown - porcelain fused to high noble metal (D2750) provided April 12, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit (99214), blood draw (36415), specimen delivery 
(99000), and annual wellness visit (G0439) provided on May 19, 2021. 
 
You asked the Plan to pay for the outpatient services. You say that the filing limit should be overridden, and 
the claim paid. The Plan denied your request. The Plan says the enrollees claim would be covered under 
Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the 
last day of the month in which hospice is revoked. The Plan also says it is the providers responsibility to verify 
the enrollees coverage before rendering services and to know proper billing procedures for a Medicare 
Advantage member on hospice.  
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for office visit (99214), blood draw (36415), specimen delivery 
(99000), and annual wellness visit (G0439) provided on May 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional payment for the periodontal maintenance (D4910) 
provided March 30, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to provide additional payment for the periodontal maintenance. You say that this service 
should be covered 100%. The Plan denied your request. The Plan says the coinsurance has been applied 
correctly to 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 
periodontal maintenance with 20% coinsurance when provided OON. 
 
We looked at the file and Medicare rules. In this case the periodontal maintenance was provided OON. You 
have been asked to pay $29 ($145 total cost x 20% coinsurance = $29). 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 provide 
additional payment for the periodontal maintenance (D4910) provided March 30, 2022, by an out-of-network 
(OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 77003 billed for date of service January 15, 2022. 
 
You asked the Plan to pay for procedure code 77003. The Plan denied your request. The Plan says payment for 
code 77003 is bundled into payment for code 64483. 
 
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 77003 
is a column II code to column I code 64483. 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 77003 billed for date of service January 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on November 6, 2021, billed 
with codes 81206, 81235, 81292, 81301, and 81321. 
 
You asked the Plan to pay for the genetic testing 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. 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 
November 6, 2021, billed with codes 81206, 81235, 81292, 81301, and 81321.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 83721 billed for date of service December 
28, 2021. 
 
You asked the Plan to pay for procedure code 83721. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 83721 is bundled into payment for code 80061.  
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 83721 
is a column II code to column I code 80061. 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 83721 billed for date of service December 28, 
2021.