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

 
We decided that the Plan does not have to pay for eight (8) additional units of procedure code 87149 billed for 
date of service November 18, 2021. 
 
You asked the Plan to pay for procedure code 87149. You say that these services are supported as billed. The 
Plan denied your request. The Plan says only four units of code 87149 are supported in the medical records. 
They have agreed to pay for four units; however, the other eight units billed remain denied. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
 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 pay for procedure code 87149 Our reviewer says 
that the documentation provided does not support the billing of more than four units of code 87149 for the date 
in question. Our physician reviewer found the records document two sets of blood cultures were obtained from 
the enrollee on November 18, 2021, one from the left arm and one from the left hand. Only one organism grew 
on the cultures, Staphylococcus epidermidis from the left hand and the Verigene nucleic acid test was 
performed on this organism. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 87149 have not been met. Therefore, we decided that the Plan 
does not have to pay for eight (8) additional units of procedure code 87149 billed for date of service November 
18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for consultation (D9310), pulp vitality test (D0460), cone beam 
computed tomography (CT) and interpretation with limited field of view less than one whole jaw (D0364), and 
bone replacement graft (D7953) provided from January 11, 2022, to May 6, 2022. 
 
You asked the Plan to pay for consultation (D9310), pulp vitality test (D0460), cone beam computed 
tomography (CT) and interpretation with limited field of view less than one whole jaw (D0364), and bone 
replacement graft (D7953). You say that your provider submitted all documents, and you should not have to 
pay for services. The Plan denied your request. The Plan says the services are not covered under your Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
consultation (D9310), pulp vitality test (D0460), cone beam computed tomography (CT) and interpretation 
with limited field of view less than one whole jaw (D0364), and bone replacement graft (D7953) provided from 
January 11, 2022, to May 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for treatment of root canal obstruction (D3331), a crown, 
(D2740), a core buildup (D2950), and endodontic therapy (D3330) provided on May 5, 2022. 
 
You asked the Plan to pay for the dental services. You say that you did not know that you would have to pay 
the full amount. The Plan denied your request. The Plan says the services at issue 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 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 treatment 
of root canal obstruction (D3331), a crown, (D2740), a core buildup (D2950), and endodontic therapy (D3330) 
provided on May 5, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that the clinical value and effectiveness of bone marrow aspirate in the 
setting of spinal fusion surgery have not been demonstrated in the peer-reviewed literature. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Bone marrow 
aspirate remains experimental. More research is needed to show safety and efficacy. Our physician reviewer 
found that the enrollee's condition does not meet criteria for coverage of these services. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve bone marrow aspirate for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a flex-foot system (L5980). 
 
You asked the Plan to pre-approve a flex-foot system. You say that this is medically necessary for the enrollee's 
condition. The Plan denied your request. The Plan says the requested flex-foot system would exceed the 
enrollee's needs at this time. 
 
The Plan must follow Medicare rules. Medicare rules say that a flex-foot system is covered for beneficiaries 
whose functional level is 3 or above. 
 
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 flex-foot system. Our reviewer says 
that the criteria for coverage have not been met for the requested flex-foot system. Our physician reviewer 
found that the enrollee is a 62-year-old male with a medical history of sarcoidosis, hyperlipidemia, 
cardiovascular disease, osteoarthritis of hip requiring hip arthroplasty, peripheral artery disease, renal failure 
requiring hemodialysis. They also have had bilateral transtibial amputations. According to a prosthetic clinical 
progress note dated April 15, 2022, the enrollee is currently ambulating with his prostheses with a single point 
cane. A clinical progress note dated May 16, 2022, indicated that the enrollee has been using a wheelchair for mobility. 
 
In this case, the documentation provided does not support the use of bilateral K3 prosthetic feet and that the 
enrollee has the potential to be a K3 level ambulator as required for the flex-foot system. There is insufficient 
documentation regarding the enrollees potential K level. There is insufficient documentation regarding the 
patients physical examination, including motor strength and range of motion in the lower extremities. There is 
also insufficient documentation provided by the enrollees physician regarding the ability of the enrollee to 
ambulate at a K3 level with bilateral prostheses given his multiple comorbidities (cardiovascular disease and 
renal failure requiring dialysis) and the increased energy demands of ambulating at K3 level with bilateral 
transtibial prostheses. 
 
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 flex-foot system have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a flex-foot system (L5980).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 77065 billed for date of service March 25, 
2022.  
You asked the Plan to pay for procedure code . You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 77065 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code  have not been met. Therefore, we decided that the Plan does not have to pay for procedure 
code 77065 billed for date of service March 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on June 9, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services provided 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 18, 2020. 
Therefore, we decided that the Plan does not have to pay for the dental services on June 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an interim lower denture (D5811) provided on June 3, 2022. 
 
You asked the Plan to pay for an interim lower denture. You say that the service should be somewhat covered 
by the Plan. The Plan denied your request. The Plan says the service at issue 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 an interim 
lower denture (D5811) provided on June 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services on April 19, 2021, to November 10, 2021. 
 
You asked the Plan to pay for dental services. You say that you would like to request reconsideration for 
payment and that you didn't know you had to go to a specific dentist. The Plan denied your request. The Plan 
says they can't pay this charge. The service was provided from a provider who chose not to receive Medicare 
funds. This means they're on the Medicare opt-out list. For this benefit, you can see any licensed provider, in 
the U.S., that isn't on the opt-out list. 
 
 
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 dental 
services on April 19, 2021, to November 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140), a periapical x-ray 
(D0220), and a resin-based composite filling on tooth #10 (D2335) provided on April 6, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were traveling, and there were no available 
in-network dentists. The Plan denied your request. The Plan says the dental services were received from an out-
of-network provider and are not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a limited oral evaluation (D0140), a periapical x-ray (D0220), and a resin-based composite filling on 
tooth #10 (D2335) provided on April 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on April 
20, 2022. 
 
You asked the Plan to pay for the dental services. You say that you had to see another provider and the service 
was 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 August 20, 2019. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) 
provided on April 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), and teeth cleaning 
(D1110) provided on May 10, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were not aware that you did not have out-
of-network benefits. The Plan denied your request. The Plan says the dental services were received from an 
out-of-network provider and are not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a periodic oral evaluation (D0120), and teeth cleaning (D1110) provided on May 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve scoliosis brace and additions for the scoliosis brace 
(CPT code(s): L0999, L1210 x2, L1220 x2, L1240 x2, L1250 x2, L1260, L1270 and L1290). 
 
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your 
request. The Plan says the enrollee has been approved for L1300 which is considered all-inclusive; therefore, 
any additional codes used with L1300 must be denied as unbundled. The Plan states the requested L0999 spinal 
orthosis not otherwise specified is considered incorrect coding and unbundling. 
 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 DME. Our physician reviewer 
found code L3100 covers the needed scoliosis brace. All other codes are included in the L3100 code and con 
not be unbundled. There is no medical need to bill the other codes. 
 
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 DME have not been met. Therefore, we decided that the Plan does not have 
to pre-approve scoliosis brace and additions for the scoliosis brace (CPT code(s): L0999, L1210 x2, L1220 x2, 
L1240 x2, L1250 x2, L1260, L1270 and L1290).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on May 23, 2022. 
 
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 the service 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 the dental 
services on May 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pulp vitality tests (D0460) provided February 21, 2022. 
 
You asked the Plan to pay for the pulp vitality tests. You say that you cannot afford the cost of these services. 
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 pulp 
vitality tests (D0460) provided February 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 4 additional acupuncture visits. 
 
You asked the Plan to pre-approve acupuncture. You say that acupuncture has helped to improve your 
condition. The Plan denied your request. The Plan says you have been approved for 20 acupuncture visits this 
year, so additional acupuncture treatments are not covered by Medicare or the Plan. 
 The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, you have already been approved for 20 acupuncture 
visits this year. Therefore, no further acupuncture treatments may be covered in 2022. Therefore, we decided 
that the Plan does not have to pre-approve 4 additional acupuncture visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99140 billed for date of service May 6, 2022. 
 
You asked the Plan to pay for procedure code 99140. You say that you would like this claim reprocessed based 
on the medical records. The Plan denied your request. The Plan says procedure code 99140 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 procedure code. 
 
We find that procedure code 99140 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99140 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99140 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99140 billed for date of service May 6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on September 21, 2021 billed 
with codes 81206, 81210, 81235, 81272, 81275, 81276, 81301, and 81311. 
 
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 
September 21, 2021 billed with codes 81206, 81210, 81235, 81272, 81275, 81276, 81301, and 81311.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on June 14, 2022 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says 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 04/07/2022. Therefore, 
we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on June 14, 2022
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on June 
7, 2022. 
 
You asked the Plan to pay for the dental services. You say that you couldn't get a cleaning without the 
examination. 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 October 22, 2020. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) 
provided on June 7, 2022.