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

 
We decided that the Plan does not have to pay for the mandibular partial denture - cast metal framework with 
resin denture bases (including retentive/clasping materials, rests and teeth) (D5214) provided December 22, 
2021. 
 
You asked the Plan to pay for the lower partial denture. You say that your teeth were removed due to cancer. 
The denture to replace the extracted teeth should be covered under your medical benefits. The Plan denied your 
request. The Plan says this service is not covered under your dental benefits and is not eligible for coverage 
under your medical 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 services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. 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 mandibular partial denture - cast metal framework with resin denture bases (including 
retentive/clasping materials, rests and teeth) (D5214) provided December 22, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for advanced care planning (99497) provided on August 5, 2021. 
 
You asked the Plan to pay for advanced care planning. You say that these services were billed appropriately. 
The Plan denied your request. The Plan says a National Correct Coding Initiatives (NCCI) Procedure to 
Procedure (PTP) edit exists between 99223 and 99497. This PTP edit has a modifier indicator of 1, meaning 
modifiers associated with NCCI are allowed. However, an appropriate modifier was not billed with this PTP 
code edit. This service was not billed appropriately by Medicare coding regulations. 
 
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 99497 
is a column II code to column I code 99223. 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 advanced care planning (99497) provided on August 5, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for collagen cross links, any method (82523) provided 
December 8, 2021. 
 
You asked the Plan to pay for the laboratory service. You say that please review attached medical records and 
lab reports for date of service 12/08/2021. The Plan denied your request. The Plan says collagen cross links is 
not a Medicare benefit for the diagnosis listed 
 
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 pay for the laboratory service. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found based on the medical records provided there is no documentation that supports the 
medical necessity of the service billed. The provided records only document diagnoses of urinary tract 
infection and unspecified abnormal findings in urine. The provided records do not document that the enrollee 
has any of the diagnoses or conditions for coverage of the collagen cross links testing (82523) as required by 
the National Coverage Determination (NCD) Collagen Crosslinks, any Method 190.19. 
 
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 laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pay for collagen cross links, any method (82523) provided December 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve abutment supported porcelain/ceramic crowns (code 
D6058) and custom abutment (code D6057) for tooth # 15, 18, 19, 2 and 31. 
 
You asked the Plan to pre-approve the dental abutments and crowns. You say that your condition will worsen if 
you do not get these services. The Plan denied your request. The Plan says these specific dental services are not 
covered under your supplemental 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 pre-approve abutment supported porcelain/ceramic 
crowns (code D6058) and custom abutment (code D6057) for tooth # 15, 18, 19, 2 and 31.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for occupational therapy services (97530) provided on August 5, 
2021. 
 
You asked the Plan to pay for occupational therapy services. You say that you have provided medical records 
to support the services billed. The Plan denied your request. The Plan says rules for payment have not been 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that the services of an OTA shall not be billed as 
services incident to a physician/NPP's service, because they do not meet the qualifications of a therapist. 
 
We looked at the file and Medicare rules. In this case, the record shows that the services of an OTA have been 
billed as services incident to a physician/NPP's service. Based on this information, we decided that Medicare 
rules for coverage of occupational therapy services have not been met. Therefore, we decided that the Plan does 
not have to pay for occupational therapy services (97530) provided on August 5, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve shoulder arthroscopy (29824) and repair of shoulder 
rotator cuff using an endoscope (29827). 
 
You asked the Plan to pre-approve the surgery services. You say that this surgery is medically reasonable and 
necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage 
have not been met for these specific procedures. 
 
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 surgery services. 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 74-year-old female being treated for strain of muscle and tendon 
of the rotator cuff; superior glenoid labrum lesion of the left shoulder. She presented with left shoulder pain that is constant, moderate and is aggravated by reaching over her head. The exam reveals tenderness in the 
biceps tendon. Strength is 4/5 in external rotation and supraspinatus. Hawkins, cross arm, and impingement 
testing are positive. 
 
However, detailed documentation is not evident regarding trial and failure of recent, reasonable, and 
comprehensive less invasive conservative care measures. Additionally, there is a lack of large volume, long-
term peer-reviewed outcome studies to support the use of superior capsular release as an effective treatment. 
There was no evidence of extenuating circumstances in this patient's specific case either. Therefore, the 
requested shoulder arthroscopy (29824) and repair of shoulder rotator cuff using an endoscope (29827), 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 surgery services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve shoulder arthroscopy (29824) and repair of shoulder rotator cuff using an 
endoscope (29827).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), first intraoral periapical 
x-ray (D0220), and bitewing x-rays (D0274) provided on December 22, 2021 by a provider who opted out of 
Medicare. 
 
You asked the Plan to pay for the periodic oral evaluation, first intraoral periapical x-ray, and bitewing x-rays. 
You say that these services are covered by the Plan, and the Plan should pay for the services as a dental charge. 
You also say that this has nothing to do with Medicare. The Plan denied your request. The Plan says you 
received these services from a provider who chose not to receive Medicare funds. 
 
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 
covered when they are rendered by a provider who has opted out of Medicare. Therefore, we decided that the 
Plan does not have to pay for the periodic oral evaluation (D0120), first intraoral periapical x-ray (D0220), and 
bitewing x-rays (D0274) provided on December 22, 2021 by a provider who opted out of Medicare.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete maxillary denture (D5110) provided on January 
26, 2021. 
 
You asked the Plan to pay for the complete maxillary denture. You say that the endodontic office assured you 
they would file your insurance, but later found out your claim was never filed. The Plan denied your request. 
The Plan says this claim was received after timely filing limitations. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the complete maxillary denture was not filed until February 23, 2022. This 
means that more than one calendar year from the date of service had passed before a claim was filed. 
Therefore, we decided that the Plan does not have to pay for the complete maxillary denture (D5110) provided 
on January 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out-of-network dental services (D7140, D0140, D0220) 
provided from October 18, 2021, to October 21, 2021. 
 
You asked the Plan to pay for the out-of-network dental services. You say that the services should be covered 
as you disagree with the charges. The Plan denied your request. The Plan says the services denied correctly as 
the provider you saw is not in their network. 
 
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 out-
of-network dental services (D7140, D0140, D0220) provided from October 18, 2021, to October 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dentures (D9999, D5120, D5110) provided on February 15, 2022. 
 
You asked the Plan to pay for the dentures. You say that the services should be covered as you disagree with 
the charges. The Plan denied your request. The Plan says the dentures denied correctly as they do not fall under 
your dental coverage. 
 
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 dentures 
(D9999, D5120, D5110) provided on February 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established 
patient (D0150) and panoramic radiographic image (D0330) provided January 12, 2022. 
 
You asked the Plan to pay for the comprehensive oral exam and panoramic x-ray. You say that you were led to 
believe you had $3500 to spend for dental. You were not comfortable with your previous dentist. The Plan 
denied your request. The Plan says you have exceeded the frequency limit for 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. The Plan covers the 
comprehensive oral exam and panoramic x-ray once every three plan years. 
 
We looked at the file and Medicare rules. The Plan provided documentation showing that a comprehensive 
exam and panoramic x-ray were previously covered on November 11, 2021. Based on this information, we 
decided that the Plan's frequency limit for coverage of the comprehensive oral exam and panoramic x-ray has 
been exceeded. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation 
- new or established patient (D0150) and panoramic radiographic image (D0330) provided January 12, 2022.  
Your complaint about feeling you were potentially misled about your coverage and concerns about the Plan's 
business practices are not valid appeals for medical coverage. This part of your complaint is a grievance that 
must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for discharge day management (99239) provided on July 31, 2021. 
 
You asked the Plan to pay for discharge day management. You say that this is supported in the records. The 
Plan denied your request. The Plan says this service is not documented. 
 
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 99239 is hospital discharge day management; more than 
30 minutes. 
 
We find that CPT code 99239 is not supported in the medical record. Specifically, the records do not include a 
discharge note documenting at least 31 minutes of care. Based on this information, we decided that Medicare rules for coverage of discharge day management have not been met. Therefore, we decided that the Plan does 
not have to pay for discharge day management (99239) provided on July 31, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospice services provided on September 3, 2021.
You asked the Plan to pay for the hospice service. You say that the service was medically necessary. The Plan denied your request. The Plan says Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services.
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 the hospice services provided on September 3, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resection or transplantation of long tendon of biceps 
services coded 23440 and the arthroscopy services coded 29822 provided on October 7, 2021. 
 
You asked the Plan to pay for the resection or transplantation of long tendon of biceps services and the 
arthroscopy services. You say that you would like the plan to reconsider their denial. The Plan denied your 
request. The Plan says the services billed are not supported by the documentation. 
 
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 find that CPT codes 23440 and 29822 are not supported in the medical record. Specifically, the operative 
report did not include documentation of resection or transplantation of the long tendon of biceps; therefore, 
code 23440 cannot be verified. 
 
Procedure code 29822, a surgical shoulder arthroscopy, with limited debridement, for 1 or 2 discrete structures 
(eg, humeral bone, humeral articular cartilage, glenoid bone, glenoid articular cartilage, biceps tendon, biceps 
anchor complex, labrum, articular capsule, articular side of the rotator cuff, bursal side of the rotator cuff, 
subacromial bursa, foreign body[ies]) is documented in the operative note submitted for review; however, this 
procedure is considered inclusive to code 29827, a surgical shoulder arthroscopy, with rotator cuff repair; 
therefore, code 29822 cannot be verified. 
 
Based on this information, we decided that Medicare rules for coverage of the resection or transplantation of 
long tendon of biceps services and the arthroscopy services have not been met. Therefore, we decided that the 
Plan does not have to pay for the resection or transplantation of long tendon of biceps services coded 23440 
and the arthroscopy services coded 29822 provided on October 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pontics (D6245), abutment supported retainers (D6068), 
and custom fabricated abutments (D6057) provided on October 25, 2021 by an out-of-network (OON) 
provider. 
 
You asked the Plan to pay for the pontics, abutment supported retainers, and custom fabricated abutments. You 
say that you would like the cost of these services to be reimbursed. The Plan denied your request. The Plan 
says the treating provider is not a network provider with the Plan and the services were not referred by a 
network provider or rendered in an in-network facility. The Plan also says that these services are not urgent or 
emergent, nor were they approved in advance. 
 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 
covered when they are received out-of-network. Therefore, we decided that the Plan does not have to pay for 
the pontics (D6245), abutment supported retainers (D6068), and custom fabricated abutments (D6057) 
provided on October 25, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve abutment-supported crowns (D6063) and implant 
supported crowns (D6065). 
 
You asked the Plan to pre-approve supported crowns. You say that these services are necessary. The Plan 
denied your request. The Plan says these services are not covered by your dental 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 pre-approve 
abutment-supported crowns (D6063) and implant supported crowns (D6065).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the adjacent tissue transfer or rearrangement services coded 
14302 provided on August 18, 2021. 
 
You asked the Plan to pay for the adjacent tissue transfer or rearrangement services. You say that you would 
like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are 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, we have confirmed that code the 
adjacent tissue transfer or rearrangement services is an add-on code and has not been billed with an appropriate 
primary procedure code. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, 
we decided that the Plan does not have to pay for the adjacent tissue transfer or rearrangement services coded 
14302 provided on August 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a tooth extraction to be performed by an oral surgeon. 
 
You asked the Plan to pre-approve a tooth extraction to be performed by an oral surgeon. You say that your 
tooth is cracked, and you dentist has referred you to an oral surgeon to pull the tooth. The Plan denied your 
request. The Plan says services are not covered when rendered by an oral surgeon. 
 
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 Plan covers a tooth 
extraction when performed by a participating general dentist. 
 
We looked at the file and Medicare rules. In this case the requested extraction will be performed by an oral 
surgeon. Based on this information, we decided that the Plan's rules for coverage of a tooth extraction to be 
performed by an oral surgeon have not been met.  
 
Therefore, we decided that the Plan does not have to pre-approve a tooth extraction to be performed by an oral 
surgeon.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the bone marrow aspiration (20939). 
 
You asked the Plan to pre-approve the bone marrow aspiration. You say that please see the attached recent 
physical therapy notes. The Plan denied your request. The Plan says 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 looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the bone marrow aspiration have not been met.  
  
Therefore, we decided that the Plan does not have to pre-approve the bone marrow aspiration (20939).