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

 
We decided that the Plan does not have to pay for prophylaxis - adult (D1110) provided on July 6, 2022. 
 
You asked the Plan to pay for the dental services. You say that you found the dentist on the website and would 
like the services to be approved. 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 prophylaxis - adult (D1110) provided on July 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a semi-precision attachment (D6192) and an implant 
supported removable mandibular denture (D6113) provided on June 9, 2022. 
 
You asked the Plan to pay for the dental services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says a semi-precision attachment (D6192) and an implant supported removable 
mandibular denture (D6113) are not covered by your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a semi-
precision attachment (D6192) and an implant supported removable mandibular denture (D6113) provided on 
June 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone replacement graft for ridge preservation - per site 
(D7953), and surgical placement of implant body: endosteal implant (D6010) tooth #10. 
 
You asked the Plan to pre-approve the dental services.. You say that you wanted a bone graft replacement, but 
it is not covered. The Plan denied your request. The Plan says dental implants and all associated services are 
excluded form coverage. 
 
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 a 
bone replacement graft for ridge preservation - per site (D7953), and surgical placement of implant body: 
endosteal implant (D6010) tooth #10.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a protective restoration (D2940) and pulpal debridement 
(D3221) provided by an out-of-network provider on May 23, 2022. 
 
You asked the Plan to pay for a protective restoration and pulpal debridement. You say that you disappointed 
that the service was denied prior to the completion of the treatment needed. The Plan denied your request. The 
Plan says the rendered dental services 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 a 
protective restoration (D2940) and pulpal debridement (D3221) provided by an out-of-network provider on 
May 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 83516 x 9 and 86235 x 1 billed for date of 
service March 1, 2022. 
 
You asked the Plan to pay for procedure code 83516 x 9 and 86235 x 1. You say that you would like the Plan 
to reconsider their denial of payment. 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 for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for code 83516 is 4 and the MUE for code 86235 is 10. The provider billed 13 units of 
code 83516 and 11 units of code 86235, exceeding the MUE. Based on this information, we decided that 
Medicare rules for coverage of 9 units of code 83516 and 1 unit of code 86235 have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure code 83516 x 9 and 86235 x 1 billed for date of 
service March 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on January 6, 2022, to February 4, 
2022. 
 
You asked the Plan to pay for the dental services. You say that you do not understand why the dental services 
are not being covered. 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 dental services provided on January 6, 2022, to February 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gingival irrigation  per quadrant (D4921) tooth #30 and 40 
provided on April 4, 2022. 
 
You asked the Plan to pay for gingival irrigation  per quadrant (D4921). You say that you would like the Plan 
to pay for your dental services. The Plan denied your request. The Plan says this service is 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 gingival irrigation  per 
quadrant (D4921) is not among those covered under this benefit. Therefore, we decided that the Plan does not 
have to pay for gingival irrigation  per quadrant (D4921) tooth #30 and 40 provided on April 4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (83789-59) provided on March 7, 
2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says payment cannot be made for the services 
rendered. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Specifically, we find that the testing described by the 
billed code is considered specimen validity testing which is not separately payable. Therefore, we decided that 
the Plan does not have to pay for the laboratory services (83789-59) provided on March 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve biologic materials (D3431). 
 
You asked the Plan to pre-approve biologic materials (D3431). You say that you have to pay $650 because this 
is not a covered benefit. You also say that you do not have that money. The Plan denied your request. The Plan 
says this service is not covered under the 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 (D3431).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the dental services on April 20, 2022. 
 
You asked the Plan to pay more 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 enrollee is eligible for non-Medicare 
covered comprehensive dental services up to the allowable $750 per year. Claims from 2022 indicate that this 
enrollee has used their annual limit for this benefit year. 
 
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. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to pay more for the dental services on April 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-prescription drugs provided on May 26, 2022. 
 
You asked the Plan to pay for the non-prescription drugs. You say that you are appealing this claim and you 
would like to be reimbursed. The Plan denied your request. The Plan says this service is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and the non-
prescription drugs is an OTC item. Therefore, we decided that the Plan does not have to pay for the non-
prescription drugs and the outpatient skin surgery provided by a network provider on May 26, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychiatric inpatient admission provided from March 12, 
2022, to March 14, 2022. 
 
You asked the Plan to pay for the psychiatric inpatient admission. You say that the medical chart did support 
the medical necessity of inpatient admission, and did include all required elements. The Plan denied your 
request. The Plan says medical necessity has not been met for the inpatient level of care. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 psychiatric inpatient admission. Our 
reviewer says that the enrollee does not meet the Medicare criteria for continued inpatient psychiatric care. Our 
physician reviewer found it was not expected this enrollee would improve in a reasonable period of time for the 
dates in question as she did not have suicidal or homicidal ideation, auditory or visual hallucinations. Our 
reviewer found that the enrollee was compliant with treatment while not showing any acute threats to safety. 
Our physician reviewer also found that it did not appear medically necessary and reasonable to have psychiatric 
care provided at the acute inpatient level of care rather than a lower level of care. 
 
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 psychiatric inpatient admission have not been met. Therefore, we decided 
that the Plan does not have to pay for the psychiatric inpatient admission provided from March 12, 2022, to 
March 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for sensor; invasive (e.g., subcutaneous), disposable, for use 
with interstitial continuous glucose monitoring system, one unit = 1 day supply (A9276) and transmitter; 
external, for use with interstitial continuous glucose monitoring system (A9277). 
 You asked the Plan to pay for the CGM device and supplies. You say that the enrollee is due to start insulin 
pump therapy which has been approved. Without CGM, the enrollee will not be able to get the maximum 
benefit from pump therapy. The Plan denied your request. The Plan says the Medicare criteria for the requested 
therapeutic CGM, Dexcom G6, are met and the Plan has approved the correct code for the requested 
therapeutic CGM and supplies. 
 
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 CGM requested by the provider coded as A9276 and A9277 has 
not been approved by the FDA (Food and Drug Administration). The codes that were used for this appeal are 
not the correct codes. The "A codes" that were requested are never covered by Medicare and apply to non-
therapeutic continuous glucose monitors (CGMs). Neither Medicare nor the Plan covers a non-therapeutic 
CGM. Based on this information, we decided that Medicare rules for coverage of the CGM device and supplies 
have not been met. Therefore, we decided that the Plan does not have to pay for sensor; invasive (e.g., 
subcutaneous), disposable, for use with interstitial continuous glucose monitoring system, one unit = 1 day 
supply (A9276) and transmitter; external, for use with interstitial continuous glucose monitoring system 
(A9277).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 29, 2021, billed with 
codes 81225, 81227, 81230, 81238, 81240, 81241, 81291 and 81355. 
 
You asked the Plan to pay for the genetic testing billed. You say that these services were necessary and are 
supported in the records. The Plan denied your request. The Plan says this claim was not billed in accordance 
with Medicare rules. 
 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 
June 29, 2021, billed with codes 81225, 81227, 81230, 81238, 81240, 81241, 81291 and 81355.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the preventive procedure (D1999) provided on May 9, 2022. 
 
You asked the Plan to pay for the dental service. You say that everything was one dental service and should be 
covered. The Plan denied your request. The Plan says the denial of payment for this service is correct, because 
the preventive procedure is not covered by the 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 the 
preventive procedure (D1999) provided on May 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve full mouth - scaling in presence of generalized moderate 
or severe gingival inflammation full mouth, after oral evaluation (D4346), localized delivery of antimicrobial 
agents via a controlled release vehicle into diseased crevicular tissue, per tooth-tooth #14 (D4381) and gingival 
irrigation per quadrant (D4921) x's 2. 
 
You asked the Plan to pre-approve dental services. You say that you need these services, and you would like 
them approved. The Plan denied your request. The Plan says these 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 full mouth - scaling in 
presence of generalized moderate or severe gingival inflammation full mouth, after oral evaluation (D4346), 
localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per 
tooth-tooth #14 (D4381) and gingival irrigation per quadrant (D4921) x's 2 are not among those covered under 
this benefit. Therefore, we decided that the Plan does not have to pre-approve full mouth - scaling in presence 
of generalized moderate or severe gingival inflammation full mouth, after oral evaluation (D4346), localized 
delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth-tooth 
#14 (D4381) and gingival irrigation per quadrant (D4921) x's 2.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), intraoral imaging 
(D0210), 2D oral photo (D0350), and a detailed oral evaluation (D0160), provided by an out-of-network 
provider on April 28, 2021, to May 18, 2021. 
 
You asked the Plan to pay for the dental services. You say that you do not have money for this. 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 comprehensive oral evaluation (D0150), intraoral imaging (D0210), 2D oral photo (D0350), and a 
detailed oral evaluation (D0160), provided by an out-of-network provider on April 28, 2021, to May 18, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 93040-59, 95923, and 95924 provided on 
March 9, 2022. 
 
You asked the Plan to pay for procedure codes 93040-59, 95923, and 95924. You say that the medical records 
support the use of modifier 59 with code 93040 and the medical records support the billing of codes 95923 and 
95924. The Plan denied your request. The Plan says the medical records do not support the use of modifier 59 
with code 93040 and the medical records do not support the billing of codes 95923 and 95924. 
 
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 95923 is Testing of autonomic nervous system function; 
sudomotor, including 1 or more of the following: quantitative sudomotor axon reflex test (QSART), silastic 
sweat imprint, thermoregulatory sweat test, and changes in sympathetic skin potential. The definition of code 
95924 is Testing of autonomic nervous system function; combined parasympathetic and sympathetic 
adrenergic function testing with at least 5 minutes of passive tilt. 
 
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 procedure codes 93040-59, 95923, and 95924. Our reviewer 
says that the medical records do not support the use of modifier 59 with code 93040 and the medical records do 
not support the billing of codes 95923 and 95924. Our reviewer found the reviewed documentation indicates 
that Current Procedural Terminology (CPT) code 95923 (1 Unit) remains not supported. The medical records 
submitted don't include documentation to support that testing of autonomic nervous system function; 
sudomotor, including 1 or more of the following: quantitative sudomotor axon reflex test (QSART), silastic 
sweat imprint, thermoregulatory sweat test, and changes in sympathetic skin potential was performed. Current 
Procedural Terminology (CPT) code 93040 59 (1 Unit) remains not supported. Documentation does not 
support the comprehensive procedure codes 95923 and 95924. Since there is a CCI conflict between 95923, 
95924 and 93040 we cannot review the component code 93040 nor the use of modifier 59. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 93040-59, 95923, and 95924 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 93040-59, 95923, and 95924 provided on March 
9, 2022.