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

 
We decided that the Plan does not have to pay for maxillary partial denture  cast metal framework with resin 
denture bases (D5213) provided on April29, 2022. 
 
You asked the Plan to pay for the dental services. You say that you need a new upper denture because you lost 
your denture. 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. Routine dental benefits 
include maxillary partial denture  cast metal framework with resin denture bases (D5213)  one every five 
plan years. 
 
We looked at the file, the Plans rules, and Medicares rules. You previously received covered maxillary partial 
denture  cast metal framework with resin denture bases (D5213) on July 2, 2020. Therefore, these benefits 
were exhausted as of April 29, 2022. Therefore, we decided that the Plan does not have to pay for maxillary 
partial denture  cast metal framework with resin denture bases (D5213) provided on April 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the extraction of tooth #5 and 6 (D7111) provided on 
May 9, 2022. 
 
You asked the Plan to pay more for extractions. You say that extractions should be paid at 50%. The Plan 
denied your request. The Plan says this cost sharing was charged correctly. 
 The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 50% 
coinsurance for simple extractions.  
 
You have been asked to pay $60, which is 50% coinsurance of the allowed amount for each extraction ($120 
allowed amount x 50% coinsurance = $60). You have been asked to pay a total of $120 ($60 coinsurance x 2 
extractions = $120). This item/service falls within the dental services benefit category. This means that you 
have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to pay more for the extraction of tooth #5 and 6 (D7111) provided on May 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a resin-based composite (D2330 and D2392) for tooth #27 
and #29 provided on November 18, 2020. 
 
You asked the Plan to pay for the dental services. You say that you cannot pay for these dental services, and 
you would like the Plan to cover them. 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 the date of service of October 29, 2020. 
Therefore, we decided that the Plan does not have to pay for a resin-based composite (D2330 and D2392) for 
tooth #27 and #29 provided on November 18, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (15777, 19364, 88305, 88342, A9270,
C1781, J0690, J1100, J1170, J2370, J2405, J2704, J3010, J3490, J7120, L8600) provided on April 15, 2022.

You asked the Plan to pay for the surgical services. You say that the services were medically necessary. The
Plan denied your request. The Plan says the claim cannot be paid as billed.

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 15777, 19364, 88305, 88342, A9270, C1781, J0690, J1100, J1170, J2370, J2405,
J2704, J3010, J3490, J7120, & L8600 are not supported in the medical record. Specifically, code 19364 is
listed as an inpatient only procedure. Procedure code 19364 is listed as an inpatient procedure but is not found
on the inpatient separate procedure list. Since the inpatient only procedure was billed on this date of service as
the other procedures on the claim, coverage rules are not met.

Based on this information, we decided that Medicare rules for coverage of the surgical services have not been
met. Therefore, we decided that the Plan does not have to pay for surgical services (15777, 19364, 88305,
88342, A9270, C1781, J0690, J1100, J1170, J2370, J2405, J2704, J3010, J3490, J7120, L8600) provided on
April 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve expandable controller and related accessories (E2311, 
E2313, E2377). 
 You asked the Plan to pre-approve expandable controller and related accessories. You say that an expandable 
controller with its related accessories is necessary for your power wheelchair. The Plan denied your request. 
The Plan says there is no medical need for the expandable controller. 
 
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 expandable controller and related 
accessories. Our reviewer says that the requested expandable controller is not medically reasonable and 
necessary. Our physician reviewer found the enrollee has impaired mobility but functional upper extremities. In 
this case, their condition does not require an expandable controller to facilitate their control of power drives as 
Medicare coverage criteria for the expandable controller requires. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of expandable controller and related accessories have not been met. Therefore, we 
decided that the Plan does not have to pre-approve expandable controller and related accessories (E2311, 
E2313, E2377).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve power seat elevation feature (E2300) and expandable 
controller (E2377, E2311, E2313). 
 
You asked the Plan to pre-approve power seat elevation feature and expandable controller. You say that the 
requested equipment is medically necessary. The Plan denied your request. The Plan says the power seat 
elevation feature and expandable controller are not medically necessary as dictated by Medicare coverage rules. 
 
The Plan follows Medicare rules. Medicare rules say that a power seat elevation feature (E2300) is non-covered 
because it is not primarily medical in nature. 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 power seat elevation feature and 
expandable controller. Our reviewer says that the requested expandable controller is not medically necessary. 
Our physician reviewer found the enrollee is a 67-year-old male with a medical history including traumatic 
injury to the spinal cord resulting in incomplete quadriplegia and cervical spine stenosis who has been 
authorized to have a group 3 power wheelchair with multiple power options. In this case, the requested 
electrical accessories are not medically necessary as the enrollee does have use of the upper extremity and can 
operate and control the power options using the switches that are included in the basic wheelchair. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of power seat elevation feature and expandable controller have not been met. 
Therefore, we decided that the Plan does not have to pre-approve power seat elevation feature (E2300) and 
expandable controller (E2377, E2311, E2313).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anterior resin-based composite (D2330) and two 
posterior resin-based composites (D2392 x2) provided on February 17, 2022. 
 
You asked the Plan to pay for the resin-based composites. You say that the dental office had the wrong 
identification number in their system, and showed you had a $3,000 dental allowance. The Plan denied your 
request. The Plan says your dental allowance has already been exhausted. The Plan also says that you did not 
contact the Plan to verify your benefits prior to these services being rendered. 
 
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 dental allowance was exhausted on date of service February 17, 2022. Therefore, we decided that 
the Plan does not have to pay for the anterior resin-based composite (D2330) and two posterior resin-based 
composites (D2392 x2) provided on February 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 83789 billed for date of service November 
29, 2021. 
 
You asked the Plan to pay for procedure code 83789. You say that please re-review the attached laboratory 
results. The Plan denied your request. The Plan says payment for code 83789 is bundled into payment for code 
80307 and G0480. 
 
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 83789 
included in CPT codes 80307 and G0480. This code is not separately reimbursed when billed for specimen 
validity testing on urine specimens utilized for drug testing. 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 83789 billed for date of service 
November 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the re-cement or re-bond crown (D2920) provided on March 
3, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the charges. 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 March 3, 2022. 
Therefore, we decided that the Plan does not have to pay for the re-cement or re-bond crown (D2920) provided 
on March 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation services (99153) provided on 
December 4, 2021. 
 
You asked the Plan to pay for procedure code 99153. 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. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We looked at the file and Medicare rules. In this case, the review shows that the medical records provided 
represent professional charges; however, procedure code 99153 was provided in a facility with a place of 
service code of 21. Procedure code 99153 has a PC/TC Modifier Status of 3, which specifies a Technical 
Component only code. Therefore, we decided that the Plan does not have to pay for the moderate sedation 
services (99153) provided on December 4, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (83789-59) provided on May 3, 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 this code is not eligible for separate 
reimbursement. 
 
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 May 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 81400, 81401, 81406, 81226, 81225, 81335, 
81230, 81241, 81291, and 81240 billed for date of service September 9, 2021. 
 
You asked the Plan to pay for procedure codes 81400, 81401, 81406, 81226, 81225, 81335, 81230, 81241, 
81291, and 81240. You say that you would like the Plan to reconsider their denial of payment. The Plan denied 
your request. The Plan says payment for codes 81400, 81401, and 81406 are bundled into payment for code 
87798. Procedure codes 81226, 81225, 81335, 81230, 81241, 81291, and 81240 are not covered as billed. 
 
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 codes 
81400, 81401, and 81406 are column II codes to column I code 87798. This claim has not been billed with an 
appropriate modifier to bypass the edit.  
 
The rules also 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. Procedure codes 81226, 81225, 81335, 81230, 81241, 81291, and 81240 were part of an NGS panel and 
were not billed with a single panel code as required. 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 codes 81400, 81401, 
81406, 81226, 81225, 81335, 81230, 81241, 81291, and 81240 billed for date of service September 9, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services coded 35221-59 and 47120 provided on 
March 22, 2022. 
 
You asked the Plan to pay for the medical services as billed. You say that you would like this claim 
reprocessed and approved for payment based on the submitted documentation. The Plan denied your request. 
The Plan says the documentation does not support payment for the services as billed. 
 
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 35221 is a column II code to column I code 48150; however, 35221 
was billed with a modifier.  
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the medical services as billed. Our reviewer says that the 
submitted documentation does not support the services as billed. Our reviewer found regarding CPT 35221-59, 
the inferior vena cava (IVC) needed repaired as a result of the primary procedure. Therefore, modifier -59 is 
not supported, as the repair is incidental to primary procedure. The documentation does not support the use of 
the modifier to bypass the NCCI edit in this case. 
 
In this case, the CPT Code Manual definition of code 47120 is hepatectomy, resection of liver; partial 
lobectomy. 
 
Our reviewer found that the operative report does not include enough documentation to confirm a Hepatectomy 
was performed. The National Comprehensive Coding Initiative Policy describes the service as the following: 
The physician exposes the liver via an upper midline incision through skin, fascia, and muscle. The fibrous 
connections of the liver to the diaphragm are divided and the portal structures are controlled. The portal and 
hepatic vessels associated with the affected lobe are divided. The portal structures are clamped. The liver 
parenchyma is divided by pressure or coagulation hemostasis. The portal clamp is removed and hemostasis is 
assured before the abdomen is closed with sutures. In this case, the operative report documents the following: 
Finding no other lesions a partial hepatectomy was performed and the lesion was sent for permanent. In this 
case, this procedure cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the medical services as billed have not been met. Therefore, we decided that the 
Plan does not have to pay for the medical services coded 35221-59 and 47120 provided on March 22, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lower 
extremity other than joint; without contrast material (73718). 
 
You asked the Plan to pre-approve an MRI of the foot without contrast. You say that you are in a lot of pain. 
The doctor is unable to do anything for you until the MRI is done. The Plan denied your request. The Plan says 
you have been approved for an MRI of the ankle. The Plan also says since there is no specific complaint in the 
foot, and no physical exam or x-ray findings related to the foot, the MRI of the foot exam request will be 
denied. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
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 MRI of the foot without contrast. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found you have left ankle 
painful swelling. There are no left foot or ankle plain x-rays. MRI left ankle; the symptomatic region has been 
approved. No pain or other abnormality in the left foot has been described in the submitted medical records. No 
left foot x-ray series in the chart. The medical necessity of an MRI of the left foot in addition to the already 
approved left ankle MRI has not been demonstrated in the submitted records. 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 MRI of the foot without contrast have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lower extremity other 
than joint; without contrast material (73718).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient services billed with codes A4930 and S1015. 
 
You asked the Plan to pay for codes A4930 and S1015. You say that these services were provided in good faith 
and were medically necessary. The Plan denied your request. The Plan says these codes are not payable as 
billed.  
The Plan must follow Medicare rules. Medicare rules say that outpatient codes with a status indicator of N are 
not separately payable.  Medicare rules also say that S codes are not valid for Medicare purposes.  In this case, 
billed code A4930 has a status indicator of N, meaning that it is not separately payable.  In addition, code 
S1015 is not valid for Medicare purposes and there may be a more appropriate code to bill. We looked at the 
file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of codes 
A4930 and S1015 have not been met. Therefore, we decided that the Plan does not have to pay for outpatient 
services billed with codes A4930 and S1015.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services billed for date of service March 10, 
2022, described by two units of codes 64490 and 64491, 94760, and J2001. 
 
You asked the Plan to pay for the services as billed. You say that this should be paid as the services were 
medically necessary. The Plan denied your request. The Plan says the denied codes are not payable as billed. 
 
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 codes 64490 and 64491 is 1. The MAI value for this code is 2. You billed 2 
units of each of these codes, exceeding the MUE.  
 
In addition, code 94760 has a status indicator of T on the Physician Fee Schedule. This means that this code is 
only payable if no other Physician Fee Schedule codes are reported on the claim. Lastly, code J2001 is a 
Column 2 code in relation to both codes 64490 and 64491. No modifier was reported to bypass this edit. Based 
on this information, we decided that Medicare rules for coverage of the services as billed have not been met. 
Therefore, we decided that the Plan does not have to pay for the medical services billed for date of service 
March 10, 2022, described by two units of codes 64490 and 64491, 94760, and J2001.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown - porcelain/ceramic (D2740) provided January 20, 
2022. 
 
You asked the Plan to pay for the crown. You say that you were told that you have 50% coinsurance for 
crowns. The Plan denied your request. The Plan says this service is not covered under your benefits. The Plan 
states a review of their records shows that you were provided to correct information about this benefit being 
uncovered. 
 
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 crown 
- porcelain/ceramic (D2740) provided January 20, 2022.  
 Your complaint about potentially being provided misinformation about coverage is not a valid appeal 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.