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

 We decided that the Plan does not have to pay for procedure codes 75736 and 75774 billed for date of service 
March 17, 2022. 
 
You asked the Plan to pay for procedure codes 75736 and 75774. You say that you disgaree with the denial. 
The Plan denied your request. The Plan says payment for code 75736 and 75774 is bundled into payment for 
code 37243. 
 
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 
75736 and 75774 are column II codes to column I code 37243. This claim has not been billed with an 
appropriate modifier to bypass the edit. The -59 modifier is not supported as a separate and distinct procedural 
service. 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 75736 and 75774 billed for date of service March 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the removal of lateral exostosis (D7471) provided by a 
participating provider. 
 
You asked the Plan to pre-approve the removal of lateral exostosis. You say that you would like the Plan to 
approve these services. The Plan denied your request. The Plan says the requested dental 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 pre-approve the 
removal of lateral exostosis (D7471) provided by a participating provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the manual therapy techniques (97140) provided on  
January 17, 2022 and February 15, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not covered under your 
contractual policy or by Medicare. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the manual therapy techniques (97140) provided on January 17, 2022 and 
February 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the treatment of a root canal obstruction on tooth #14 
(D3331) provided on July 13, 2022. 
 
You asked the Plan to pay for a root canal obstruction. The Plan denied your request. The Plan says the 
treatment of a root canal obstruction (D3331) is 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 the 
treatment of a root canal obstruction on tooth #14 (D3331) provided on July 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for an extraction of tooth #10 (D7140) and does not have 
to pay for a limited oral evaluation (D0140) and a periapical x-ray (D0220) provided on April 22, 2022. 
 
You asked the Plan to pay more for an extraction and to pay for an evaluation and x-ray. You say that these 
services were the result of an emergency. The Plan denied your request. The Plan says you are responsible for 
any charged amount above the Plans cost-sharing amount when your services are received from an out-of-
network provider. The Plan also says that a limited oral evaluation (D0140) and a periapical x-ray (D0220) 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. 
 
 You have been asked to pay $30, which is 50% coinsurance of the allowed amount for an extraction ($60 
allowed amount x 50% coinsurance = $30). You also may be 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.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, a limited oral evaluation and periapical 
x-ray are not among those covered under this benefit.  Therefore, we decided that the Plan does not have to pay 
more for an extraction of tooth #10 (D7140) and does not have to pay for a limited oral evaluation (D0140) and 
a periapical x-ray (D0220) provided on April 22, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa for the left knee. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that Euflexxa is covered when specific criteria are 
met. 
 
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 services are not medically necessary. Our physician reviewer found the enrollee has right knee pain and 
Euflexxa has been approved for this knee. The records do not indicate that treatment for the left knee is 
indicated or planned. Euflexxa for the left knee is not reasonable or medically necessary at this time. 
 
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 Euflexxa for the left knee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the unclassified drug coded J3490 provided on March 2, 2022.

You asked the Plan to pay for the unclassified drug. 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. 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 J3490 is unclassified drugs.


We find that CPT code J3490 is not supported in the medical record. Specifically, this service was provided on the same date of service as the injection procedure for sacroiliac joint coded 27096. This means that code J3490 is included in the global surgery period of the minor procedure provided on the same date. Based on this information, we decided that Medicare rules for coverage of the unclassified drug have not been met. Therefore, we decided that the Plan does not have to pay for the unclassified drug coded J3490 provided on March 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a custom abutment on tooth #14 (D6057) and an abutment 
supported crown on tooth #14 (D6059) provided on July 14, 2022. 
 
You asked the Plan to pay for an abutment and crown. You say that you have coverage for crown repairs. The 
Plan denied your request. The Plan says a custom abutment (D6057) and an abutment supported crown 
(D6059) 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 custom 
abutment on tooth #14 (D6057) and an abutment supported crown on tooth #14 (D6059) provided on July 14, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a consultation (D9310) provided on February 24, 2022. 
 
You asked the Plan to pay for a consultation. You say that other services were approved but not the 
consultation. The Plan denied your request. The Plan says a consultation (D9310) is 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 
consultation (D9310) provided on February 24, 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 
3, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
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 January 20, 2020. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) 
provided on June 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a seat elevation system (E2300), essential box with 
lights (K0108), a memory seat program (K0108), a manual swingaway, retractable or removable mounting 
hardware for joystick, other control interface or positioning accessory (E1028) and push handles (K0108). 
 
You asked the Plan to pre-approve wheelchair accessories. You say that you disagree with the denial and 
would like to request reconsideration for the wheelchair accessories. The Plan denied your request. The Plan 
says the requested items are not considered medically necessary per Medicare. 
 The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a seat elevation system (E2300), essential box with lights 
(K0108), a memory seat program (K0108), a manual swingaway, retractable or removable mounting hardware 
for joystick, other control interface or positioning accessory (E1028) and push handles (K0108).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core build up on tooth #22, 25, 26, and 27 (D2950) and 
crowns on tooth #23, 24, 25, 26, and 27 (D2740) provided on January 27, 2022. 
 
You asked the Plan to pay for core build up and crowns. You say that you do not believe you have exhausted 
your crown benefit. The Plan denied your request. The Plan says core build up (D2950) is not covered by your 
dental benefits. The Plan also says that your benefit for crowns 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, core build up is not among those 
covered under this benefit. The record shows your benefit for crowns has been exhausted on date of service 
January 27, 2022. Therefore, we decided that the Plan does not have to pay for core build up on tooth #22, 25, 
26, and 27 (D2950) and crowns on tooth #23, 24, 25, 26, and 27 (D2740) provided on January 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the unspecified preventive procedure, by 
report (D1999) provided on April 11, 2022. 
 
You asked the Plan to issue reimbursement for this service. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says this service is not covered under 
your contractual policy. 
 
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 service provided is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to issue reimbursement for 
the unspecified preventive procedure, by report (D1999) provided on April 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an immediate mandibular partial denture (D5224). 
 
You asked the Plan to pre-approve an immediate mandibular partial denture. You say that you do not have the 
funds to purchase this partial. 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an 
immediate mandibular partial denture (D5224).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) 
provided on December 15, 2021. 
 
You asked the Plan to pay for the problem focused limited oral evaluation. You say that neither you, nor the 
Plan, should have to pay for this service because it was not rendered to you. The Plan denied your request. The 
Plan says your benefit for the requested 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 service was exhausted on date of service March 17, 2021. Therefore, we 
decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on 
December 15, 2021.  
 Your complaint about not receiving the evaluation you were billed for 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.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance supplies coded A0382 provided on April 8, 
2022. 
 
You asked the Plan to pay for the ambulance supplies. You say that you disagree with the Plan's 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 ambulance supplies are considered part of the 
general ambulance service and payment for them is included in the payment rate for the transport. Therefore, 
we decided that the Plan does not have to pay for the ambulance supplies coded A0382 provided on April 8, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custom abutments on tooth #19 and 31 (D6057) and 
abutment supported crowns on tooth #19 and 31 (D6060). 
 
You asked the Plan to pre-approve the dental services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says custom abutments (D6057) and abutment supported crowns (D6060) 
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 pre-approve 
custom abutments on tooth #19 and 31 (D6057) and abutment supported crowns on tooth #19 and 31 (D6060).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and a complete 
mandibular denture (D5120). 
 
You asked the Plan to pre-approve the complete dentures. You say that you need your teeth. The Plan denied 
your request. The Plan says your benefits for the requested items have 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 June 17, 2019.  
 
 
 
 
  
 
Therefore, we decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and a 
complete mandibular denture (D5120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a periodic oral evaluation (D0120) and 
prophylaxis (D1110) provided on April 27, 2022. 
 
You asked the Plan to waive the coinsurance for an evaluation and prophylaxis. You say that the website says 
that the provider is in-network. The Plan denied your request. The Plan says you have been charged the correct 
cost sharing amount. The Plan also says you are responsible for any charged amount above the Plans cost-
sharing amount when your services are received from an out-of-network provider. The record shows you received services from an out-of-network provider. You have been asked to pay a total 
of $60.30. You have been asked to pay the difference between the out-of-network providers charges and the 
Plans payment. An evaluation and prophylaxis fall within the Dental Services 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 waive the coinsurance for a periodic oral evaluation (D0120) and prophylaxis (D1110) 
provided on April 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mass spectrometry and tandem mass spectrometry (83789) 
billed for date of service March 9, 2022. 
 
You asked the Plan to pay for mass spectrometry services. You say that these services are supported in the 
medical records. The Plan denied your request. The Plan says they have agreed to pay for the drug testing 
services (G0481, 80307); however, code 83789 is being used to report specimen validity testing which is not 
separately payable. 
 
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 mass spectrometry 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 mass spectrometry and tandem mass spectrometry (83789) billed for date 
of service March 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on May 
11, 2022. 
 
You asked the Plan to pay for the comprehensive oral evaluation. You say that you feel you should not have to 
pay for this service because you were told multiple times it would be covered. The Plan denied your request. 
The Plan says your benefit for the requested 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 service was exhausted on date of service August 27, 2020. Therefore, we 
decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on May 11, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), periapical x-rays 
(D0220, D0230), bitewing x-rays (D0274), and prophylaxis (D1110) provided on May 12, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were told that you could go to an out-of-
network provider. 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), periapical x-rays (D0220, D0230), bitewing x-rays 
(D0274), and prophylaxis (D1110) provided on May 12, 2022.