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

 
We decided that the Plan does not have to pay for the cone beam computed tomography (CT) capture and 
interpretation (D0367), sinus augmentation (D7951), bone replacement graft for ridge preservation (D7953), 
first 15 minutes of deep sedation/general anesthesia (D9222), and five subsequent 15 minute increments of 
deep sedation/general anesthesia (D9223 x5) provided on May 12, 2021, and October 6, 2021. 
 
You asked the Plan to pay for the cone beam CT capture and interpretation, sinus augmentation, bone 
replacement graft, and deep sedation/general anesthesia services. You say that you would like these services to 
be reconsidered for coverage. The Plan denied your request. The Plan says these services are not covered. 
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 the cone 
beam computed tomography (CT) capture and interpretation (D0367), sinus augmentation (D7951), bone 
replacement graft for ridge preservation (D7953), first 15 minutes of deep sedation/general anesthesia (D9222), 
and five subsequent 15 minute increments of deep sedation/general anesthesia (D9223 x5) provided on May 
12, 2021, and October 6, 2021.
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 6, 2021. 
 
You asked the Plan to pay for the problem focused limited oral evaluation. You say that you had to switch 
dentists because your previous dentist retired. You also say that you wanted the new dentist to provide a 
checkup/oral evaluation because you lost a tooth. The Plan denied your request. The Plan says this service is 
not a covered expense under your dental plan. The Plan also says that you did not contact the Plan prior to the 
date of service to verify benefits and provider eligibility. 
 
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 the 
problem focused limited oral evaluation (D0140) provided on December 6, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs received from November 10, 2021, 
to November 12, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says this service is not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs received 
from November 10, 2021, to November 12, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital subsequent care provided on September 15, 2021. 
 
You asked the Plan to pay for hospital subsequent care. The Plan denied your request. The Plan says Original 
Medicare would be responsible for payment of all Medicare covered services related or unrelated to the 
members terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all 
hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-
for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until 
the first day of the month following the month in which hospice was revoked or discharged. Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on September 6, 2021. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for hospital subsequent 
care provided on September 15, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost share for a cystourethroscopy provided on November 
4, 2021. 
 
You asked the Plan to reduce the cost share for a cystourethroscopy. You say that you were given an estimate 
of $180 for surgery on November 4, 2021. The Plan denied your request. The Plan says you have been charged 
the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is $300 deductible which applies to outpatient surgery at an outpatient 
hospital. The Plan contract also says that the enrollee must pay 10% coinsurance for each outpatient surgery visit at an outpatient hospital after the deductible is met.  
 
You have been asked to pay a total of $466.38 for the cystourethroscopy. The deductible was not met at the 
time of service; therefore, $180.07 was applied to satisfy the remainder of the deductible. The Plan has 
followed Medicare rules by clearly disclosing in the contract that there is $300 deductible which applies to 
outpatient surgery at an outpatient hospital. This cost sharing is a contractual obligation that had not been met 
at the time a cystourethroscopy was received on November 4, 2021. 
 
The allowed amount remaining after you paid your deductible is $2,863.06 ($3,043.13 original allowed amount 
- $180.07 deductible paid = $2,863.06 remaining allowed amount). You have been asked to pay $286.31, 
which is 10% of the remaining allowed amount for the cystourethroscopy ($2,863.06 remaining allowed 
amount x 10% coinsurance = $286.31). 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 reduce the cost share for a 
cystourethroscopy provided on November 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prefabricated abutment (D6056), and an abutment 
supported crown (D6058) for teeth number #2, #3, #4, and #5 to be provided by a participating provider. 
 
You asked the Plan to pre-approve a prefabricated abutment and an abutment supported crown. You say that 
you do not have the money to pay for these services. The Plan denied your request. The Plan says restoration 
and restorative 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 pre-approve a 
prefabricated abutment (D6056), and an abutment supported crown (D6058) for teeth number #2, #3, #4, and 
#5 to be provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gingival irrigation (D4921) provided on November 24, 2021. 
 
You asked the Plan to pay for the gingival irrigation. The Plan denied your request. The Plan says this service 
is not covered by your health plan or Medicare. 
 
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 the 
gingival irrigation (D4921) provided on November 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (96377) provided August 21, 2020. 
 
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the code billed shares a bundled relationship with another code 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 96377 
is a column II code to column I code 96413. 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 physician services (96377) provided August 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Transcutaneous electrical nerve stimulation (tens) 
device (E0730). 
 
You asked the Plan to pre-approve a tens device. You say that you would like the Plan to reconsider their 
denial. The Plan denied your request. The Plan says a tens device is not covered for chronic lower back pain 
unless the enrollee is enrolled in an approved clinical study. 
 
The Plan must follow Medicare rules. Medicare rules say in order to support additional research on the use of 
tens for chronic lower back pain, the enrollee must be enrolled in an approved clinical study. 
 
We looked at the file, the Plan's contract, and Medicare rules. The file shows the request for a tens device is for 
chronic lower back pain. The file does not show that the enrollee in enrolled in an approved clinical study. 
Therefore, we decided that the Plan does not have to pre-approve a Transcutaneous electrical nerve stimulation 
(tens) device (E0730).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care (99309) provided on 
September 29, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the subsequent nursing facility care. You say that the rendering physician is a 
Hospitalist physician with the group and depends upon the hospital staff to verify eligibility and to obtain the 
proper authorization from the patient's insurance company. You also say that the physician provided medically 
necessary services to the patient in good faith. The Plan denied your request. The Plan says this service was 
rendered by a non-network provider. The Plan also says that there were no notes provided that show this was 
an emergency, and Plan providers are available for this service.  
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care (99309) 
provided on September 29, 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 dental services to be provided by an out-of-network 
provider. 
 
You asked the Plan to pre-approve dental services. You say that you would like the Plan to approve and pay for 
these services. The Plan denied your request. The Plan says services provided by an out-of-network 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 Plan's coverage rules apply in this case. The Plan covers dental 
services when the services are provided by an assigned contracted provider. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of dental services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve dental services to be provided by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (87486, 87496, 87498, 87502, 87532, 
87541, 87581, 87634, 87640, 87798) provided on February 4, 2021. 
 
You asked the Plan to pay for laboratory services. You say that this should be covered. The Plan denied your 
request. The Plan says this was not billed with the correct place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place 
where the sample was taken is reported as the Place of Service (POS).  
 We looked at the file and Medicare rules. The services at issue were billed with POS 11 for an office setting, 
but the record shows the sample was taking in a nursing facility. Based on this information, we decided that 
Medicare rules for coverage of laboratory services have not been met. Specifically, this claim was billed with 
the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. 
Therefore, we decided that the Plan does not have to pay for laboratory services (87486, 87496, 87498, 87502, 
87532, 87541, 87581, 87634, 87640, 87798) provided on February 4, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (82728, 83540, 83550) provided on 
November 1, 2021. 
 
You asked the Plan to pay for laboratory services. You say that there is no contractual agreement in place to 
include these services in the dialysis rate. The Plan denied your request. The Plan says these services are not 
separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that all laboratory services furnished to individuals 
for the treatment of end-stage renal disease (ESRD) are included in the ESRD Prospective Payment System 
(PPS) as Part B services and are not paid separately. 
 
 
 We looked at the file and Medicare rules. The laboratory services at issue were provided for the treatment of 
ESRD. Based on this information, we decided that Medicare rules for coverage of laboratory services have not 
been met. Therefore, we decided that the Plan does not have to pay for laboratory services (82728, 83540, 
83550) provided on November 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and diagnostic radiology provided from 
January 7, 2021, through February 27, 2021. 
 
You asked the Plan to pay for an office visit and diagnostic radiology. The Plan denied your request. The Plan 
says the services are not covered by the Plan under any circumstance. 
 
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 service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for an office visit and diagnostic radiology provided from January 7, 2021, 
through February 27, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient therapy services provided from December 1, 
2020, through December 23, 2020. 
 
  You asked the Plan to pay for the outpatient therapy services. You say that the claim was submitted utilizing 
the standard Part B guidelines and the patient's October claim was paid that was submitted the same. You say 
that the claim should be sent back for review and reprocessing. The Plan denied your request. The Plan says the 
claim was not submitted with the required modifiers to process and pay claim. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Modifier GP must be reported for services delivered under an outpatient physical therapy plan of care and 
modifier GO must be reported for services delivered under an outpatient occupational therapy plan of care. 
 
We find that the outpatient therapy services are not supported in the medical record. Specifically, therapy codes 
must be reported with the appropriate therapy modifier. Based on this information, we decided that Medicare 
rules for coverage of the outpatient therapy services have not been met. Therefore, we decided that the Plan 
does not have to pay for the outpatient therapy services provided from December 1, 2020, through December 
23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional supplies and materials (99072) provided on 
June 21, 2021. 
 
You asked the Plan to pay for the additional supplies and materials (99072). You say that plans are required to 
pay non-contract providers at the preferred provider rate when services are not available from preferred 
providers in the service area. You say that the in-network benefits should be honored, and the claim processed 
for payment. The Plan denied your request. The Plan says bundled services are not eligible for separate 
payment. 
 
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 99072 is additional supplies, materials, and clinical staff 
time over and above those usually included in an office visit or other non-facility service(s), when performed 
during a Public Health Emergency, as defined by law, due to respiratory-transmitted infectious disease. 
 
We find that CPT code 99072 is not supported in the medical record. Specifically, CPT code 99072 has a status 
indicator of B. This means that CPT code 99072 is considered bundled and not separately payable. Based on 
this information, we decided that Medicare rules for coverage of the additional supplies and materials (99072) 
have not been met. Therefore, we decided that the Plan does not have to pay for the additional supplies and 
materials (99072) provided on June 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services (00920) provided on November 15, 
2021. 
 
You asked the Plan to pay for code 00920. 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. 
 
We looked at the file, the Plan's contract, and Medicare rules. Medicare says in order to submit code 00920 for 
payment consideration, modifier G8 must be appended to the code. In this case, the file shows that modifier G8 was not appended to code 00920 on the claim submitted for payment. Therefore, we decided that the Plan does 
not have to pay for the anesthesia services (00920) provided on November 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2750) for tooth #30 to be provided by a 
participating provider. 
 
You asked the Plan to pre-approve a crown. You say that your current crown is too big. You say that it is 
causing you pain. The Plan denied your request. The Plan says medical necessity has not been met. 
 
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 Plan covers a crown when 
the services are medically necessary and reasonable.  
 
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 a crown. Our reviewer says that the 
requested crown is not medically necessary. Our physician reviewer found based on the documentation that 
was provided, the criteria for a crown have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of a crown have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a crown (D2750) for tooth #30 to be provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service (A0999) provided on October 12, 
2021. 
 
You asked the Plan to pay for the ambulance service.. You say that you would like to appeal this service. The 
Plan denied your request. The Plan says non-transport ambulance services are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on October 12, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance service (A0999) provided on 
October 12, 2021.