Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a facet joint injection at a third additional level. 
 
You asked the Plan to pre-approve facet joint injection services. You say that this procedure is medically 
necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that one to two levels, either unilateral or bilateral, are 
allowed per session per spine region. The need for a three or four-level procedure bilaterally may be considered 
under unique circumstances and with sufficient documentation of medical necessity on appeal.
 
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 facet joint injection services. Our 
reviewer says that the requested additional facet joint injection is not medically reasonable and necessary. Our 
physician reviewer found that the enrollee is a 76-year-old female with a history of breast cancer, 
gastrointestinal issues, and chronic low back pain due to lumbar spondylosis without myelopathy or 
radiculopathy, status post compression fracture L5.  She has failed conservative treatment with Tylenol, 
Ibuprofen, and Lidocaine patches.  
The enrollee's pain has responded to Ketorolac. Lumbar magnetic resonance imaging shows lumbar disc 
degeneration and facet joint disease (L2-L5), moderate foraminal stenosis at L4-L5. The provider is requesting 
bilateral 3-level medial branch blocks. Per the LCD, three or four-level procedure bilaterally may be considered 
under unique circumstances and with sufficient documentation of medical necessity on appeal.  The review has 
determined that the enrollee does not have a covered indication for the requested third level facet joint 
injection. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of facet joint injection services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a facet joint injection at a third additional level.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical and occupational therapy services provided on 
August 30 to October 1, 2021. 
 
You asked the Plan to pay for physical and occupational therapy services. You say that the provided medical 
records support the level of service. The Plan denied your request. The Plan says rules for payment have not 
been met. 
The Plan must follow Medicare rules. Medicare rules say that the services of a PTA shall not be billed as 
services incident to a physician/NPP's service, because they do not meet the qualifications of a therapist. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of physical and occupational therapy services have not been met. Specifically, the documentation 
shows that this claim was billed by a nurse practitioner but the therapy services at issue were rendered by a 
Physical Therapy Assistant. A Nurse Practitioner cannot bill for the services of a Physical Therapy Assistant 
because they do not meet the qualifications of a therapist. Therefore, we decided that the Plan does not have to 
pay for physical and occupational therapy services provided on August 30 to October 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional payment for the periodontal maintenance (D4910) 
provided August 31, 2021. 
 
You asked the Plan to provide additional payment for the periodontal maintenance. You say that you feel you 
only had a regular cleaning. The Plan denied your request. The Plan says the records show the periodontal 
maintenance was rendered and the coinsurance has been applied correctly. 
 
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 the periodontal maintenance with 50% coinsurance. 
 
We looked at the file and Medicare rules. You have been asked to pay $46 ($91.99 total cost x 50% 
coinsurance = $46) for the periodontal maintenance. The dental records provided by the dentist show that the 
periodontal maintenance was performed. This means you have been asked to pay the correct amount based on 
your contract with the Plan.  Therefore, we decided that the Plan does not have to provide additional payment 
for the periodontal maintenance (D4910) provided August 31, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Mass spectrometry and tandem mass spectrometry 
(83789-59) provided on July 19, 2021. 
 
You asked the Plan to pay for code 83789-59. You say that the medical records support the use of modifier 59 
with code 83789 provided on July 19, 2021. The Plan denied your request. The Plan says the medical records 
do not support the use of modifier 59 with code 83789 provided on July 19, 2021. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
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 code 83789-59. Our reviewer says that the 
medical records do not support the use of modifier 59 with code 83789 provided on July 19, 2021. 
Our physician reviewer found the review indicates that code 83789-59 is included in the code G0480 therefore 
it cannot be separately reimbursed. The documentation does not support that the procedure or service was 
independent from other services performed, therefore the use of modifier 59 is not supported. The review has 
determined that the medical records did not support the use of modifier 59 with code 83789 provided on July 
19, 2021. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 83789-59 have not been met. Therefore, we decided that the Plan does not 
have to pay for the Mass spectrometry and tandem mass spectrometry (83789-59) provided on July 19, 2021.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for a surgical laparoscopy with cholecystectomy (47562) provided on 
December 9, 2020. 
 
You asked the Plan to pay for a surgical laparoscopy with cholecystectomy. You say that the services at issue 
were a medical necessity for the enrollee. The Plan denied your request. The Plan says that rules for payment 
have not been met because the provided medical records do not support the service billed. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan did not forward the medical records provided to the Plan 
and used by the Plan in its review. It is the responsibility of the Plan to substantiate its denial. In this case, the 
denial has not been substantiated by the Plan and therefore we must find in your favor. Therefore, we decided 
that the Plan has to pay for a surgical laparoscopy with cholecystectomy (47562) provided on December 9, 2020.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for resin-based composites (D2330 and D2332) provided by a 
participating provider on December 2, 2021. 
 
You asked the Plan to pay for resin-based composites. You say that you believe that the Plan should pay for 
this. The Plan denied your request. The Plan says the benefit limit for D2330 and D2332 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 Plan's coverage rules apply in this case. The Plan covers two resin-
based composites per calendar year.  
 
We looked at the file and Medicare rules. Evidence was provided to show that the Plan paid for D2330 and 
D2332 for tooth #7 and tooth #9; therefore, D2330 and D2332 for tooth #6, #8, #10, and #11. Based on this 
information, we decided that the Plan's rules for coverage of resin-based composites have already been met. 
Therefore, we decided that the Plan does not have to pay for resin-based composites (D2330 and D2332) 
provided by a participating provider on December 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core build up (D2950). 
 
You asked the Plan to pre-approve the dental service. You say that you have a big hole in the root of your 
tooth. You say that it is exposed and having some pain. You also say that you do not understand why part of 
the authorization is approved but the core build up was denied. The Plan denied your request. The Plan says 
core build up is not a covered service. 
 
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 core build up is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve core 
build up (D2950).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided November 9, 2021. 
 
You asked the Plan to pay for the periodontal maintenance. You say that your heart doctor recommends that 
you have dental cleanings every three months to remain heart healthy. The Plan denied your request. The Plan 
says you have exceeded the frequency limit for this service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the 
periodontal maintenance three times per plan year. 
 
We looked at the file and Medicare rules. The Plan provided documentation showing that periodontal 
maintenance was previously covered on January 26, 2021, May 3, 2021, and August 3, 2021. Based on this 
information, we decided that the Plan's frequency limit for coverage of the periodontal maintenance has been 
exceeded. Therefore, we decided that the Plan does not have to pay for the periodontal maintenance (D4910) 
provided November 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for two crowns (D2740) and two core 
buildups (D2950) provided on July 1, 2021. 
 
You asked the Plan to waive the copayments for the dental restorations. You say that you were not aware that 
you would be responsible for a copayment for these services. The Plan denied your request. The Plan says this 
claim was processed correctly, and your copayments were assessed in accordance with your contract. You are 
responsible for a $20 copayment for each of these services. 
 
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 a 
copayment between $20 and $350 for restorative dental services.  
 
You have been asked to pay a $20 copayment for each of the dental restoration services. While the contract is 
not clear regarding the exact copayment amount that applies to each restoration service, it is clear that dental 
restorations require a $20 copayment at a minimum. 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 copayments for 
two crowns (D2740) and two core buildups (D2950) provided on July 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation feature, expandable controller 
with harness, and electronic connection. 
 
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 covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature and electronic 
connection are non-covered. The rules say that an expandable controller and harness are approved to control 
multiple power switches. 
 
We looked at the file and Medicare rules. The requested power seat elevation system and electronic connection 
are not covered. The expandable controller and harness are not needed to control the approved power options. 
Therefore, we decided that the Plan does not have to pre-approve a power seat elevation feature, expandable 
controller with harness, and electronic connection.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral exam (D0120) provided on November 9, 2021. 
 
You asked the Plan to pay for the dental service. You say that there was 6 months and 4 days between your last 
2 cleaning appointments. You also say that this service should be covered. The Plan denied your request. The 
Plan says 2 oral exams are covered per plan year. The Plan also says that the frequency limit has been 
exceeded. 
 
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 and oral exams are covered, the 
frequency limit of 2 oral exams per plan year has been exceeded. The record shows that the Plan paid for oral 
exams that you received on January 21, 2021, and May 5, 2021. Therefore, we decided that the Plan does not 
have to pay for the oral exam (D0120) provided on November 9, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing services rendered on April 21, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure codes 95955, 95885, 95937, 95927, and 95907 are not supported. 
 
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 95955 is electroencephalogram (EEG) during 
nonintracranial surgery (eg, carotid surgery). The definition of code 95885 is needle electromyography, each 
extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and 
latency/velocity study; limited (List separately in addition to code for primary procedure). The definition of 
code 95937 is neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method. 
The definition of code 95927 is short-latency somatosensory evoked potential study, stimulation of any/all 
peripheral nerves or skin sites, recording from the central nervous system; in the trunk or head. The definition 
of code 95907 is nerve conduction studies; 1-2 studies. 
 
We find that CPT codes 95955, 95885, 95937, 95927, and 95907 are not supported in the medical record. 
Specifically, there is no documentation of an EEG during nonintracranial surgery to support code 95955. There 
is no documentation of limited needle electromyography to support code 95885. The file shows that Train of 
Four testing was performed, and there is a more appropriate code for these services other than 95937. There is 
no documentation of a short-latency somatosensory evoked potential study in the trunk or head to support code 
95927. There is no documentation of up to two nerve conduction studies to support code 95907. 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 pay for the testing services rendered on April 21, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unspecified mass spectrometry services provided on 
September 1, 2021, billed with code 83789. 
 
You asked the Plan to pay for the unspecified mass spectrometry services. You say that this is medically 
necessary testing. The Plan denied your request. The Plan says the drug testing was paid, but the specimen 
validity testing is not 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. This testing represents specimen validity testing which is not 
separately payable. Based on this information, we decided that Medicare rules for coverage of the unspecified 
mass spectrometry services have not been met. Therefore, we decided that the Plan does not have to pay for the 
unspecified mass spectrometry services provided on September 1, 2021, billed with code 83789.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a gingival flap procedures (D4241 x 2), bone 
replacement graft (D4623), guided tissue regeneration (D4266), and subepithelial connective tissue graft 
(D4273). 
 
You asked the Plan to pre-approve the dental services. You say that your periodontist has recommended these 
services. The Plan denied your request. The Plan says gingival flap procedure, bone replacement graft, guided 
tissue regeneration, and subepithelial connective tissue graft are not listed as covered services. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested gingival flap procedure, 
bone replacement graft, guided tissue regeneration, and subepithelial connective tissue graft are not among 
those covered under this benefit.  Therefore, we decided that the Plan does not have to pre-approve a gingival flap procedures (D4241 x 2), bone replacement graft (D4623), guided tissue regeneration (D4266), and subepithelial connective tissue graft 
(D4273).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance (D4910) and fluoride varnish 
application (D1206) provided on November 8, 2021. 
 
You asked the Plan to pay for the dental services. You say that this service should be covered twice per year 
and not just on a six-month basis because it makes scheduling your appointments more difficult. The Plan 
denied your request. The Plan says the fluoride treatment is not covered by your dental benefit, and periodontal 
maintenance may only be covered once every 6 months. You previously had periodontal maintenance provided 
and covered for you on June 3, 2021, which is less than 6 months before the date in question. 
 
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 only covers services that are listed in the benefits chart. The Plan can cover one periodontal cleaning every 6 months. 
 
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 or were provided in a frequency that exceeds what is covered by this 
benefit. Therefore, we decided that the Plan does not have to pay for periodontal maintenance (D4910) and 
fluoride varnish application (D1206) provided on November 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on November 3, 2021. 
 
You asked the Plan to pay for the dental service. You say that you were not aware you had a specific number of 
visits during the calendar year. You say that your plan should pay $99. You also say that you needed this 
service to determine the pain you were experiencing in tooth # 18. The Plan denied your request. The Plan says 
1 limited oral evaluation per plan year. The Plan also says that the frequency limit has been exceeded. 
 
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 and 1 limited oral evaluation is covered 
per plan year, the frequency limit has been exceeded. The record shows that the Plan paid for a limited oral 
evaluation that you received on September 1, 2021. Therefore, we decided that the Plan does not have to pay 
for the limited oral evaluation (D0140) provided on November 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an endosteal implant (D6010), and implant supported 
crown (D6066) for tooth # 12. 
 
You asked the Plan to pre-approve the dental services. You say that you want to have this space fixed. The Plan 
denied your request. The Plan says endosteal implant is not listed as a covered service. The Plan says that 
implant supported crown is not listed as a covered service either. 
 
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 endosteal implant and 
implant supported crown are not among those covered under this benefit. Therefore, we decided that the Plan 
does not have to pre-approve an endosteal implant (D6010), and implant supported crown (D6066) for tooth # 12.