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

 
We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150). 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says dental services from an out-of-network provider are not 
covered by the 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. 
 
You are requesting a dental service to be rendered by an out-of-network provider. Though the Plan offers a 
dental benefit in excess of Medicare coverage, the requested service is not covered under this benefit when 
received from an out-of-network provider. Therefore, we decided that the Plan does not have to pre-approve a 
comprehensive oral evaluation (D0150).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a porcelain pontic for tooth number 13 (D6240) and a 
retainer crown for tooth number 14 (D6750). 
 
You asked the Plan to pre-approve these dental items. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says your benefit for the requested items 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 items has been exhausted.  Specifically, the Plans contract states that coverage for pontics and retainer crowns is limited to four units of a 
fixed denture per year. The Plan previously authorized coverage for four units of a fixed denture for teeth 
number 9, 10, 11, 12. Therefore, you have exhausted the allowable benefit for the requested items in this case 
at this time. Therefore, we decided that the Plan does not have to pre-approve a porcelain pontic for tooth 
number 13 (D6240) and a retainer crown for tooth number 14 (D6750).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a consultation - diagnostic service provided by dentist or 
physician (D9310) provided on December 19, 2022. 
 
You asked the Plan to pay for the consultation (D9310). You say that your dentist stated you needed to see an 
endodontist for an examination and determine the diagnosis. You also say that you are requesting the $96 back 
for the exam because D0140 is covered under your plan. The Plan denied your request. The Plan says we 
confirmed that you did not receive code D0140 on the date of service, and the provider billed for code D9310. 
The plan confirmed via outreach to yourself that you were now aware that you did receive code D9310 and not 
D0140 as suggested in the initial appeal correspondence, and that you still wished to appeal code D9310. 
 
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 - diagnostic service provided by dentist or physician (D9310) provided on December 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive oral evaluation (D0150), intraoral - complete 
series of radiographic images (D0210), panoramic radiographic image (D0330) and immediate denture - 
mandibular (D5140) provided on August 24, 2022. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says the dental services were received from an out-of-network provider and are not covered 
by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for comprehensive oral evaluation (D0150), intraoral - complete series of radiographic images (D0210), 
panoramic radiographic image (D0330) and immediate denture - mandibular (D5140) provided on August 24, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on October 24, 2022, billed with 
codes 81347. 
 
You asked the Plan to pay for the genetic testing billed. You say that this service was medically necessary. The 
Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
October 24, 2022, billed with codes 81347.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy services provided from December 2, 
2021, to June 30, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the psychotherapy services. You say that you think that these services should be 
covered. The Plan denied your request. The Plan says you must receive your care from a network provider. 
 
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 psychotherapy services provided from 
December 2, 2021, to June 30, 2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided on July 14, 2022, billed with code 
72100-26. 
 
You asked the Plan to pay for imaging services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim 
and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on August 12, 2022. Comparison of the two claims shows these are exact duplicates. There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for imaging services provided have not been 
met. Therefore, we decided that the Plan does not have to pay for imaging services provided on July 14, 2022, 
billed with code 72100-26.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete intraoral radiographic image capture (D0709) 
provided on December 19, 2022. 
 
You asked the Plan to pay for the dental service. You say that you are appealing the denied dental service. The 
Plan denied your request. The Plan says the denial of payment for this service is correct, because the complete 
intraoral radiographic image capture is not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
complete intraoral radiographic image capture (D0709) provided on December 19, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital discharge day management services coded 
99283 provided on August 19, 2022. 
 
You asked the Plan to pay for the hospital discharge day management services. You say that you disagree with 
the Plan's denial. The Plan denied your request. The Plan says the services are not separately 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 99283 is hospital discharge day management; 30 minutes 
or less. 
 
 
 We find that CPT code 99283 is not supported in the medical record. Specifically, this service was billed on the 
same date of service as a surgical procedure 61107 (Twist drill hole(s) for subdural, intracerebral, or ventricular 
puncture; for implanting ventricular catheter, pressure recording device, or other intracerebral monitoring 
device). This means payment for code 99283 is included in the global surgical package of code 61107 and is 
not separately payable as billed. Based on this information, we decided that Medicare rules for coverage of the 
hospital discharge day management services have not been met. Therefore, we decided that the Plan does not 
have to pay for the hospital discharge day management services coded 99283 provided on August 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for AlloSure Heart provided on August 12, 2022. 
 
You asked the Plan to pay for AlloSure Heart. You say that AlloSure Heart was medically necessary and is not 
experimental and investigational. The Plan denied your request. The Plan says Acute Cellular Rejection occurs 
rarely after two years, and standards for ongoing surveillance are not clear. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 AlloSure Heart. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the Allosure test is described as a blood test designed to detect the presence of donor cell-
free DNA in the recipients blood as a measure of the probability of rejection in heart transplant recipients. The 
enrollee had a heart transplant in 2020. There is no documentation provided to support the basis for the 
requested testing in 2022. As such, there is no evidence to support its role in this enrollee's clinical 
management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of AlloSure Heart have not been met. Therefore, we decided that the Plan does not 
have to pay for AlloSure Heart provided on August 12, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the injectafer (J1439). 
 You asked the Plan to pre-approve the injectafer. You say that the drug is medically necessary. The Plan denied 
your request. The Plan says the member has not met the step therapy requirements. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 the injectafer. Our reviewer says that 
the drug is not medically necessary. Our physician reviewer found the provided records do not indicate that the 
enrollee has tried and failed the plan's preferred step one alternative or that the enrollee has a contraindication 
to, or would have an adverse effect from the plan's preferred step one alternative. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the injectafer have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the injectafer (J1439).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the walker you purchased on November 6, 2022. 
 
You asked the Plan to pay for the walker. You say that you were told that this walker would be approved. The 
Plan denied your request. The Plan says the supplier from which you purchased this item is not a Medicare-
certified provider. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the walker you purchased on November 
6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a gingival flap procedure, including root planing - one to 
three contiguous teeth or tooth bounded spaces per quadrant (D4241) provided on October 19, 2022. 
 
You asked the Plan to pay for the dental service. You say that you have no teeth and don't understand why this 
is being processed under dental. You also say that you suffered with gum pain and had to see a periodontist and 
a surgeon. The Plan denied your request. The Plan says the records indicate that you called the Plan on October 
17, 2022 and were advised that the plan was code specific. You were also emailed a copy of the policy which 
shows what codes are covered under the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a gingival 
flap procedure, including root planing - one to three contiguous teeth or tooth bounded spaces per quadrant 
(D4241) provided on October 19, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 93010 and 99285 provided on October 26, 2022. 
 
You asked the Plan to pay for codes 93010 and 99285. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the claim is 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. 
 
We find that CPT codes 93010 and 99285 are not supported in the medical record. Specifically, these codes 
were billed with diagnosis codes U07.1 (Covid-19); R05.1 (Acute Cough); R41.0 (Disorientation Unspecified); 
R41.82 (Altered Mental Status Unspecified). Diagnosis codes R41.82 (Altered Mental Status Unspecified) and 
R41.0 Disorientation Unspecified, should not be reported together. Therefore, this claim is not payable as 
billed. Based on this information, we decided that Medicare rules for coverage of codes 93010 and 99285 have 
not been met. Therefore, we decided that the Plan does not have to pay for codes 93010 and 99285 provided on 
October 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation - problem focused (D0140), 
intraoral - periapical first radiographic image (D0220), and each additional radiographic image (D0230) 
provided on December 28, 2022. 
 
You asked the Plan to pay for the dental codes represented by D0140, D0220, and D0230. You say that the 
procedures were a necessity due to having a bad tooth ache. The Plan denied your request. The Plan says these 
services are not covered under the benefit package. 
 
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 limited 
oral evaluation - problem focused (D0140), intraoral - periapical first radiographic image (D0220), and each 
additional radiographic image (D0230) provided on December 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for alcohol treatment provided from March 13, 2022, to April 
16, 2022. 
 
You asked the Plan to pay for alcohol treatment. You say that the Plan told you that alcohol treatment is 
covered by the Plan. The Plan denied your request. The Plan says this service is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that a Substance Abuse Facility is not eligible to 
participate in the Medicare program. 
 
We looked at the file and Medicare rules. The provider at issue in this case is a Substance Abuse Facility. 
Medicare says that a Substance Abuse Facility is not eligible to participate in the Medicare program. Therefore, 
we decided that the Plan does not have to pay for alcohol treatment provided from March 13, 2022, to  
April 16, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service December 3, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that the member had multiple exams done on 
this date of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into 
payment for code 70496. 
 
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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service December 3, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on September 19, 2022, billed 
with procedure codes 74230, 70310, 72040, 70100, 71045, and 74240. 
 
You asked the Plan to pay for the medical services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the wrong place of service was billed. 
 
The Plan must follow Medicare rules. Medicare rules say that when services are furnished in a mobile unit, 
they are often provided to serve an entity for which another POS code exists.  
 We looked at the file and Medicare rules. Place of service 11 was billed, however the documentation does not 
support that the services were done in an office setting. According to the documentation, the services were 
performed in a mobile setting at a skilled nursing facility. Based on this information, we decided that Medicare 
rules for coverage of the medical services have not been met. Therefore, we decided that the Plan does not have 
to pay for the medical services provided on September 19, 2022, billed with procedure codes 74230, 70310, 
72040, 70100, 71045, and 74240.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 94010, 947226, and 94729 billed for date 
of service July 15, 2022. 
 
You asked the Plan to pay for procedure code(s) 94010, 947226, and 94729. You say that the services should 
be covered due to medical necessity. The Plan denied your request. The Plan says these codes are included in 
the facility payment and are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that this service was provided to the enrollee while an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 94010, 947226, and 
94729. This means there is both a professional and technical component for the CPT code(s). In this case, an 
appropriate modifier to indicate the professional component has not been billed with CPT code(s) 94010, 
947226, and 94729. Based on this information, we decided that Medicare rules for coverage of procedure codes 
94010, 947226, and 94729 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code(s) 94010, 947226, and 94729 billed for date of service July 15, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99601 and 99602 billed for date of service 
August 21, 2022. 
 
You asked the Plan to pay for procedure codes 99601 and 99602. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the billed codes are invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure codes 99601 and 99602 have a Status Indicator of I on the Physician Fee Schedule. 
This means that procedure codes 99601 and 99602 are not valid for Medicare purposes. Based on this 
information, we decided that Medicare rules for coverage of procedure codes 99601 and 99602 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes 99601 and 99602 billed for 
date of service August 21, 2022.