Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the drug testing provided on October 16, 2018. 
 
You asked the Plan to pay for the drug testing. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says that the documentation submitted does not 
support the services 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 G0482 and 80307 is drug test(s), definitive, utilizing (1) drug identification methods able to identify 
individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but 
not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding 
immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable 
isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, 
interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched 
quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or 
quantitative, all sources, includes specimen validity testing, per day; 15-21 drug class(es), including 
metabolite(s) if performed. 
 
We find that CPT code G0482 is supported in the medical record. Specifically, the lab report clearly shows that 
15-21 drug classes were tested in this case. Please note, we counted the classes based on the separately billable 
tests from the CPT Handbook. Additionally, the Plan has not forwarded any evidence to support why CPT code 
80307 is not eligible for payment. It is the burden of the Health Plan to substantiate their denial with evidence. 
In this case, the Plan's denial has not been substantiated so we must find in your favor. Also, the record 
indicates that this provider was directed by the Plan to not obtain records. With this direction, it is inappropriate 
for the Plan to deny these services based on the physician signature. Based on this information, we decided that 
Medicare rules for coverage of the drug testing have been met. Therefore, we decided that the Plan has to pay 
for the drug testing provided on October 16, 2018.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care, first hour (99291) provided on December 5, 2021. 
 
You asked the Plan to pay for critical care. You say that this service was billed appropriately and is supported 
in the record. The Plan denied your request. The Plan says the provided documentation does not support this 
service 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 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, the medical record does not 
show that critical care services were provided for 30-74 minutes on the date in question. Based on this 
information, we decided that Medicare rules for coverage of critical care have not been met. Therefore, we 
decided that the Plan does not have to pay for critical care, first hour (99291) provided on December 5, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the magnetic resonance imaging (MRI) scan services coded 
73723 provided on September 17, 2021. 
 
You asked the Plan to pay for the MRI scan services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says the documentation does not support the 
services as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 73723 is magnetic resonance (eg, proton) imaging, any joint of lower extremity; without contrast material(s), followed by contrast material(s) and further sequences. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the MRI scan services. Our reviewer says that the 
documentation does not support payment for the services billed. Our reviewer found that the reviewed 
documentation indicates that Current Procedural Terminology (CPT) code 73723 RT (1 unit) remains not 
supported. The medical records submitted do not include documentation to support that magnetic resonance 
(e.g., proton) imaging, any joint of lower extremity; without contrast material(s), followed by contrast 
material(s) and further sequences was performed; therefore, the billed service cannot be verified. The review 
has determined that the documentation does not support payment for CPT 73723. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the MRI scan services have not been met. Therefore, we decided that the Plan 
does not have to pay for the magnetic resonance imaging (MRI) scan services coded 73723 provided on 
September 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral - periapical first radiographic image (D0220) 
and intraoral - periapical each additional radiographic image (D0230) provided March 2, 2022. 
 
You asked the Plan to pay for the first and additional periapical x-rays. You say that x-rays are shown as 
covered on the website. The Plan denied your request. The Plan says this service is not covered under your 
benefits. The Plan also says that you are not enrolled in the additional optional supplemental dental 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. 
 
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 
intraoral - periapical first radiographic image (D0220) and intraoral - periapical each additional radiographic 
image (D0230) provided March 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core build up on tooth #7 and 10 (D2950) and crowns on 
tooth #7 and 10 (D2740) provided on January 20, 2022. 
 
You asked the Plan to pay for core build up and crowns. You say that you were unaware you no longer had 
coverage for this service. The Plan denied your request. The Plan says core build up (D2950) and crowns 
(D2740) are not covered by your supplemental 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. 
 
The record shows the estimate of benefits is not a guarantee of payment. 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 core build up on tooth #7 and 10 (D2950) 
and crowns on tooth #7 and 10 (D2740) provided on January 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for out of network providers.
You asked the Plan to provide coverage for out of network providers. You say that you prefer to see the
requested provider. The Plan denied your request. The Plan says this provider is not in network. Maximus
overturned the Plans denial because the case file lacked a 2022 Evidence of Coverage. The Plan requested a
reopen and submitted the 2022 plan contract.
The Plan is correct in this case. 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 provide coverage for care from out-of-network
providers only in cases involving emergencies, out of area urgent care and pre-approved care. The provider in
this case is not a network provider. The Plan had network providers available who render treatment. There is no
indication in the records that you have tried and been unsuccessful with the providers available in the Plans
network. Therefore, we decided that the Plan does not have to provide coverage for out of network providers.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and intraoral x-
rays (D0210) provided on October 14, 2021. 
 
You asked the Plan to pay for an evaluation and x-rays. You say that you need these services to prevent losing 
more teeth. The Plan denied your request. The Plan says these services are covered by your Plan's dental 
benefits; your benefits for one comprehensive oral evaluation and one intraoral x-ray every three years has 
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. 
 
We looked at this case file, the Plans rules, and Medicare rules. The record shows the Plan paid for a 
comprehensive oral evaluation and intraoral x-rays provided on October 16, 2019; therefore, the benefit for a 
comprehensive oral evaluation and intraoral x-rays has been exhausted. Therefore, we decided that the Plan 
does not have to pay for a comprehensive oral evaluation (D0150) and intraoral x-rays (D0210) provided on 
October 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve overdenture, complete, mandibular (code D5865). 
 
You asked the Plan to pre-approve the overdenture. You say that the overdenture is needed due to the loss of 
natural teeth. The Plan denied your request. The Plan says this service is not covered by the Plan's 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 
overdenture, complete, mandibular (code D5865).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral - complete series of radiographic images 
(D0210) provided April 6, 2022. 
 
You asked the Plan to pay for the complete series of x-rays. You say that your provider should have checked 
your benefits to confirm coverage. The Plan denied your request. The Plan says this service is not covered 
under your 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 
intraoral - complete series of radiographic images (D0210) provided April 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on August 30, 2021. 
 
You asked the Plan to pay for the dental service. You say that the provider did not properly check your 
insurance prior to taking your x-rays. The Plan denied your request. The Plan says the claim processed 
correctly. 
 
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 limited oral evaluation is listed as 
covered, the frequency limit of 2 oral exams per calendar year has been exceeded. The record shows that the 
Plan paid for a limited oral evaluation that you received on September 14, 2021, and a comprehensive oral 
evaluation that you received on April 7, 2021. Therefore, we decided that the Plan does not have to pay for the 
limited oral evaluation (D0140) provided on August 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) and intraoral x-rays 
(D0220) provided on March 3, 2022. 
 
You asked the Plan to pay for an evaluation and x-rays. You say that these services were medically necessary. 
The Plan denied your request. The Plan says these services are covered by the Plan's dental benefits; however, 
your benefit for oral evaluations and intraoral x-rays have 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. The Plan covers one oral 
evaluation every six months and one intraoral x-ray per year. 
 
We looked at this case file, the Plans rules, and Medicare rules. The record shows the Plan paid for a limited 
oral evaluation provided on December 3, 2021, and paid for intraoral x-rays provided on February 23, 2022; 
therefore, the benefit for oral evaluations and intraoral x-rays have been exhausted. Therefore, we decided that 
the Plan does not have to pay for a limited oral evaluation (D0140) and intraoral x-rays (D0220) provided on 
March 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established 
patient (D0150) provided March 24, 2022. 
 
You asked the Plan to pay for the comprehensive oral exam. You say that you were unable to take an 
appointment with your previous dentist, so it was necessary to make an appointment with a closer dentist. 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 Plans coverage rules apply in this case. The Plan covers the 
comprehensive or periodontal oral exam once every three calendar years. 
 
We looked at the file and Medicare rules. The Plan provided documentation showing that a comprehensive 
periodontal exam was previously covered February 22, 2022. Based on this information, we decided that the 
Plan's frequency limit for coverage of the comprehensive oral exam has been exceeded. Therefore, we decided 
that the Plan does not have to pay for the comprehensive oral evaluation - new or established patient (D0150) 
provided March 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dental observation regular hours office visit (code 
D9430). 
 
You asked the Plan to pre-approve dental visit. You say that this denial is unfair. The Plan denied your request. 
The Plan says the denial of authorization for this service is correct. 
 
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 
dental observation regular hours office visit (code D9430).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the neuromonitoring services provided on November 2, 2021. 
 
You asked the Plan to pay for the services provided. You say that the procedures prevent mechanical injury to 
the nervous system. The Plan denied your request. The Plan says the billed services cannot be verified. 
 
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 95886 is needle electromyography, each extremity, with 
related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; 
complete, five or more muscles studied, innervated by three or more nerves or four or more spinal levels. The 
CPT Code Manual definition of code 95909 is nerve conduction studies; 5-6 studies. We find that CPT codes 
95886 and 95909 are not supported in the medical record. Specifically, the records do not show that the billed 
services were provided. 
 The CPT Code Manual definition of code 95937 is neuromuscular junction testing (repetitive stimulation, 
paired stimuli), each nerve, any 1 method. We find that Train of Four Testing does not fit the criteria set by 
CMS and Insurance Carriers for CPT 95937. There is no separate code for Train of Four monitoring, therefore, 
it would be inappropriate to bill the Neuromuscular Junction Testing code for Train of Four monitoring. Based 
on this information, we decided that Medicare rules for coverage of the services provided have not been met. 
Therefore, we decided that the Plan does not have to pay for the neuromonitoring services provided on 
November 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crowns - porcelain fused to high noble metal (D2750) 
provided March 16, 2022. 
 
You asked the Plan to pay for the crowns. You say that you would like the crowns to be covered. 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 Plans coverage rules apply in this case. The Plan covers the crowns 
twice per year.  
 
We looked at the file and Medicare rules. The Plan provided documentation showing that two crowns (D2750) 
were previously covered on January 26, 2022. Based on this information, we decided that the Plan's frequency 
limit for coverage of the crowns has been exceeded. Therefore, we decided that the Plan does not have to pay 
for the crowns - porcelain fused to high noble metal (D2750) provided March 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an extraction (dental code D7140). 
 
You asked the Plan to pre-approve an extraction. You say that you need your tooth extracted and your dentist 
was not able to do it. The Plan denied your request. The Plan says the service is covered when performed by a 
participating general dentist. Dental services performed by an oral surgeon 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 Plans coverage rules apply in this case. The Plan covers tooth 
extractions only when performed by a participating general dentist. 
 
  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 when performed by an oral surgeon. Therefore, we decided that the 
Plan does not have to pre-approve an extraction (dental code D7140).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custom fabricated abutment (D6057) and an abutment 
supported porcelain (D6059), provided by a participating provider 
 
You asked the Plan to pre-approve custom fabricated abutment and an abutment supported porcelain. You say 
that these implants are medically necessary. The Plan denied your request. The Plan says the requested 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 pre-approve 
custom fabricated abutment (D6057) and an abutment supported porcelain (D6059), provided by a participating 
provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a precision attachment, by report (D5862). 
 
You asked the Plan to pre-approve a precision attachment. You say that your original dental provider no longer 
accepts your Plan. You found a new provider and he is willing to do the work you need with your teeth. You 
have discomfort and it is very difficult to eat, and you have to apply orajel on your gums all day. You are 
requesting reconsideration. The Plan denied your request. The Plan says the requested 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 a 
precision attachment, by report (D5862).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral exam, bitewings, and periodontal maintenance 
provided on April 18, 2022. 
 
You asked the Plan to pay for the oral exam, bitewings, and periodontal maintenance. You say that you verified 
the provider was in-network with the Plan prior to services being rendered. The Plan denied your request. The 
Plan says there is no coverage when services are rendered by an out-of-network provider. 
 
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 when received from an out-of-network provider. Therefore, we decided 
that the Plan does not have to pay for the periodic oral exam (code D0120), bitewings-four radiographic images 
(code D0274), and periodontal maintenance (code D4910) provided on April 18, 2022.