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

 
We decided that the Plan does not have to pay for the adjacent tissue transfer or rearrangement (14301 and 
14302) provided on November 19, 2021. 
 
You asked the Plan to pay for the adjacent tissue transfer or rearrangement (14301 and 14302). You say that 
the operative report clearly states the enrollee underwent a right mastectomy and was found to have a posterior 
margin that required resection. You say that the doctor performed the doctor performed a right breast 
reconstruction with adjacent tissue transfer. The Plan denied your request. The Plan says procedure codes 
14301 and 14302 are not supported by the medical records submitted. 
 
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 14301 is adjacent tissue transfer or rearrangement, any 
area; defect 30.1 sq cm to 60.0 sq cm. The CPT Code Manual definition of code 14302 adjacent tissue transfer 
or rearrangement, any area; each additional 30.0 sq cm, or part thereof (List separately in addition to code for 
primary procedure). 
 
  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 adjacent tissue transfer or rearrangement (14301 and 
14302). Our reviewer says that the documentation submitted was reviewed and does not meet the criteria for 
coverage. Our reviewer found the operative report does not describe healthy skin and other tissues transferred 
to the area adjacent to the skin defect. In this case, the operative report describes a complex closure. Therefore, 
these procedures cannot be verified. 
 
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 adjacent tissue transfer or rearrangement (14301 and 14302) have not been 
met. Therefore, we decided that the Plan does not have to pay for the adjacent tissue transfer or rearrangement 
(14301 and 14302) provided on November 19, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says the 
records do not support the necessity of the intensity of service at a LTACH level. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the medical record does not indicate that the enrollee requires services that she is not 
currently receiving, but that would be available at the LTACH facility. The elements of the coverage rules are 
not satisfied. Our reviewer also found that the requested service cannot be recommended. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on September 26, 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 the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.  
 
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and 
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on September 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services coded 99100 provided on January 18, 2021. 
 You asked the Plan to pay for the anesthesia services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says no separate payment is made for this code 
per Medicare rules. 
 
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 code 99100 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99100 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of the anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for the 
anesthesia services coded 99100 provided on January 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an extraction (D7210) provided by a participating provider 
on March 17, 2022. 
 
You asked the Plan to pay for an extraction. You say that you had a referral to see this dentist. You say that this 
should be covered. The Plan denied your request. The Plan says the rendered dental service is not a covered 
benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 an 
extraction (D7210) provided by a participating provider on March 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the periodic oral evaluation (D0120), first intraoral 
periapical x-ray (D0220), additional intraoral periapical x-ray (D0230), bitewing x-rays (D0274), and 
prophylaxis (D1110) provided on April 27, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay more for the dental services. You say that you think the Plan should be covering this 
charge. The Plan denied your request. The Plan says the fee charged exceeds the maximum allowance. 
 
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, you are responsible for the difference 
between the billed amount and allowed amount. Therefore, we decided that the Plan does not have to pay more 
for the periodic oral evaluation (D0120), first intraoral periapical x-ray (D0220), additional intraoral periapical 
x-ray (D0230), bitewing x-rays (D0274), and prophylaxis (D1110) provided on April 27, 2022 by an out-of-
network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on February 15, 2022. 
 
You asked the Plan to pay for the medical services. You say that the patient's hospice enrollment ended on 
February 5, 2022, so the Plan should pay for this. The Plan denied your request. The Plan says Original 
Medicare, not the Plan, is responsible for this bill. 
 
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 February 5, 2022. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for medical services 
provided on February 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene panel testing provided on September 13, 2021. 
 
You asked the Plan to pay for the testing services. You say that you enable physicians to deliver personalized 
cancer care. The Plan denied your request. The Plan says the testing is not medically necessary. 
 
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 the gene panel was billed with multiple codes. If a single procedure is performed, only one code 
with one unit of service may be reported for the procedure. Based on this information, we decided that 
Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does 
not have to pay for the gene panel testing provided on September 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on December 10, 2021. 
 
You asked the Plan to pay for the dental services. You say that this was not a routine dental visit. The Plan 
denied your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service November 2, 2021. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on 
December 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the incision and drainage of an abscess (D7510) provided on 
March 23, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says the incision and drainage of an abscess (D7510) is 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. 
 
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 
incision and drainage of an abscess (D7510) provided on March 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an unspecified preventive procedure (D1999), custom 
fabricated abutment (D6057), and an implant supported crown (D6066) provided on March 25, 2021. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says an unspecified preventive procedure (D1999), custom fabricated 
abutment (D6057), and an implant supported crown (D6066) are not covered by your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an 
unspecified preventive procedure (D1999), custom fabricated abutment (D6057), and an implant supported 
crown (D6066) provided on March 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the four two dimensional (2D) oral/facial photographic 
images (D0350 x4) provided on March 22, 2022. 
 
You asked the Plan to pay for the 2D oral/facial photographic images. You say that you went to the office for a 
consultation which you were told was free, and covered under your plan along with x-rays. The Plan denied 
your request. The Plan says this service is not covered under your plan. The Plan also says that you did not 
enroll in the dental rider offered 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the four 
two dimensional (2D) oral/facial photographic images (D0350 x4) provided on March 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an excision of a lesion (D7410) and deep sedation (D9222, 
D9223) provided on March 14, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were told to submit to the Plan, and they 
would reimburse you. The Plan denied your request. The Plan says an excision of a lesion (D7410) and deep 
sedation (D9222, D9223) are not covered by your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an 
excision of a lesion (D7410) and deep sedation (D9222, D9223) provided on March 14, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Emergency room services (ER) on 
December 04, 2021, to December 05, 2021. 
 
You asked the Plan to waive the copayment for Emergency room services (ER). You say that you should only 
have a $90 copayment because you went to the ER. The Plan denied your request. The Plan says the cost-
sharing you are being charged is correct 
 
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 $200 
copayment for Medicare-covered outpatient hospital observation. Observation services are hospital outpatient 
services given to determine if you need to be admitted as an inpatient or can be discharged. For outpatient 
hospital observation services to be covered, they must meet the Medicare criteria and be considered reasonable 
and necessary. Observation services are covered only when provided by the order of a physician or another 
individual authorized by state licensure law and hospital staff bylaws to admit patients to the hospital or order 
outpatient tests. 
 You have been asked to pay a $200 copayment for Emergency room services (ER). Emergency room services 
(ER) falls within the Outpatient hospital observation benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for Emergency room services (ER) on December 04, 2021, to December 05, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and panoramic 
radiographic imaging (D0330), provided by a participating provider on March 1, 2022. 
 
You asked the Plan to pay for the dental services. You say that you called and verified that these services were 
covered. The Plan denied your request. The Plan says your benefit for the requested item or service has already 
been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service August 31, 2021. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and 
panoramic radiographic imaging (D0330), provided by a participating provider on March 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional extractions (D7210 x 13), deep sedation 
(D9222, D9223), and immediate upper denture (D5140) provided on September 8, 2021. 
 You asked the Plan to pay for 13 additional extractions, deep sedation, and immediate denture. You say that 
you contacted the plan prior to receiving the services to confirm the provider accepted your plan. You also say 
that the services were medically necessary. 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage and extractions are listed as covered, 
frequency limits may apply. The record shows that the Plan paid the in network rate for 2 extractions that you 
received on the date of service in this case. Additionally, the deep sedation services and immediate denture are 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
additional extractions (D7210 x 13), deep sedation (D9222, D9223), and immediate upper denture (D5140) 
provided on September 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), prophylaxis (D1110), 
bitewing x-rays (D0272), intraoral x-rays (D0220), and an amalgam filling (D2140) provided on March 8, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were unaware your coverage had changed. 
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 Plan's coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a periodic oral evaluation (D0120), prophylaxis (D1110), bitewing x-rays (D0272), intraoral x-rays 
(D0220), and an amalgam filling (D2140) provided on March 8, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 26605-54 billed for date of service October 
27, 2021. 
 
You asked the Plan to pay for procedure code 26605-54. You say that this service was coded correctly. The 
Plan denied your request. The Plan says procedure code 26605-54 is not supported in the medical record. 
 
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 26605-54 is Closed treatment of metacarpal fracture, 
single; with manipulation, each bone. 
 
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 procedure code 26605-54. Our reviewer says that procedure 
code 26605-54 is not supported in the medical record. Our reviewer found the procedure report documents 
"Procedure: The fracture was not displaced and did not require manipulation in the ED". In this case, there is a 
more appropriate code to report for service provided.  
 We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 26605-54 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 26605-54 billed for date of service October 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on January 6, 2022. 
 
You asked the Plan to pay for an evaluation. You say that the provider was in-network, and you were in 
excruciating pain. The Plan denied your request. The Plan says a limited oral evaluation (D0140) is 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 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 a limited 
oral evaluation (D0140) provided on January 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composite-two surfaces, posterior (D2392) 
and the extractions, of an erupted tooth requiring removal of bone and/or sectioning of tooth (D7210 x 2) 
provided on March 2, 2022 and March 8, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says the dental services at issue are not 
covered under your contractual policy. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
  
Though the Plan offers a dental benefit in excess of Medicare coverage, the services provided are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the resin-based 
composite-two surfaces, posterior (D2392) and the extractions, of an erupted tooth requiring removal of bone 
and/or sectioning of tooth (D7210 x 2) provided on March 2, 2022 and March 8, 2022.