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

 
We decided that the Plan does not have to pay for the resin-based filling (D2330) provided on April 28, 2021. 
 
You asked the Plan to pay for the resin-based filling. You say that you only remember having one filling done. 
The Plan denied your request. The Plan says documentation shows that you were provided fillings for tooth 
#27 and #28 on April 28, 2021. One of these fillings has been covered by your plan, but the second filling 
exceeds the frequency limitation for this service and remains denied. 
 
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 can cover one resin 
filling or restoration per year. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the filling is requested in a frequency 
that exceeds what is covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
the resin-based filling (D2330) provided on April 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye refraction (92015) provided on July 22, 2021. 
 
You asked the Plan to pay for an eye refraction. You say that your provider indicated the procedure was part of 
a pre-diabetic eye exam. You were under the impression that this would be covered. The Plan denied your 
request. The Plan says the service at issue is not a covered benefit. Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when it is performed as a routine screening by a participating 
provider. 
 
We looked at the file and the Plan's rules. The eye refraction was performed as part of a medical vision exam, 
and therefore is not a covered benefit. Based on this information, we decided that the Plan's rules for coverage 
of an eye refraction have not been met. Therefore, we decided that the Plan does not have to pay for an eye 
refraction (92015) provided on July 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Brief emotional/behavioral assessment (96127) and 
additional supplies (99072) provided on July 26, 2021. 
You asked the Plan to pay for codes 96127 and 99072. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 96127 is Brief emotional/behavioral assessment (eg, 
depression inventory, attention-deficit/hyperactivity disorder [ADHD] scale), with scoring and documentation, 
per standardized instrument. 
 
We find that CPT codes 96127 and 99072 are not supported in the medical record. Specifically, the 
documentation submitted did not include documentation of brief emotional/behavioral assessment for the billed 
date of service. Furthermore, code 99072 has a status code of "B" under the Medicare Physicians Fee Schedule 
Database (MPFSDB) and no separate payment is made for this code under the fee schedule as payment is 
bundled into the payment for the services to which this code is incident to. Based on this information, we 
decided that Medicare rules for coverage of codes 96127 and 99072 have not been met. Therefore, we decided 
that the Plan does not have to pay for the Brief emotional/behavioral assessment (96127) and additional 
supplies (99072) provided on July 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided October 21, 2021. 
 
You asked the Plan to pay for the periodontal maintenance. You say that you did not realize that your opt out 
status would affect patients and would like an exception until you are able to opt back in. The Plan denied your 
request. The Plan says this service is not covered when rendered by a provider who has opted out of Medicare. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the 
periodontal maintenance when the enrollee sees any licensed dental provider who accepts Medicare patients in 
the United States and has not opted out of Original Medicare. 
 
We looked at the file and Medicare rules. The services at issue in this appeal were provided in a non-urgent, 
non-emergent situation by the provider who has opted out of the Medicare program. Based on this information, 
we decided that the Plan's rules for coverage of the periodontal maintenance have not been met. Therefore, we 
decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided October 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the protective restoration (D2940) provided on November 9, 2021. 
 
You asked the Plan to pay for the protective restoration. You say that you did not realize that you were 
receiving a non-covered service, and this cost is too high. The Plan denied your request. The Plan says this 
service is not covered by your dental 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 the 
protective restoration (D2940) provided on November 9, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lower lumbar fusion L4-5 for the enrollee. 
 
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your 
request. The Plan says the provided clinical documentation does not support the medical necessity of the 
surgery. 
 
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 pre-approve the surgery. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found detailed documentation is not evident regarding trial and failure of recent, reasonable, and 
comprehensive less invasive conservative care measures. Additionally, the provided x-rays do not corroborate 
lumbar instability. Detailed documentation is not evident regarding potential impending/inevitable temporary 
intra-operative instability. There is no compelling rationale presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception to guidelines. Therefore, the request for anterior 
lumbar interbody fusion L4-5 (22845, 22558, 22853) is not medically reasonable or necessary. 
 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 surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a lower lumbar fusion L4-5 for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction, erupted tooth or exposed root (elevation 
and/or forceps removal) (D7140), limited oral evaluation - problem focused (D0140), and intraoral - periapical 
first radiographic image (D0220) provided October 27, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the tooth extraction, limited oral exam and intraoral x-ray. You say that you 
weren't informed that you needed to see a network dentist. The Plan denied your request. The Plan says these 
services are not covered when provided OON. 
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 tooth 
extraction, limited oral exam and intraoral x-ray when the services are provided in-network.  
 
We looked at the file and Medicare rules. 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. Based on this information, we decided that the Plan's rules for coverage of 
the tooth extraction, limited oral exam and intraoral x-ray have not been met. Therefore, we decided that the 
Plan does not have to pay for the extraction, erupted tooth or exposed root (elevation and/or forceps removal) 
(D7140), limited oral evaluation - problem focused (D0140), and intraoral - periapical first radiographic image 
(D0220) provided October 27, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve microprocessor knee (CPT code L5856, L5828, L5845, 
and L5848). 
 
You asked the Plan to pre-approve the items. You say that the items are necessary. The Plan denied your 
request. The Plan says the requested computerized knee exceeds your needs. 
 
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 items. Our physician reviewer 
found the physician's notes do not show why a mechanical K3 knee cannot be used for your initial prosthesis, 
especially given the weight a microprocessor knee and your co-morbidities. While the vendor states that you 
require a microprocessor knee, there are no notes from your physician to support this or to show why a 
mechanical K3 knee cannot be used for your prosthesis. The review indicates that the medical records provided 
did not meet the requirements listed in the LCD for Medicare coverage. 
 
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 items have not been met. Therefore, we decided that the Plan does not have 
to pre-approve microprocessor knee (CPT code L5856, L5828, L5845, and L5848).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic activities, direct (one-on-one) patient contact 
(97530) provided on September 22, 2021. 
 You asked the Plan to pay for therapeutic activities. You say that this claim was billed appropriately and should 
be paid. The Plan denied your request. The Plan says the service is not supported 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 code 97530 is not supported in the medical record. Specifically, the documentation shows 
that this claim was billed by a Nurse Practitioner but the therapy services at issue were rendered by an 
Occupational Therapy Assistant. There is no indication that the Nurse Practitioner was present on site while the 
therapy services were being rendered. The incident-to requirements have not been met in this case. Based on 
this information, we decided that Medicare rules for coverage of therapeutic activities have not been met. 
Therefore, we decided that the Plan does not have to pay for therapeutic activities, direct (one-on-one) patient 
contact (97530) provided on September 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) 
provided November 24, 2021. 
 
You asked the Plan to pay for the limited oral exam. You say that an exam is necessary to perform a tooth 
extraction. The Plan denied your request. The Plan says you have exceeded the frequency limit for dental 
exams. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers dental exams 
twice per year. 
 
We looked at the file and Medicare rules. The Plan provided documentation showing that dental exams were 
previously covered on February 8, 2021, and August 12, 2021. Based on this information, we decided that the 
Plan's frequency limit for coverage of the limited oral exam has been exceeded. Therefore, we decided that the 
Plan does not have to pay for the limited oral evaluation - problem focused (D0140) provided November 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the full mouth debridement (D4355) and full mouth x-rays 
(D0210) provided on October 27, 2021, by an out-of-network provider. 
 
You asked the Plan to pay for the dental services. You say that these services should be covered with a $0 
copayment. The Plan denied your request. The Plan says this claim was processed correctly and in accordance 
with your contract. The Plan has agreed to pay for the periodic oral exam and has reprocessed this service for 
payment. The Plan has paid the full allowed amount for the x-rays, and you are responsible for the additional 
charges for this service as it was performed by an out-of-network provider. The full mouth debridement service 
is not covered by your dental benefit under any circumstance and is denied in full. 
 
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 $0 
copayment for full mouth x-rays (D0210). However, for services obtained out-of-network the Plan only pays 
up to a certain amount. If you choose to see an out-of-network provider, you might be billed for any amount 
greater than what the Plan pays, even for services listed as a $0 copayment. 
 
The record shows that the provider billed the Plan $122 for the x-rays provided on October 27, 2021. The 
Plans allowed cost for this service is $67. This is the amount that an in-network provider would accept as full 
payment for this service, but out-of-network providers do not have this agreement with the Plan and are 
allowed to remain you the difference between the Plans payment and the full amount billed. The Plan paid the 
total $67 allowed amount for this service, as you are responsible for a $0 copayment. Cost sharing is always 
based on the Plans allowed rate for a service. You have been asked to pay $55 for the x-rays, which is the 
difference between what the provider billed and the Plans payment. ($122 - $67 = $55). 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 pay any additional amount for the full mouth x-rays (D0210) provided on October 27, 2021, 
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 Plans coverage rules apply in this case. The Plan does not cover 
services or codes that are not listed in the Plans dental benefits chart section of the contract. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the full mouth debridement (D4355) is 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
full mouth debridement (D4355) provided on October 27, 2021, by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on July 7, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed with the incorrect place of service. 
 
 
 The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or 
other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.  
 
We looked at the file and Medicare rules. The documentation shows that the services in question were billed 
with POS code 81. However, the records do not show that the specimen was collected in a laboratory setting. 
This means that the claim was billed with the incorrect POS code. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab services provided on July 7, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an endoscopy performed on July 15, 2021. 
 
You asked the Plan to waive the copayment for the endoscopy. You say that you were unable to schedule the 
procedure at the hospital. You say that the procedure would have been less expensive. The Plan denied your 
request. The Plan says you have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $300 
copayment for surgery provided at an outpatient hospital or ambulatory surgical center.  
 
 
 You have been asked to pay a $300 copayment for the endoscopy. Please note that the copayment amount is 
the same regardless of the location. The endoscopy falls within the Outpatient Surgery, Including Services 
Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 an endoscopy performed on July 15, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for outpatient rehabilitation services provided 
on October 11, 2021. 
 
You asked the Plan to waive the deductible for outpatient rehabilitation services. You say that you paid your 
copayment and feel that the Plan should pay the remaining balance. The Plan denied your request. The Plan 
says the claims were processed correctly and you are being charged the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $750 deductible which applies to out-of-network outpatient 
rehabilitation services.  
 
You received outpatient rehabilitation services at an out-of-network provider on October 11, 2021. Therefore, 
you are responsible to pay your share of the out-of-network cost-sharing charges. The record shows that you 
had paid $0 toward the $750 deductible prior to receiving the services. Therefore, you are responsible to pay 
the allowed amount of $158.90.  The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient 
rehabilitation services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a 
$750 deductible which applies to outpatient rehabilitation services. This cost sharing is a contractual obligation 
that had not been met at the time outpatient rehabilitation services were received on October 11, 2021. 
Therefore, we decided that the Plan does not have to waive the deductible for outpatient rehabilitation services 
provided on October 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) and an intraoral-periapical 
X-ray (D0220) provided on November 1, 2021. 
 
You asked the Plan to pay for a limited oral evaluation and an intraoral-periapical X-ray. You say that the 
services at issue are covered as a benefit in the EOC. The Plan denied your request. The Plan says rules for 
payment have not been met. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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) and an intraoral-periapical X-ray (D0220) provided on November 1, 2021.  
Your complaint about the Plan's access to information about your network providers and about the care you 
have received from Plan-affiliated optometrists is not a valid appeal for medical coverage. This part of your 
complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision 
about these types of complaints.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the computed tomography (CT) scan and 
the bone imaging you had on July 15, 2021. 
 
You asked the Plan to waive the deductible for the CT scan and the bone imaging. You say that you should 
only have to pay a $125 copayment for each service.  You said that this should not have been applied to the 
deductible. The Plan denied your request. The Plan says you were charged this deductible correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $1000 deductible which applies to outpatient diagnostic radiological 
services.  
 
The CT scan and the bone imaging fall within the benefit category of outpatient diagnostic radiological 
services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1000 
deductible which applies to outpatient diagnostic radiological services. This cost sharing is a contractual 
obligation that had not been met at the time the CT scan and the bone imaging were received on July 15, 2021. Therefore, we decided that the Plan does not have to waive the deductible for the computed tomography (CT) 
scan and the bone imaging you had on July 15, 2021.