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

 
We decided that the Plan does not have to pre-approve a posterior resin-based composite of one surface 
(D2391). 
 
You asked the Plan to pre-approve the posterior resin-based composite of one surface. You say that you are a 
low-income elderly pensioner, which is why you asked for a double predetermination. You also say that you 
cannot pay larger amounts. 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 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 item or service was exhausted on October 9, 2022, when the Plan 
approved coverage for the anterior resin-based composite of one surface (D2330) and posterior resin-based 
composite of two surfaces (D2392). Therefore, we decided that the Plan does not have to pre-approve a 
posterior resin-based composite of one surface (D2391).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) and intraoral imaging 
(D0230) provided on November 4, 2022. 
 
You asked the Plan to pay for the dental services. You say that this was an emergency. 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 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 item or service was exhausted on date of service January 25, 2022. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) and intraoral 
imaging (D0230) provided on November 4, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xolair. 
 
You asked the Plan to pre-approve Xolair. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Xolair.  
 
Benefits for Xolair may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional moderate sedation time provided on date of 
service July 28, 2022, billed with code 99153. 
 
You asked the Plan to pay for procedure code 99153. You say that this service was medically necessary. The 
Plan denied your request. The Plan says code 99153 is not payable in the facility setting. 
 
Medicare rules say that the OPPS recognizes that CPT code 99153 is a PE only code and that PE are not 
payable to the physician for services provided in the facility setting.  
 
We find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment to the 
physician for CPT code 99153 when performed in the facility setting. Therefore, we decided that the Plan does not have to pay for the additional moderate sedation time provided on date of service July 28, 2022, billed with 
code 99153.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A4649 provided on February 9, 2022. 
 
You asked the Plan to pay for procedure code A4649. 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.  
We find that code A4649 has a status code of "P" 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. Therefore, we decided that the Plan does not have 
to pay for procedure code A4649 provided on February 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and an extraction 
(D7140) provided by September 1, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for these 
services. 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, D7140 is not covered under this benefit when received 
from an out-of-network provider. D0150 is not a covered dental benefit. Therefore, we decided that the Plan 
does not have to pay for a comprehensive oral evaluation (D0150) and an extraction (D7140) provided by 
September 1, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service August 12, 
2022. 
 You asked the Plan to pay for procedure code 76641. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 76641 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 76641 billed for date of service August 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for extraction, erupted tooth requiring removal of bone, 
sectioning of tooth and including elevation of mucoperiosteal flap (D7210) x2. We decided that the Plan does 
not have to pay for maxillary partial denture-resin bast (D5211) provided on July 26, 2022. 
  You asked the Plan to pay more for the dental services. You say that you would like the billed services to be 
covered and you would like to be reimbursed. The Plan denied your request. The Plan says you are responsible 
for any charged amount above the Plans cost-sharing amount when your services are received from 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. Enrollees must pay 50% 
coinsurance for covered out-of-network dental services and may be billed by the out-of-network provider for 
any charged amount greater than the payment made by the Plan. This benefit includes only those items and 
services specifically listed in your Plan contract. Maxillary partial denture-resin bast (D5211) is not covered 
under the Plans dental benefits. 
 
The allowed amount of the covered dental service total $108, resulting in a coinsurance amount of $54 and 
Plan payment amount of $54. 
 
You may also be asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 
 
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 more for extraction, erupted tooth requiring removal of bone, 
sectioning of tooth and including elevation of mucoperiosteal flap (D7210) x2.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, code D5211 is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for maxillary partial 
denture-resin bast (D5211) provided on July 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intra-oral periapical each additional radiographic image 
(D0230), oral hygiene instructions (D1330), topical application of fluoride varnish (D1206), adjunctive pre-
diagnostic test (D0431), and the dental scaling (D4346) provided on September 27, 2022. 
 
You asked the Plan to pay for these items/services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says these items/services are not a covered 
benefit. Additionally, the Plan says you have exhausted the allowable benefit for the intra-oral periapical 
radiographic images provided. 
 
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. Additionally, the Plan provides coverage for one periapical radiographic 
image per calendar year. The record shows that you received two periapical radiographic images on this day, in 
which one was paid for by the Plan. Therefore, you have exhausted the allowable benefit for this service. 
Therefore, we decided that the Plan does not have to pay for the intra-oral periapical each additional 
radiographic image (D0230), oral hygiene instructions (D1330), topical application of fluoride varnish 
(D1206), adjunctive pre-diagnostic test (D0431), and the dental scaling (D4346) provided on September 27, 
2022.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pay for SNF care provided from June 29, 2022, through July 16, 2022. 
 
You asked the Plan to pay for SNF care. You say that the enrollee would like reconsideration because the 
services are medically necessary. The Plan denied your request. The Plan says that the enrollee no longer had 
skilled nursing care needs. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, medical records were not submitted to support the Plans denial 
that SNF care was not medically necessary. Therefore, we decided that the Plan has to pay for continued SNF 
care provided on June 29, 2022, through July 16, 2022.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the respiratory virus detection by nucleic acid using 
amplified probe technique, 12-25 targets (87633) provided on January 4, 2022. 
 
You asked the Plan to pay for the respiratory virus detection, 12-25 targets. You say that you would like this 
claim paid. The Plan denied your request. The Plan says this testing is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that panels with >5 respiratory pathogens performed 
in the Part B outpatient setting are considered not medically reasonable and necessary.  
 
We looked at the file and Medicare rules. In this case the requested testing is for greater than 5 respiratory 
pathogens. Based on this information, we decided that Medicare rules for coverage of the respiratory virus 
detection, 12-25 targets have not been met. Therefore, we decided that the Plan does not have to pay for the 
respiratory virus detection by nucleic acid using amplified probe technique, 12-25 targets (87633) provided on 
January 4, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic radiology provided on October 
3, 2022. 
 
You asked the Plan to waive the copayment for a diagnostic radiology. You say that you disagree with the 
copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 $150 
copayment for outpatient diagnostic tests/diagnostic radiology.  
 
You have been asked to pay a $150 copayment for a diagnostic radiology. This item/service falls within the 
outpatient diagnostic tests/diagnostic radiology 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 a diagnostic radiology provided on October 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for out-of-network office visit provided on 
August 13, 2022. 
 
You asked the Plan to waive the copayment for out-of-network office visit. You say that you disagree with the 
copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 $50 
copayment for out-of-network physician/practitioner services.  
 
You have been asked to pay a $50 copayment for out-of-network office visit. This item/service falls within the 
out-of-network physician/practitioner services 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 out-of-network office visit provided on August 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on August 26, 2022. 
 
You asked the Plan to pay for office visit. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for office visit provided on 
August 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab work provided on August 22, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for lab work. You say that these services were medically necessary. The Plan denied 
your request. The Plan says prior authorization was not obtained for these services. 
 
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 lab work provided on August 22, 2022, by an out-
of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service September 7, 
2022. 
 
You asked the Plan to pay for procedure code 76641. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the number of units billed exceeds the 
maximum allowed. 
 The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 76641 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 76641 billed for date of service September 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildup, including any pins when required (D2950) 
x2 and pontic - porcelain/ceramic (D6245). 
 
You asked the Plan to pre-approve dental services. You say that you hope the Plan will pay for some of the 
services requested because this is a more permanent solution. The Plan denied your request. The Plan says 
these services are not covered under your 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. Core buildup, including any 
pins when required (D2950) x2 and pontic - porcelain/ceramic (D6245) are not covered under the Plans dental 
benefits. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D2950 x2 and D6245 are 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
core buildup, including any pins when required (D2950) x2 and pontic - porcelain/ceramic (D6245).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes 87900 and 87899 billed for date of service March 28, 
2022. 
 
You asked the Plan to pay for procedure codes 87900 and 87899. You say that these services were necessary 
and are supported as billed. The Plan denied your request. The Plan says that these services are 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. In this case, the CPT Code Manual definition of 
code procedure code 87899 is infectious agent antigen detection by immunoassay with direct optical (i.e., 
visual) observation; not otherwise specified. The definition of procedure code 87900 is infectious agent drug 
susceptibility phenotype prediction using regularly updated genotypic bioinformatics. 
 
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 codes 87900 and 87899. Our reviewer says that 
these services are supported as billed. Our reviewer found the medical records do support the use of procedure 
codes 87900 and 87899 for the number of units billed. The lab report supports these tests being done and the 
results being written. 
 
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 codes 87900 and 87899 have been met. Therefore, we decided that 
the Plan has to pay for procedure codes 87900 and 87899 billed for date of service March 28, 2022.  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from August 18, 
2022, through August 20, 2022. 
 
You asked the Plan to pay for SNF care. You say that you want the Plan to pay for the services. The Plan 
denied your request. The Plan says the services were not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) care provided from August 18, 2022, through August 20, 2022.