Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fluoroscopic guidance services coded 77003 provided on 
June 29, 2022. 
 
You asked the Plan to pay for the fluoroscopic guidance services. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code the 
fluoroscopic guidance services is an add-on code and has not been billed with an appropriate primary 
procedure code. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the fluoroscopic guidance services coded 77003 provided on 
June 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an oral occlusal appliance (D7880) provided on November 
23, 2021. 
 
You asked the Plan to pay for an oral occlusal appliance. You say that you needed this for your sleep apnea. 
The Plan denied your request. The Plan says this cannot be covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that oral occlusal appliances used to treat 
temporomandibular joint (TMJ) disorders are classified as dental devices and are not classified as durable 
medical equipment. Oral occlusal appliances used to treat temporomandibular joint (TMJ) disorders are coded 
D7880 - occlusal orthotic appliance.  
 
We looked at the file and Medicare rules. The item at issue was billed as an oral occlusal appliance to treat 
TMJ, which is not covered. Based on this information, we decided that Medicare rules for coverage of an oral 
occlusal appliance have not been met. Therefore, we decided that the Plan does not have to pay for an oral 
occlusal appliance (D7880) provided on November 23, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have reduce the copayment for an MRI provided on August 5, 2022. 
 
You asked the Plan reduce the copayment for an MRI. You say that you already paid $161.70 for your 
copayment as advised by the provider. 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 $250 
copayment for diagnostic radiology (not including x-rays).  
 
You have been asked to pay $240.23 for an MRI. This amount is less than the standard $250 copayment. This 
item/service falls within the diagnostic radiology (not including x-rays) 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 reduce the copayment for magnetic resonance imaging (MRI) provided on August 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oral hygiene instructions (D1330), re-evaluation  post-
operative office visit (D0171), and occlusal adjustment - limited (D9951) provided from March 25, 2021 to 
October 11, 2021. 
 
You asked the Plan to pay for oral hygiene instructions (D1330), re-evaluation  post-operative office visit 
(D0171), and occlusal adjustment - limited (D9951). You say that you understood that you were responsible for 
a 20% coinsurance for receiving the dental services from an out-of-network provider. The Plan denied your 
request. The Plan says these services are not covered under the benefit package. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.  
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for oral 
hygiene instructions (D1330), re-evaluation  post-operative office visit (D0171), and occlusal adjustment - 
limited (D9951) provided from March 25, 2021 to October 11, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for to pay for lab services billed with code 87150 for date of 
service April 4, 2022. 
 
You asked the Plan to pay for code 87150. You say that you had to have this test and it was medically 
necessary. The Plan denied your request. The Plan says the lab records do not support the billing of this code. 
 
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 87150 is Culture, typing; identification by nucleic acid 
(DNA or RNA) probe, amplified probe technique, per culture or isolate, each organism probed. 
 
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 code 87150. Our reviewer says that code 87150 is not 
supported in the medical record. Our reviewer found the laboratory documents "no organisms 
detected".  Culture typing is done when the lab analyst performs an analysis using amplified DNA or RNA 
probe technique on a previously isolated and identified organism to categorize the organism more specifically, 
such as to the taxonomic level of type.  In this case, there is no organism to further test, and therefore this code 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 code 87150 have not been met. Therefore, we decided that the Plan does not 
have to pay for to pay for lab services billed with code 87150 for date of service April 4, 2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for the partial excision (28124) provided on July 15, 2022. 
 
You asked the Plan to pay for the partial excision (28124). You say that procedure code 28124 was for the 
resection of the osteophyte under the nail which was identified clinically as well as on the x-ray. You say that 
the procedure code is associated with a separate diagnosis code which required a separate incision at a different 
part of the foot. The Plan denied your request. The Plan says that procedure code 28124 is considered inclusive 
to CPT code 28299. 
 
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, the Plan cited the operative report, but medical records were not 
submitted to support this procedure code was considered inclusive to procedure code 28299. It is the burden of 
the Health Plan to substantiate their denial with evidence. In this case, the denial has not been substantiated so 
we must find in your favor. Therefore, we decided that the Plan has to pay for the partial excision (28124) 
provided on July 15, 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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a telehealth behavioral health visit provided on  
February 4, 2022. 
 
You asked the Plan to pay for the telehealth behavioral health visit. The Plan denied your request. The Plan 
says telehealth behavioral health visits are not covered out-of-network. 
 
The Plan contract covers Telehealth-Behavioral health visits. The Plan contract says that a Medicare-covered 
Telehealth-Behavioral health visit is not covered out-of-network. 
 
We looked at the file and the Plans rules. The file shows that the Plan does not cover Medicare-covered 
Telehealth-Behavioral health visits out-of-network. Therefore, we decided that the Plan does not have to pay 
for a telehealth behavioral health visit provided on February 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on August 11, 
2022, and the extraction of tooth #3 (D7210) provided on September 1, 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 dental services were received from an out-of-network provider 
and are not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a limited oral evaluation (D0140) provided on August 11, 2022, and the extraction of tooth #3 
(D7210) provided on September 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a partial mandibular denture (D4214) provided by a 
participating provider on April 5, 2021. 
 
You asked the Plan to pay for a partial mandibular denture. You say that you would like this paid. The Plan 
denied your request. The Plan says this claim was not filed timely. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a partial 
mandibular denture (D4214) provided by a participating provider on April 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a resin-based composite (D2392) for tooth #2 provided by an 
out-of-network provider on July 18, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for this. 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 August 16, 2021. 
Therefore, we decided that the Plan does not have to pay for a resin-based composite (D2392) for tooth #2 
provided by an out-of-network provider on July 18, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound rendered on May 9, 2022. 
 
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 procedure code 51798 is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 51798 
is a column II code to column I code 76857 with a modifier indicator of 0. The column II code is therefore not payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for the ultrasound rendered on May 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a retainer crown (D6740), and a pontic (D6242) provided by 
an out-of-network provider on January 17, 2022. 
 
You asked the Plan to pay for a retainer crown and a pontic. You say that you would like the Plan to pay for 
this. The Plan denied your request. The Plan says the rendered dental work 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 pay for a retainer 
crown (D6740), and a pontic (D6242) provided by an out-of-network provider on January 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bitewings - four radiographic images (D0274), periodic oral 
evaluation - established patient (D0120), and prophylaxis - adult (D1110) provided on July 7, 2022. 
 
You asked the Plan to pay for the dental services. You say how was the Plan allowed to change their coverage 
without notifying us in advance. The Plan denied your request. The Plan says the dental services were received 
from an out-of-network provider and are not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
 The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for bitewings - four radiographic images (D0274), periodic oral evaluation - established patient (D0120), 
and prophylaxis - adult (D1110) provided on July 7, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care services provided on March 4, 2021. 
 
You asked the Plan to pay for the home health care services. You say that you would like this claim to be 
reprocessed. The Plan denied your request. The Plan says the non-contracted provider did not submit the RAP 
claim for services for dates of service March 4, 2021, to March 12, 2021, until August 23, 2021. 
 
The Plan must follow Medicare rules. Medicare rules say that all HHAs must submit a RAP within 5 calendar 
days after the start of care date for initial 30-day periods and within 5 calendar days after the from date for 
each subsequent 30-day period of care. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health care services have not been met. Specifically, the record indicates the RAP was 
not submitted within 5 days from the start of care date. Therefore, we decided that the Plan does not have to 
pay for the home health care services provided on March 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on April 13, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you are appealing with supporting documentation. 
The Plan denied your request. The Plan says the enrollee must receive care from a network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for an office visit provided on April 13, 2022, by an 
out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the enrollee would like reconsideration because the services are medically necessary. The Plan denied your request. The Plan says an IRF admission is not medically necessary, and the enrollee can safely receive the care they need in other settings.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.


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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the enrollee is medically stable and does not require close supervision for the ongoing management of any active or acute exacerbations of chronic medical conditions. While the enrollee can benefit from physical and occupational therapy, their needs can be safely provided in an alternate level of care such as a skilled nursing facility.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete maxillary denture (D5110), and a mandibular 
partial denture (D5214) provided by a participating provider on July 18, 2022. 
 
You asked the Plan to pay for the dental services. You say that your old dentures do not fit rit. 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 August 10, 2021. 
Therefore, we decided that the Plan does not have to pay for a complete maxillary denture (D5110), and a 
mandibular partial denture (D5214) provided by a participating provider on July 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core build up on tooth #3 and 5 (D2950) and retainer 
crowns on tooth #3 and 5 (D6740). 
 
You asked the Plan to pre-approve core build up and crowns. You say that the requested services are medically 
necessary. The Plan denied your request. The Plan says that tooth #3 is not present in the enrollee's mouth. The 
Plan also says that tooth #5 already has a crown and no decay is noted around the present crown that would 
demonstrate a need for replacement. 
 
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 core build up 
and crowns when the services are medically necessary and reasonable.  
 
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 core build up and crowns. Our reviewer 
says that the coverage criteria has not been met. Our physician reviewer found that tooth #3 is missing and 
would not be an abutment tooth as requested. The physician reviewer also says that tooth #5 has an existing crown with no apparent defects. In this instance, the incorrect teeth numbers are supplied, and the teeth that 
may be used as abutments are not in adequate condition to utilize at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of core build up and crowns have not been met. Therefore, we decided that the 
Plan does not have to pre-approve core build up on tooth #3 and 5 (D2950) and retainer crowns on tooth #3 and 
5 (D6740).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on January 19, 2021, to April 20, 2021. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says that the dental services (D5820, D7410 and D4341) 
are not covered benefits. The plan also says that dental services (D0230 and D0210) were denied due your 
benefit for these services having 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, the requested services (D5820, D7410 
and D4341) are not among those covered under this benefit. Therefore, we decided that the Plan does not have 
to pay for the dental services on January 19, 2021, to April 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive periodontal evaluation (D0180) provided by 
an out-of-network provider on June 21, 2022. 
 
You asked the Plan to pay for comprehensive periodontal evaluation. You say that you believe 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 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 
comprehensive periodontal evaluation (D0180) provided by an out-of-network provider on June 21, 2022.