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

 
We decided that the Plan does not have to pay for an artery x-ray of the arms/legs (75716-XU) and artery x-
rays of each vessel (75774-XU) provided on June 15, 2021. 
 
You asked the Plan to pay for the artery x-rays. You say that these codes do not bundle with 37229 and are 
separately payable and supported. The Plan denied your request.  The Plan says these services are included in another billed procedure, which has already been paid. These services are not supported as billed with the XU modifier. 
 
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 codes 
75716 and 75774 are both column II codes to column I code 37229; however, 75716 and 75774 were each 
billed with a modifier.  
 
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 artery x-rays. Our reviewer says that these services are 
not supported as billed with modifier XU. Our reviewer found that procedure code 75716-XU, an angiography 
for bilateral extremity with radiological supervision and interpretation is documented in the operative note 
submitted for review; however, this procedure is considered inclusive to CPT code 37229-LT, an open or 
percutaneous endovascular revascularization of a unilateral tibial or peroneal artery for the initial vessel with 
atherectomy, including angioplasty within the same vessel, when performed. Therefore, the code cannot be 
verified. After careful review of the operative report, the Medical Director states; "The requested service code 
is not substantiated by the clinical documentation in the operative report submitted for review. As a result, the 
requested procedure code has an NCCI conflict with CPT code 37229-LT; it would be considered inclusive and 
consequently be denied by reason of 'Misuse of column two code with column one code.' No acceptable 
Modifier has been approved. 
 
Procedure code 75774-XU, a selective angiography, for each additional vessel studied after basic examination, 
radiological supervision and interpretation (listed separately in addition to code for primary procedure) is 
documented in the operative note submitted for review; however, this procedure is considered inclusive to CPT 
code 37229-LT. Therefore, the code cannot be verified. The review has determined that the documentation 
does not support billing modifier XU to indicate that CPT codes 75716 and 75774 are separate and distinct 
from CPT code 37229. 
 
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 artery x-rays have not been met. Therefore, we decided that the Plan does 
not have to pay for an artery x-ray of the arms/legs (75716-XU) and artery x-rays of each vessel (75774-XU) 
provided on June 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an out-of-network provider on 
October 27, 2021. 
 
You asked the Plan to pay for dental services. You say that you were told this provider was in-network. The 
Plan denied your request. The Plan says services provided by an out-of-network provider are not covered 
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 Plan covers dental 
services when the services are medically necessary and reasonable.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of dental services have not been met. Therefore, we decided that the Plan does not have to pay for 
dental services provided by an out-of-network provider on October 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the addition, endoskeletal system, below knee, alignable 
system (L5910). 
 
You asked the Plan to pre-approve the endoskeletal below knee, alignable system. You say that you 
respectfully request for review of the clinical file submission and overturn the codes. The Plan denied your request. The Plan says the preparatory prosthesis is a non-alignable system, therefore, the medical necessity for 
the requested alignable system (L5910) is not met. 
 
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 endoskeletal below knee, alignable 
system. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee was approved for a preparatory prosthesis 
(L5540-Preparatory, below knee (BK) PTB type socket, non-alignable system, pylon, no cover, SACH foot, 
laminated socket, molded to model). The preparatory prosthesis is a non-alignable system, therefore, the 
medical necessity for the requested alignable system (L5910) is not met. The review has determined 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 endoskeletal below knee, alignable system. have not been met. Therefore, 
we decided that the Plan does not have to pre-approve the addition, endoskeletal system, below knee, alignable 
system (L5910).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2751) for tooth #20. 
 
You asked the Plan to pre-approve the crown. You say that you are in pain and need this crown. The Plan 
denied your request. The Plan says this service is not medically necessary. The Plan also says that tooth #20 
does not appear to have significant breakdown due to decay or trauma. 
 
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 crown 
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 the crown. Our reviewer says that there 
is no necessity for a crown on tooth #20. Our physician reviewer found the x-rays reveal many broken down 
teeth in both arches, and it is not clear why a crown is being requested for tooth #20. Our reviewer found that 
there are insufficient involved surfaces to consider the use of a full coverage crown. Our physician reviewer 
also found that if a restoration is necessary then a conventional material for direct filling can be used. 
 
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 the crown have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a crown (D2751) for tooth #20.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for Prolia for the enrollee.
You asked the Plan to provide coverage for Prolia. You say that Prolia is medically necessary. The Plan denied
your request. The Plan says the required step therapy criteria are not met. We overturned the Plans denial
for insufficient medical records.
The Plan requested a reopen and provided additional information. The Plan notes that a discussion with your
physician confirmed that you have not tried and failed the required medications prior to coverage of Prolia and
that you did not meet the required coverage criteria at the time of the appeal. The Plan provided the medical
records that confirm this statement by your physician.
The Plan is correct in this case. Medicare covers Part B medications when they are reasonable and necessary
but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented
such criteria for certain Part B medications. Based on the medical records provided and the statement from
your physician, you did not meet these criteria at the time of the appeal. Therefore, we decided that the Plan
does not have to provide coverage for Prolia for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for lap sleeve surgery.
You asked the Plan to provide coverage for this surgery. You say that this surgery is medically necessary. The
Plan denied your request. The Plan says Medicare coverage criteria are not met. We overturned the Plans
denial. The Plan requested a reopen and stated that we did not apply the correct LCD criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for lap sleeve
gastrectomy. Our Physician Reviewer determined the procedure was reasonable and necessary. The
Plan requested a reopen noting the documentation shoes there is a failure to cease tobacco use. The medical
records show you are diagnosed with morbid obesity. It is documented in the medial records that you are
currently an every-day smoker, 0.5 packs per day. Therefore, the Plan is correct in this case. Per LCD L35022,
failure to cease tobacco use is an absolute contraindication to bariatric surgery. The case file does not contain
documentation that you have attempted to cease tobacco use. The required coverage criteria are not met.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of this surgery have not been met. Therefore, we decided that the Plan does not
have to pre-approve lap sleeve surgery.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown repair necessitated by restorative material failure 
(D2890) provided on December 14, 2021. 
 
You asked the Plan to pay for the dental service. You say that this service was to finish a root canal. You also 
say that you feel this service was needed. The Plan denied your request. The Plan says crown repair 
necessitated by restorative material failure is not listed as a covered service. 
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 crown repair necessitated by 
restorative material failure is not among those covered under this benefit. Therefore, we decided that the Plan 
does not have to pay for the crown repair necessitated by restorative material failure (D2890) provided on 
December 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional payment for the resin-based composite - one 
surface, posterior (D2391) and endodontic therapy, molar tooth (excluding final restoration) (D3330) provided 
December 6, 2021. 
 
You asked the Plan to provide additional payment for the filling and root canal. You say that you feel the 
services should be covered because the dental services were for an emergency. The Plan denied your request. 
The Plan says you have met your annual dental maximum; therefore, no payment is due. 
 
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 filling and 
root canal up to your $2,000 annual dental allowance.  
We looked at the file and Medicare rules. The Plan provided documentation showing that at the time of the 
services provide December 6, 2021, you had $881 remaining in your dental allowance. This amount was 
applied towards your services. Based on this information, we decided that the Plan has provided payment for 
you services according to your contract. Therefore, we decided that the Plan does not have to provide 
additional payment for the resin-based composite - one surface, posterior (D2391) and endodontic therapy, 
molar tooth (excluding final restoration) (D3330) provided December 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the simple extraction (D7140) and surgical extraction 
(D7210) provided on October 5, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay more for the extractions. You say that when you contacted the Plan you were 
advised that the extractions would be covered at 50%. You also say that you were not told that OON dentists 
could balance bill, and you would like the extractions to be covered at 50% like you were told they would be. 
The Plan denied your request. The Plan says you are responsible for your copayment plus the difference 
between the dentist's total submitted amount and the Plan's total allowed amount for services rendered by a 
non-participating dentist. The extractions were covered at 50% after your $75.00 deductible was applied. The 
Plan also says that you must pay the deductible on covered services before coverage begins. 
 
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, you are responsible for a $75 
deductible, plus a 50% coinsurance for each extraction, plus the difference between the billed amount and 
allowed amount because these services were received OON. Therefore, we decided that the Plan does not have 
to pay more for the simple extraction (D7140) and surgical extraction (D7210) provided on October 5, 2021 by 
an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wheelchair transit system (K0108) and seat cushion 
(E2623). 
You asked the Plan to pre-approve the wheelchair transit system (K0108) and seat cushion (E2623).. You say 
that these items are medically necessary. The Plan denied your request. The Plan says coverage rules have not 
been met. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The wheelchair transit system is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home.  
 
The record does not show that the enrollee has a qualifying group 2 diagnosis code that would support 
coverage of the requested seat cushion. Therefore, we decided that the Plan does not have to pre-approve a 
wheelchair transit system (K0108) and seat cushion (E2623).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient hospital services provided from February 1, 2021, to April 
22, 2021. 
 
You asked the Plan to pay for the inpatient services. The Plan denied your request. The Plan says that the items 
are inclusive and not separately reimbursed. 
 
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. 
 
We looked at the file and the rules. The Plan did not specify which G-codes are being denied. The itemized bill 
did not identify G-codes that equal the amount being denied. The Plan was extremely vague in their denial. The 
Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request.  Therefore, we decided that the Plan has to pay for the inpatient hospital services 
provided from February 1, 2021, to April 22, 2021.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the incomplete endodontic therapy (D3332), inhalation of 
nitrous oxide/analgesia, anxiolysis (D9230), and additional problem focused limited oral evaluation (D0140) 
provided on August 19, 2021, and August 23, 2021. 
You asked the Plan to pay for the incomplete endodontic therapy, inhalation of nitrous oxide/analgesia, and 
additional problem focused limited oral evaluation. You say that you would like to know why some of the 
unused dental insurance balance of $574 cannot be applied toward these bills. The Plan denied your request. 
The Plan says the incomplete endodontic therapy and inhalation of nitrous oxide/analgesia are not covered 
benefits. The Plan also says that the problem focused limited oral evaluation exceeds the maximum count 
allowed per period. 
 
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 incomplete endodontic therapy 
(D3332) and inhalation of nitrous oxide/analgesia, anxiolysis (D9230) are not among those covered under this 
benefit. The contract says that exams (codes D0120, D0140, and D0150) are limited to two procedures per 
calendar year. The record shows that you received a periodic oral evaluation (D0120) on March 26, 2021 and  
problem focused limited oral evaluations (D0140) on May 7, 2021, and August 19, 2021, and your exams 
benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the incomplete 
endodontic therapy (D3332), inhalation of nitrous oxide/analgesia, anxiolysis (D9230), and additional problem 
focused limited oral evaluation (D0140) provided on August 19, 2021, and August 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and prophylaxis 
(D1110) provided on December 1, 2021. 
 
You asked the Plan to pay for the comprehensive oral evaluation and prophylaxis. You say that you thought 
you had your procedure done in May, not June. You also say that you were out of town for 6 months from the 
date of your first procedure which took place in June. The Plan denied your request. The Plan says these 
services are allowed once every six months. 
 
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, oral exams and cleanings are each 
limited to 1 every 6 months. The record shows that you received a periodic oral evaluation (D0120) and 
prophylaxis (D1110) on June 18, 2021 and your oral exam and cleaning benefits had been exhausted through 
December 18, 2021. Therefore, we decided that the Plan does not have to pay for the comprehensive oral 
evaluation (D0150) and prophylaxis (D1110) provided on December 1, 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 October 13, 2021. 
 
You asked the Plan to pay for the limited oral exam. You say that this was necessary to evaluate an unexpected 
dental issue. The Plan denied your request. The Plan says you have exceeded the frequency limit for this 
service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the limited 
oral exam once per plan year.  
 
We looked at the file and Medicare rules. The Plan provided documentation showing that a limited oral exam 
was previously covered on August 31, 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 October 13, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for application of a uniplane (pins or wires in 1 plane), 
unilateral, external fixation system (CPT code 20690 RT) and arthrotomy, knee, with exploration, drainage, or 
removal of foreign body (eg, infection) (CPT code 27310RT) provided on March 22, 2021. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the services are not supported by the records. 
 
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 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 services. Our reviewer found CPT 20690- 
Documentation submitted was reviewed and does not meet criteria. Medical records submitted, does not 
include a procedure report to verify an application of a uniplane, external fixation system has been performed. 
A consultation visit was noted. CPT 27310 -Documentation submitted was reviewed and does not meet criteria. 
Medical records submitted, does not include a procedure report to verify knee arthrotomy with exploration was 
performed. A consultation visit was noted. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for application of a uniplane (pins or wires in 1 plane), unilateral, external fixation system (Current 
Procedural Terminology (CPT) code 20690 RT) and arthrotomy, knee, with exploration, drainage, or removal 
of foreign body (eg, infection) (CPT code 27310RT) provided on March 22, 2021.