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

 
We decided that the Plan does not have to pre-approve comprehensive orthodontic treatment of the adult 
dentition (D8090), diagnostic casts (D0470), and 2D cephalometric radiographic image (D0340). 
 
You asked the Plan to pre-approve the dental services. You say that you were in an accident in 2020. You say 
that it impacted the left side of your face and head. You say that your right jaw is bone on bone. You also say 
that you are on a limited income and cannot afford to pay for this treatment. The Plan denied your request. The 
Plan says the requested services are not listed as covered. 
 
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 comprehensive 
orthodontic treatment of the adult dentition, diagnostic casts, and 2D cephalometric radiographic image are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
comprehensive orthodontic treatment of the adult dentition (D8090), diagnostic casts (D0470), and 2D 
cephalometric radiographic image (D0340).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the debridement services coded 11042 and the chemical 
cauterization of granulation tissue services coded 17250 provided on December 24, 2021. 
 You asked the Plan to pay for the debridement services and the chemical cauterization of granulation tissue 
services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The 
Plan says the services billed are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules also state that providers may bill 
services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service.   
 
We find that CPT codes 11042 and 17250 are not supported in the medical record. Specifically, code 11042 is 
included in code 49450 (previously approved/paid by the Plan), therefore, cannot be separately paid. In 
addition, the documents received do not support that the procedure or service was distinct or independent from 
other services performed; therefore, the use of the 59 modifier is not supported. Code 17250 is included in code 
11042; therefore, cannot be separately paid. In addition, the documents received do not support that the 
procedure or service was distinct or independent from other services performed; therefore, the use of the 59 
modifier is not supported. Based on this information, we decided that Medicare rules for coverage of the 
debridement services and the chemical cauterization of granulation tissue services have not been met. 
Therefore, we decided that the Plan does not have to pay for the debridement services coded 11042 and the 
chemical cauterization of granulation tissue services coded 17250 provided on December 24, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit (99282) 
provided on February 25, 2022. 
 
You asked the Plan to waive the copayment for the ER visit. You say that the services should be covered as 
you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied correctly 
based on the services provided. 
 
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 $90 
copayment for Emergency care.  
 
 
  You have been asked to pay a $90 copayment for an ER visit. 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 the emergency room (ER) visit (99282) provided on February 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on February 8, 2022. 
 
You asked the Plan to pay for the dental service. You say that this visit was for a consultation before an oral 
surgery appointment. You say that the visit was an emergency because of pain in the tooth. You also say that 
your dentist sent you to an oral surgeon. The Plan denied your request. The Plan says the claim processed 
correctly. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage and 1 limited oral evaluation is covered 
per year, the frequency limit has been exceeded. The record shows that the Plan paid for a limited oral 
evaluation that you received on February 3, 2022. Therefore, we decided that the Plan does not have to pay for 
the limited oral evaluation (D0140) provided on February 8, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the central motor evoked potential study coded 95939 and 
the short-latency somatosensory evoked potential study coded 95927 and 95938 provided on October 17, 2021. 
 
You asked the Plan to pay for the central motor evoked potential study coded 95939 and the short-latency 
somatosensory evoked potential studies. You say that you would like the plan to reconsider their 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. 
 
We find that CPT codes 95939, 95927, and 95938 are not supported in the medical record. Specifically, you, 
the provider are a specialist/technologist. Your primary taxonomy code is not found on the Medicare 
provider/supplier list. Since you are not considered a recognized facility or a legally qualified physician, 
services are not payable under the Plan.  The Plan suggests that you should contact the physician and/or facility for any reimbursement request. Based 
on this information, we decided that Medicare rules for coverage of the central motor evoked potential study 
coded 95939 and the short-latency somatosensory evoked potential studies have not been met. Therefore, we 
decided that the Plan does not have to pay for the central motor evoked potential study coded 95939 and the 
short-latency somatosensory evoked potential study coded 95927 and 95938 provided on October 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the incisional biopsy of oral tissue (D7286) provided on 
October 22, 2021. 
 
You asked the Plan to pay for the incisional biopsy of oral tissue. You say that this service was medical 
because it affected your health, and you would like to be reimbursed. The Plan denied your request. The Plan 
says this service is not a covered expense under your dental plan. The Plan also says that you contacted the 
prior to the date of service on October 19, 2021 to verify benefits and provider eligibility, and you were advised 
the procedure was not covered under your dental policy. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the 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 
incisional biopsy of oral tissue (D7286) provided on October 22, 2021.  
 Please Note: The Plan states that this dental claim was sent to the Plans medical claims team to be reviewed 
for coverage under your medical benefit.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lamotrigine. 
 
You asked the Plan to pre-approve Lamotrigine. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested drug is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Lamotrigine.  
 
Benefits for Lamotrigine 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Drug Testing provided on October 15, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for Drug Testing. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 Drug Testing provided on October 15, 2021 by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the office visit (99214) provided on 
February 4, 2022. 
 
You asked the Plan to waive the deductible for the office visit. You say that the services should be covered as 
you disagree with the charges. The Plan denied your request. The Plan says the deductible applied correctly 
based on the services provided. 
 
 
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 Physician/Practitioner services, 
including doctors office visits.  
 
 
  The item or service you asked the Plan to waive the deductible for falls within the benefit category 
Physician/Practitioner services, including doctors office visits. The Plan has followed Medicare rules by 
clearly disclosing in the contract that there may be a deductible that applies to Physician/Practitioner services, 
including doctors office visits. Therefore, we decided that the Plan does not have to waive the deductible for 
an office visit (99214) provided on February 4, 2022, please contact your Medicaid plan to verify whether you 
have a deductible.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99213) and the electrocardiogram (93000) 
rendered by the out-of-network (OON) provider on February 9, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without prior authorization. 
 
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 in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the office visit (99213) and the electrocardiogram (93000) rendered by the out-of-
network (OON) provider on February 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Home Health Services provided on January 12, 2022 to 
February 10, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for Home Health Services. You say that you would like to request reconsideration of 
the denied claim. The Plan denied your request. The Plan says the provider is out-of-network and it was 
determined these services were not urgent or emergent. 
 
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 Home Health Services provided on January 12, 
2022 to February 10, 2022 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the brain imaging provided on March 12, 2022, billed with primary 
diagnosis code I66.01. 
 
You asked the Plan to pay for the imaging. You say that this should be paid. The Plan denied your request. The 
Plan says that diagnosis code I66.01 cannot be reported as a primary diagnosis. 
 
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. The Plan's denial rationale states that the primary diagnosis billed on this claim 
is only allowed as a secondary diagnosis. They indicate that there are other diagnoses which should be coded 
first. However, review of the diagnosis code I66.01 does not support that a code first note exists for this code. 
There is no evidence that this is not usable as a primary diagnosis as argued by the Plan. We find that the denial 
of payment is not supported. Therefore, we decided that the Plan has to pay for the brain imaging provided on 
March 12, 2022, billed with primary diagnosis code I66.01.  
 
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 mass spectrometry rendered on December 6, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable. 
 
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 83789 
is a column II code to column I code 80307. This claim has not been billed with an appropriate modifier to 
bypass the edit. 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 mass spectrometry rendered on December 6, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) care provided 
from October 4, 2021, to October 14, 2021. 
 
You asked the Plan to waive the copayment for the SNF care. You say that the services should be covered as 
you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied correctly 
based on the services provided. 
 
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 $184 
copayment per day for days 21-100 of Skilled nursing facility (SNF) care.  
 
 
  You have been asked to pay a $325 copayment for your SNF stay, which is less than the standard $184 
copayment per day. 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 skilled nursing facility (SNF) 
care provided from October 4, 2021, to October 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cone beam computed tomography (CT) capture and 
interpretation with field of view of both jaws; with or without cranium (D0367), bone graft at time of implant 
placement (D6104), and surgical placement of implant body: endosteal implant (D6010). 
 
You asked the Plan to pre-approve a cone beam CT scan, bone graft and endosteal implant. You say that the 
services are necessary, and you feel they should be covered. The Plan denied your request. The Plan says these 
services are not covered under your benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
cone beam computed tomography (CT) capture and interpretation with field of view of both jaws; with or 
without cranium (D0367), bone graft at time of implant placement (D6104), and surgical placement of implant 
body: endosteal implant (D6010).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the insertion of intervertebral biomechanical device(s) 
services coded 22859 provided on October 22, 2021. 
 
You asked the Plan to pay for the insertion of intervertebral biomechanical device(s) services. You say that you 
would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed 
are not supported by the documentation. 
 
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 22859 is insertion of intervertebral biomechanical 
device(s) (eg, synthetic cage, mesh, methylmethacrylate) to intervertebral disc space or vertebral body defect 
without interbody arthrodesis, each contiguous defect (List separately in addition to code for primary 
procedure). 
 
We find that CPT code 22859 is not supported in the medical record. Specifically, the operative report did not 
include documentation of an insertion of intervertebral biomechanical device(s) (synthetic cage, mesh, 
methylmethacrylate) into the intervertebral disc space or vertebral body defect without interbody arthrodesis, 
for each contiguous defect (listed separately in addition to code for primary procedure); therefore this code 
cannot be verified. Based on this information, we decided that Medicare rules for coverage of the insertion of 
intervertebral biomechanical device(s) services have not been met. Therefore, we decided that the Plan does not 
have to pay for the insertion of intervertebral biomechanical device(s) services coded 22859 provided on 
October 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gingivectomy or gingivoplasty (D4211) provided by a 
participating provider on January 31, 2022. 
 
You asked the Plan to pay for gingivectomy or gingivoplasty. You say that you would like the Plan to pay for 
this. 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 
gingivectomy or gingivoplasty (D4211) provided by a participating provider on January 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cleaning and inspection of removable complete upper 
denture (D9932) and cleaning and inspection of removable complete lower denture (D9933). 
 
You asked the Plan to pre-approve the dental services. You say that your dentures do not fit in your mouth. 
You say that the dentures do not fit properly. You also say that when you wear them, they cause sores in your 
mouth. The Plan denied your request. The Plan says cleaning and inspection of removable complete dentures 
are not covered services. 
 
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 pre-approve 
cleaning and inspection of removable complete upper denture (D9932) and cleaning and inspection of 
removable complete lower denture (D9933).