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

 
We decided that the Plan does not have to pay for aortography, abdominal plus bilateral iliofemoral lower 
extremity (75630-26-XU) provided on August 20, 2021. 
 
You asked the Plan to pay for aortography. You say that this service was billed appropriately. The Plan denied 
your request. The Plan says a National Correct Coding Initiatives (NCCI) Procedure to Procedure (PTP) edit exists between codes 75630 and 37225. This PTP edit has a modifier indicator of 1, meaning modifiers 
associated with NCCI are allowed. Modifier XU was billed with this claim to bypass the edit; however, the 
records provided do not support that 75630 was separate and distinct from the primary procedure, and therefore 
this service is not eligible for separate payment. 
 
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 75630 
is a column II code to column I code 37225; however, 75630 was 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 aortography. Our reviewer says that the documentation 
provided does not meet criteria for separate payment of this service. Our reviewer found CPT code 37225 
includes angiograms and/or venograms and therefore billing 75630 separately is not supported by the medical 
record. Documentation does not support that these services are separate and distinct from each other in this 
case. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of aortography have not been met. Therefore, we decided that the Plan does not 
have to pay for aortography, abdominal plus bilateral iliofemoral lower extremity (75630-26-XU) provided on 
August 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bone replacement graft on tooth #30 (D7953) and an 
extraction of tooth #30 (D7140) provided on February 24, 2022. 
 
You asked the Plan to pay for a graft and extraction. You say that you disagree with the amount the Plan paid 
towards your extraction. You also say that you thought the bone replacement graft was included in the 
extraction procedure. The Plan denied your request. The Plan says a bone replacement graft (D7953) is not 
covered by your routine dental benefits. The Plan also says that if you choose to see an out-of-network dentist 
you might be billed by that provider for any amount greater than what the plan pays. 
 
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 record shows you received services from an out-of-network provider and may be billed a greater amount 
than what the Plan paid. Though the Plan offers a dental benefit in excess of Medicare coverage, a bone 
replacement graft is not among those covered under this benefit. Therefore, we decided that the Plan does not 
have to pay for a bone replacement graft on tooth #30 (D7953) and an extraction of tooth #30 (D7140) 
provided on February 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the special anesthesia service (99100) provided on April 5, 
2021.  You asked the Plan to pay for the special anesthesia service (99100). You say that the required medical records 
are enclosed for review and the claim should be processed for payment. The Plan denied your request. The Plan 
says procedure code 01230 has been overturned and procedure code 99100 remains denied as bundled services 
are not eligible for separate reimbursement. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99100 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99100 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of the special anesthesia service (99100) have not been met. Therefore, we decided that the Plan does not have 
to pay for the special anesthesia service (99100) provided on April 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oral evaluation (dental code D0120), x-ray's (dental code 
D0220 and D0230), dental cleaning (dental code D1110), fluoride varnish (dental code D1206), and a crown 
(dental code D2752) for tooth #12 provided by an out-of-network (OON) provider on February 14, 2022, and 
February 16, 2022. 
 
You asked the Plan to pay for oral evaluation, x-ray's, dental cleaning, fluoride varnish, and a crown. You say 
that you work in the office, and you have seen the same dentist for years. The Plan denied your request. The 
Plan says the rendering provider is an OON provider, therefore; the services are not covered under the Plan's 
dental 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. The Plan covers preventive 
and comprehensive dental care through a network of dentists. 
 
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 when provided by an OON provider. Therefore, we decided that the 
Plan does not have to pay for oral evaluation (dental code D0120), x-ray's (dental code D0220 and D0230), 
dental cleaning (dental code D1110), fluoride varnish (dental code D1206), and a crown (dental code D2752) 
for tooth #12 provided by an out-of-network (OON) provider on February 14, 2022, and February 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prophylaxis (D1110) and bitewings (D0274) provided on 
March 28, 2022. 
 
You asked the Plan to pay for prophylaxis (D1110) and bitewings. You say that you are appealing the denial of 
the dental services. The Plan denied your request. The Plan says benefits received out-of-network are subject to 
any in-network benefit maximums, limitations, and/or exclusions. You may be billed by the out-of-network 
provider for any amount greater than the payment made by the Plan to the provider. 
 
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, covered benefits received out-of-
network are subject to any in-network benefit maximum, limitations, and/or exclusions. This out-of-network 
provider may bill you for any amount greater than the payment the Plan made. Therefore, we decided that the 
Plan does not have to pay for prophylaxis (D1110) and bitewings (D0274) provided on March 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental cleaning (D1110) rendered by the out-of-network 
(OON) provider on March 9, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out-of-network 
provider; therefore, it is not payable. 
 
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.  
 
We looked at this case file and the Plans rules. Based on this information, we decided that the Plan's rules for 
coverage of this service have not been met. Specifically, the Plan contract states that services are covered with 
providers in the Plans network only. The service in this case was rendered by an out-of-network provider. 
Therefore, we decided that the Plan does not have to pay for the dental cleaning (D1110) rendered by the out-
of-network (OON) provider on March 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implant placement (D6010) for tooth # 30, and surgical 
access to an implant body (D6011) for teeth # 23, 27, and 30. 
 
You asked the Plan to pre-approve the dental services. You say that the services are medically necessary. 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 2 implant placements are covered 
per year, the frequency limit has been reached. The record shows that the Plan approved implant placements for 
teeth # 23 and 27.  Additionally, the requested surgical access to an implant body for teeth # 23, 27, and 30 are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve implant placement 
(D6010) for tooth # 30, and surgical access to an implant body (D6011) for teeth # 23, 27, and 30.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the seat elevator (CPT code E2300). 
 
You asked the Plan to pre-approve the seat elevator. You say that the item is necessary. The Plan denied your 
request. The Plan says the requested seat elevator is statutorily not covered as it does not serve a primary 
medical purpose. 
 
The Plan must follow Medicare rules. The rules say that a power seat elevation feature (E2300) and power 
standing feature (E2301) are non-covered because they are not primarily medical in nature. Therefore, the seat 
elevator is not covered. We looked at the file and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the seat elevator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the seat elevator (CPT code E2300).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve abutment supported crown on tooth #10, 12, and 14 
(D6059) and fabricated abutment on tooth #10, 12, and 14 (D6057). 
 
You asked the Plan to pre-approve abutments and supported crowns. You say that the services are medically 
necessary. The Plan denied your request. The Plan says abutment supported crown (D6059) and fabricated 
abutment (D6057) are not covered by your dental 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. 
 
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 abutment supported crown on tooth #10, 12, 
and 14 (D6059) and fabricated abutment on tooth #10, 12, and 14 (D6057).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral periapical radiographic images (D0220 and 
D0230) and the pulp vitality tests (D0460) provided on April 12, 2022 
 
You asked the Plan to pay for the periapical images and pulp vitality tests. You say that you were informed by 
the Plan that your root canal would be 100% covered. The Plan denied your request. The Plan says they paid 
for the periapical images you received on January 25, 2022, so the ones provided on April 12, 2022, are not 
covered. Additionally, the Plan says the pulp vitality tests provided are not 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 Plans coverage rules apply in this case. The Plan covers the periapical 
x-rays once per year when the services are medically necessary and reasonable. Pulp vitality tests are not a 
covered benefit. 
 
  We looked at the file and Medicare rules. The record shows the Plan paid for periapical images received on 
January 25, 2022, which exhausted your periapical images benefit. Therefore, we decided that the Plan does 
not have to pay for the intraoral periapical radiographic images (D0220 and D0230) provided on April 12, 
2022. The pulp vitality tests (D0460) are not a covered benefit. Therefore, we decided that the Plan does not 
have to pay for the pulp vitality tests (D0460) provided on April 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided on October 23,2019.
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The
Plan denied your request. The Plan says you did not have prior authorization for out of network care. Maximus
overturned the Plans denial stating the claim was filed timely. The Plan requested a reopen and stated Maximus
did not apply the correct criteria. The Plan stated the claim was not the issue but that these services were
provided out of network without prior authorization.
The Plan is correct in this case. 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 was not a network provider with the Plan. The Plan had network providers available
who could have provided the services rendered. The Plan did not pre-approve these services. Therefore, we
decided that the Plan does not have to pay for out of network physician services provided on October 23, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial lower denture (D5214). 
 
You asked the Plan to pre-approve a partial lower denture. You say that the requested service is medically 
necessary. The Plan denied your request. The Plan says the service is a covered benefit, but you have exceeded 
the frequency limit of one every 5 years. 
 
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. 
 
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of a partial lower denture have not been met. Specifically, the record shows that you had exceeded the 
frequency limit prior to this service on November 30, 2021. Therefore, we decided that the Plan does not have 
to pre-approve a partial lower denture (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for resin composite fillings on tooth #10, 26, and 27 (D2331) 
provided on July 27, 2021, and resin composite fillings on tooth #26 and 27 provided on November 17, 2021. 
 
You asked the Plan to pay for fillings. You say that the Plan reimburses up to $1,000 a year for dental services. 
The Plan denied your request. The Plan says resin-based composite fillings (D2331) are not covered by your 
dental 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 pay for resin 
composite fillings on tooth #10, 26, and 27 (D2331) provided on July 27, 2021, and resin composite fillings on 
tooth #26 and 27 provided on November 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay the full amount for the oral evaluation, x-rays, and periodontal 
maintenance. provided on March 9, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay the full amount for the oral evaluation, x-rays, and periodontal maintenance. You 
say that you would like to know how you have exceeded the frequency limitation already. The Plan denied 
your request. The Plan says your intraoral x-rays benefit has been satisfied and the frequency limitation has 
been exceeded. The Plan also says that these services were performed by an out-of-network provider, and you 
are responsible for any difference between the maximum allowable fee and the amount the provider bills you 
for the 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, intraoral x-rays are limited to one 
procedure code per calendar year. The record shows the Plan paid for the intraoral periapical x-ray (D0230) and 
your intraoral x-ray benefit has been exhausted. Therefore, the other periapical x-ray you received (D0220) is 
not covered.  
 
The contract clearly states that when you receive a periodic oral evaluation (D0120), additional intraoral 
periapical x-ray (D0230), bitewing x-rays (D0274), and periodontal maintenance (D4910) from an OON 
provider, you are responsible for a 50% coinsurance for each service, plus the difference between the billed 
amount and allowed amount. 
 
Therefore, we decided that the Plan does not have to pay the full amount for the first intraoral periapical x-ray 
(D0220), and to pay more for the periodic oral evaluation (D0120), additional intraoral periapical x-ray 
(D0230), bitewing x-rays (D0274), and periodontal maintenance (D4910) provided on March 9, 2022, by an 
out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown on tooth #30 and 31 (D2750). 
 
You asked the Plan to pre-approve a crown. The Plan denied your request. The Plan says the medical records 
indicate that both teeth were previously extracted. 
 
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 a 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 a crown. Our reviewer says that the 
criteria for coverage are not met. Our physician reviewer found the submitted code of D2750 is not applicable 
to restore the implants in the area of teeth #30 and #31. D2750 is a code used for the crown restoration of a 
natural tooth, and in this instance, there are no natural teeth being restored. The provided code is not 
appropriate for the present situation as there are no nature teeth to restore. 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 a crown have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a crown on tooth #30 and 31 (D2750).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services (99100) provided on April 28, 2021. 
 
You asked the Plan to pay for anesthesia services. You say that you have provided records to support the 
services billed. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
We find that CPT code 99100 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99100 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for 
anesthesia services (99100) provided on April 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown - porcelain/ceramic (D2740) provided February 
17, 2021. 
 
You asked the Plan to pay for the crown. You say that you have been overcharged for your dental services. The 
Plan denied your request. The Plan says this claim was not filed timely and therefore is not eligible for 
reimbursement. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the crown was not filed until March 18, 2022. This means that more than one 
calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan 
does not have to pay for the crown - porcelain/ceramic (D2740) provided February 17, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a crown on tooth #6 (D2740). 
 
You asked the Plan to pre-approve a crown. You say that you had a root canal and are in a lot of pain. The Plan 
denied your request. The Plan says that the x-rays show a crown is not needed to fix your tooth. 
 
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 did not provide a clear copy of the medical records that they used in 
their review. The Plan has not supported their decision to deny your request. Therefore, we decided that the 
Plan has to pre-approve a crown on tooth #6 (D2740).  
 
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.