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

 
We decided that the Plan does not have to pre-approve the dermatology office visit to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the dermatology office visit. You say that you need to be seen by the out-of-
network dermatologist as soon as possible. The Plan denied your request. The Plan says the provider is out-of-
network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the dermatology office visit. We found no exception that would require the Plan to 
pre-approve the dermatology office visit. Therefore, we decided that the Plan does not have to pre-approve the 
dermatology office visit to be provided 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 comprehensive oral evaluation (D0150) and extraction 
(D7210) with an oral surgeon. 
 
You asked the Plan to pre-approve evaluation and extraction. You say that you do not have the money to pay 
for these services and the tooth is infected. The Plan denied your request. The Plan says dental services are not 
covered when performed by an oral surgeon. 
 
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 
covered under this benefit when performed by an oral surgeon. Therefore, we decided that the Plan does not 
have to pre-approve a comprehensive oral evaluation (D0150) and extraction (D7210) with an oral surgeon.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the simple extraction (D7140) and two adjunctive procedures 
(D9999 x2) provided on August 30, 2021 by a Medicare opt out provider. 
 
You asked the Plan to pay for the simple extraction and adjunctive procedures. You say that you were told by 
the Plan over the phone that these services would be covered, and you would not have to pay anything up front. 
The Plan denied your request. The Plan says you received these services from a provider who chose not to 
receive Medicare funds. 
 
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 
covered when they are received by a provider who has opted out of Medicare. Therefore, we decided that the 
Plan does not have to pay for the simple extraction (D7140) and two adjunctive procedures (D9999 x2) 
provided on August 30, 2021 by a Medicare opt out provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the unlisted evaluation and management (E&M) service 
for chiropractic care to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the unlisted E&M service for chiropractic care. You say that the service is 
medically necessary. The Plan denied your request. The Plan says the provider is out-of-network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the unlisted E&M service for chiropractic care. We found no exception that would 
require the Plan to pre-approve the unlisted E&M service for chiropractic care. Therefore, we decided that the 
Plan does not have to pre-approve the unlisted evaluation and management (E&M) service for chiropractic care 
to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Choledochotomy or choledochostomy with exploration, 
drainage, or removal of calculus, with or without cholecystotomy; without transduodenal sphincterotomy or 
sphincteroplasty (47420) provided on April 15, 2021. 
 
You asked the Plan to pay for code 47420. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 47420 
is a column II code to column I code 47612. 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 Choledochotomy or choledochostomy with exploration, 
drainage, or removal of calculus, with or without cholecystotomy; without transduodenal sphincterotomy or 
sphincteroplasty (47420) provided on April 15, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on October 4, 2021. 
 
You asked the Plan to pay for the lab services. You say that you would like this claim reprocessed based on the 
medical documentation. The Plan denied your request. The Plan says you billed with an incorrect place of 
service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on October 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on December 17, 2021. 
 
You asked the Plan to pay for an evaluation. You say that you needed to get a second opinion about an infected 
tooth. The Plan denied your request. The Plan says this service is covered by your Plan's dental benefits; 
however, your benefit for one procedure per year has been exhausted. 
 
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 one limited 
oral evaluation (D0140) per year. 
 
We looked at this case file, the Plan's rules, and Medicare rules. The record shows the Plan paid for a limited 
oral evaluation (D0140) provided on November 2, 2021; therefore, the benefit for one limited oral evaluation 
has been exhausted. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation 
(D0140) provided on December 17, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the physician services (93000 and 99214) provided on June 4, 2021. 
 
You asked the Plan to pay for the physician services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has not met its obligation with regards to coordination of benefits. Specifically, the Plan has not sent 
the bill directly to the primary insurer for payment, has not directed the provider to send the bill to the primary 
insurer, or has not paid for the services and submitted a bill for reimbursement to the primary insurer based on 
the documentation provided. Therefore, we decided that the Plan has to pay for the physician services (93000 
and 99214) provided on June 4, 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 occlusal guard, hard appliance, (D9944) provided on 
November 30, 2021. 
 
You asked the Plan to pay for the dental appliance. You say that there is a correlation between the enrollee's 
diagnosis and bruxism. You also say that the dental appliance is necessary both medically and dentally 
necessary. The Plan denied your request. The Plan says the occlusal guard, hard appliance, is not listed and 
therefore is 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 services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Though the Plan offers a dental benefit in excess of Medicare coverage, the occlusal guard is 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
occlusal guard, hard appliance, (D9944) provided on November 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve four prefabricated abutments (D6056 x4) and four 
abutment supported porcelain/ceramic crowns (D6058 x4). 
 
You asked the Plan to pre-approve the prefabricated abutments and abutment supported porcelain/ceramic 
crowns. You say that the existing implants need to be restored with abutment and crown. You also say that if 
they are not restored, it can lead to infection and bone loss over time. The Plan denied your request. The Plan 
says these services are not covered under your benefit plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
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 four 
prefabricated abutments (D6056 x4) and four abutment supported porcelain/ceramic crowns (D6058 x4).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) 
provided on December 13, 2021. 
 
You asked the Plan to pay for the problem focused limited oral evaluation. You say that you feel you saved 
money for the Plan by avoiding an unnecessary procedure, and visited the dentist for something you believed 
was an emergency. The Plan denied your request. The Plan says this service exceeds the frequency limitations 
in your benefit plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, problem focused limited oral 
evaluation (D0140) is limited to one procedure per plan year. The record shows that you received a problem 
focused limited oral evaluation (D0140) on January 4, 2021 and your problem focused limited oral evaluation 
(D0140) benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for the problem 
focused limited oral evaluation (D0140) provided on December 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional supplies, materials, and clinical staff time (99072) 
provided on November 17, 2021. 
 
You asked the Plan to pay for additional supplies, materials, and clinical staff time. You say that the services at 
issue are covered under your Plan benefits. 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 99072 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99072 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of additional supplies, materials, and clinical staff time have not been met. Therefore, we decided that the Plan 
does not have to pay for additional supplies, materials, and clinical staff time (99072) provided on November 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cone beam computed tomography (CT) capture and 
interpretation (D0364) and consultation (D9310) provided on February 24, 2022. 
 
You asked the Plan to pay for the cone beam CT capture and interpretation and consultation. You say that you 
would like to be refunded $185 for your out-of-pocket expense. The Plan denied your request. The Plan says 
these services are not covered by your health care plan or Medicare. 
 
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 pay for the cone 
beam computed tomography (CT) capture and interpretation (D0364) and consultation (D9310) provided on 
February 24, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services rendered on November 24, 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 procedure code 20610 is 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 20610 
is a column II code to column I code 27369. This claim has not been billed with an appropriate modifier to 
bypass the edit. The -59 modifier is not supported as a separate and distinct procedural service. 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 surgical services rendered on November 24, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the molecular pathology testing coded as 81206, 81275, 
81276 and 81301 provided October 4, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you request reconsideration of this 
determination and cover the Tempus Gene Panel test at the in-network benefit level. The Plan denied your 
request. The Plan says does not meet Medicare NCD/LCD criteria. 
 
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 find that CPT code 81206, 81275, 81276 and 81301 is not supported in the medical record. 
Specifically, Medicare denies coverage when a laboratory assays two or more genes in a patient in parallel. 
Those two or more genes will be considered part of the same panel. A panel constitutes a single procedural 
service, so one CPT code must be submitted for the panel. Based on this information, we decided that Medicare 
rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not 
have to pay for the molecular pathology testing coded as 81206, 81275, 81276 and 81301 provided October 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an occlusal guard. 
 
You asked the Plan to pre-approve an occlusal guard. You say that a mouth guard is medically necessary and 
should be covered under your dental or medical benefits. The Plan denied your request. The Plan says an 
occlusal guard is 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 an occlusal guard.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene panel provided on October 12, 2021. 
 
You asked the Plan to pay for the testing services. You say that you enable physicians to deliver personalized 
cancer care. The Plan denied your request. The Plan says one code must be submitted for the panel. 
 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 the Tempus gene panel was billed with multiple codes. If a single procedure is performed, only 
one code with one unit of service may be reported for the procedure. Based on this information, we decided 
that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not 
have to pay for the gene panel provided on October 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custom abutment (D6057) and crown restoration 
(D6059) on tooth # 3, 8, 11, 12, and 13. 
 
You asked the Plan to pre-approve abutment and restoration. You say that you need the crowns to complete the 
dental implants. The Plan denied your request. The Plan says custom abutment (D6057) and crown restoration 
(D6059) 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 pre-approve 
custom abutment (D6057) and crown restoration (D6059) on tooth # 3, 8, 11, 12, and 13.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve left elbow arthroplasty. 
 
You asked the Plan to pre-approve left elbow arthroplasty. You say that this is medically necessary for the 
enrollee's condition. The Plan denied your request. The Plan says the requested procedure is not medically 
reasonable and necessary. 
 
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 left elbow arthroplasty. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee is a 67-year-old male being treated for elbow arthritis. He presented 
with painful crepitation at the elbow. There is a constant aching sensation at rest, which he rates as 5/10. Pain 
with activity is rated at 8/10. He is unable to use the arm as a result. He is status post arthroplasty of left radial 
head replacement, open reduction and internal fixation coronoid fracture, collateral ligament repair on March 
12, 2020.  
 
However, detailed documentation is not evident regarding current objective deficits noted in the left elbow. Additionally, detailed documentation is not evident regarding trial and failure of recent, reasonable, and 
comprehensive less invasive conservative care measures. There is no compelling rationale presented or 
extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the 
requested left elbow arthroplasty, in this case, is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of left elbow arthroplasty have not been met. Therefore, we decided that the Plan 
does not have to pre-approve left elbow arthroplasty.