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

 
We decided that the Plan does not have to pay for an office visit (99213) provided December 21, 2021 
 
You asked the Plan to pay for the office visit. You say that the services were medically necessary. The Plan 
denied your request. The Plan says [Enter plan denial rationale, e.g. "...rules for SNF care 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 99213. is not supported in the medical record. Specifically, two evaluation and 
management services were reported by the same provider on the same date of service. Based on this 
information, we decided that Medicare rules for coverage of the office visit have not been met. Therefore, we 
decided that the Plan does not have to pay for an office visit (99213) provided December 21, 2021
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (82728, 83540, 83550, 83970) provided January 
12, 2022. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the services are not separately payable. 
 
 
 
 
 
 
 The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
lab services (82728, 83540, 83550, 83970) provided January 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 7, 2022 billed with 
codes 81225. 
 
You asked the Plan to pay for the genetic testing billed. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
February 7, 2022 billed with codes 81225.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87798) provided October 26, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed services. 
 
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 87798 is not supported in the medical record. Specifically, the 12 units billed are not 
supported in the records provided. Based on this information, we decided that Medicare rules for coverage of 
the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services 
(87798) provided October 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a periodic oral evaluation (D0120) and prophylaxis 
(D1110) provided on December 7, 2021. 
 
You asked the Plan to pay more for the dental services. You say that you believe there was a billing error made. 
The Plan denied your request. The Plan says you are responsible for any charged amount above the Plans cost-
sharing amount when your services are received from an out-of-network provider. 
 
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. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for a periodic oral evaluation (D0120) and 
prophylaxis (D1110) provided on December 7, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (82310, 83970, 84100) provided January 11, 
2022. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the services billed are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
lab services (82310, 83970, 84100) provided January 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair with multiple power 
options (K0861) with combination tilt and recline (E1007). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requested wheelchair exceeds medical need. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 services. Our reviewer says that the 
requested wheelchair is not medically reasonable or necessary. Our physician reviewer found that the 
documentation does not indicate that the enrollee has any pressure injuries or requires intermittent 
catheterization of the bladder that would necessitate power tilt or recline therefore the requested group 3 PWC 
with multiple accessories is not medically 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a group 3 power wheelchair with multiple power options (K0861) with combination tilt 
and recline (E1007).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), prophylaxis (D1110), 
and topical application of fluoride varnish (D1206) provided on May 27, 2021, and a crown (D2740) provided 
on June 3, 2021. 
 
You asked the Plan to pay for the dental services. You say that you were told you could see whatever provider 
you wanted. The Plan denied your request. The Plan says the provider has opted out of Medicare and is not 
eligible for payment. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for a periodic 
oral evaluation (D0120), prophylaxis (D1110), and topical application of fluoride varnish (D1206) provided on 
May 27, 2021, and a crown (D2740) provided on June 3, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 82435, 84132, & 84295 billed for date of 
service May 21, 2021. 
 You asked the Plan to pay for procedure codes 82435, 84132, & 84295. You say that the services were 
medically necessary. The Plan denied your request. The Plan says payment for these codes is bundled into 
payment for another code 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 codes 
80051 & 82435 and codes 84132 & 84295 have bundled relationships. 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 procedure codes 82435, 84132, & 84295 
billed for date of service May 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the treatment of root canal obstruction (D3331) provided on 
April 1, 2022. 
 
You asked the Plan to pay for the dental service. You say that this service occurred as part of your root canal. 
You also say that this bill could cause you a financial hardship. The Plan denied your request. The Plan says 
treatment of root canal obstruction 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 Plans coverage rules apply in this case. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the treatment of root canal obstruction 
is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
treatment of root canal obstruction (D3331) provided on April 1, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for surgery on October 01, 2021 
 
You asked the Plan to waive the copayment for surgery. You say that the cost share due should be for inpatient 
services and not outpatient services because you were admitted to the hospital. This would save you $140.00 
for the cost of surgery. The Plan denied your request. The Plan says the cost-sharing the enrollee is being 
charged is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay a $550 copayment per visit for outpatient surgery. Note: If you are having surgery in a hospital 
facility, you should check with your provider about whether you will be an inpatient or outpatient. Unless the 
provider writes an order to admit you as an inpatient to the hospital, you are an outpatient and pay the cost 
sharing amounts for outpatient surgery. Even if you stay in the hospital overnight, you might still be considered 
an outpatient.  
 
 
 The enrollee has been asked to pay a $550 copayment for surgery. Surgery falls within the Outpatient surgery, 
including services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. 
This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This 
cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for surgery on October 01, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and 
core buildup, including any pins when required (D2950) provided on March 14, 2022, and March 15, 2022. 
 
You asked the Plan to pay for the problem focused limited oral evaluation and core buildup. You say that you 
want to take care of and keep your real teeth. You also say that you believe these services should be covered. 
The Plan denied your request. The Plan says these services are not covered expenses under your dental 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 pay for the 
problem focused limited oral evaluation (D0140) and core buildup, including any pins when required (D2950) 
provided on March 14, 2022, and March 15, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for dental services provided by a participating provider on November 17, 2021. 
 
You asked the Plan to pay for dental services. You say that you would like the Plan to pay for this. The Plan 
denied your request. The Plan says that the rendered dental service is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of dental services provided on November 
17, 2021 have been met. The Plan has failed to provide a 2021 Evidence of Coverage. Therefore, we decided 
that the Plan has to pay for dental services provided by a participating provider on November 17, 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 surgical extraction (D7210), intravenous moderate 
(conscious) sedation/analgesia (D9239 and D9243), and consultation (D9310) provided on February 1, 2022 by 
a Medicare opt out provider. 
 
You asked the Plan to pay for the surgical extraction, intravenous moderate (conscious) sedation/analgesia, and 
consultation. You say that you believe the cost of having your wisdom tooth removed is an eligible expense 
under your plan. The Plan denied your request. The Plan says these services were rendered by a provider who 
has opted out of Medicare, and does not accept Medicare assignment. 
 Medicare generally does not cover dental services. The Plan follows the same rule. 
 
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. The contract also says that services rendered by a provider who has opted out of Medicare are 
not eligible for coverage. Therefore, we decided that the Plan does not have to pay for the surgical extraction 
(D7210), intravenous moderate (conscious) sedation/analgesia (D9239 and D9243), and consultation (D9310) 
provided on February 1, 2022 by a Medicare opt out provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99223) provided January 14, 2022. 
 
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the records do not support the billed services. 
 
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 99223 is not supported in the medical record. Specifically, the claim was billed with an 
invalid place of service. The claim was billed with an inpatient place of service, however records show the 
enrollee was an outpatient. Based on this information, we decided that Medicare rules for coverage of the 
physician services have not been met. Therefore, we decided that the Plan does not have to pay for physician 
services (99223) provided January 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120) and prophylaxis (D1110) 
provided on September 29, 2021. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says your annual maximum benefit for dental services has been 
exhausted. 
 
 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 clearly says that the Plan covers certain dental 
services as a supplemental (extra) benefit. This benefit includes coverage up to $1,500 for covered dental 
services. The contract also says that the enrollee is responsible for any remaining charges above the annual 
maximum amount. 
 
The record shows your annual maximum amount for dental services has been exhausted and you are 
responsible for any remaining charges above the maximum amount. An evaluation and prophylaxis fall within 
the Dental Services benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to pay for a periodic oral evaluation (D0120) and 
prophylaxis (D1110) provided on September 29, 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 (D0365) and surgical placement of implant body: endosteal implant (D6010) provided on March 
3, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the cone beam CT capture and interpretation and endosteal implant. You say that 
your insurance agent did not advise that the dentist had to be in a certain network. The Plan denied your 
request. The Plan says these procedures are not covered benefits when rendered by a dentist who does not 
participate with your 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 
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the cone 
beam computed tomography (CT) capture and interpretation (D0365) and surgical placement of implant body: 
endosteal implant (D6010) provided on March 3, 2022 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for retainer crowns on tooth #7 and 9 (D6750) and pontic on 
tooth #8 (D6240) provided on April 18, 2022. 
 
You asked the Plan to pay for retainer crowns and pontic. You say that these services were medically 
necessary. The Plan denied your request. The Plan says retainer crowns (D6750) and pontics (D6240) 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 retainer 
crowns on tooth #7 and 9 (D6750) and pontic on tooth #8 (D6240) provided on April 18, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI), of 
the brain (including brain stem); without contrast material, followed by contrast material(s) and further 
sequences (70553) provided on March 15, 2022. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service 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 $100 
copayment for diagnostic imaging services (computed tomography (CT), magnetic resonance imaging (MRI), 
and a positron emission tomography (PET) scan, etc.) rendered by an in-network provider.   
 
You have been asked to pay a $100 copayment for the diagnostic radiology service rendered by an in-network 
provider. 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 cost share for the magnetic resonance imaging (MRI), of the 
brain (including brain stem); without contrast material, followed by contrast material(s) and further sequences 
(70553) provided on March 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bone replacement grafts on tooth #7 and 15 (D7953) 
provided on January 27, 2022. 
 
You asked the Plan to pay for grafts. You say that you disagree with the denial of dental services. The Plan 
denied your request. The Plan says bone replacement grafts (D7953) are not covered by your routine 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 bone 
replacement grafts on tooth #7 and 15 (D7953) provided on January 27, 2022.