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

 
We decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950) 
provided on January 13, 2022. 
 You asked the Plan to pay for the core buildup. You say that the core buildup was billed incorrectly, and only 
the resin-based composite of one surface should have been billed for tooth #3. The Plan denied your request. 
The Plan says this service is not a covered expense under the enrollee's 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 core 
buildup, including any pins when required (D2950) provided on January 13, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an injection provided on December 6, 
2021. 
 
You asked the Plan to waive the copayment for an injection. You say that you didn't know the treatment wasn't 
covered. The Plan denied your request. The Plan says the copayment applied 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). Your contract with the Plan clearly says that you must pay $295 
copayment for Medicare covered surgery or other services provided to you at an outpatient hospital, including 
but not limited to hospital or other facility charges and physician or surgical charges.  
 
 
 
 
 You have been asked to pay $99.23 which is less than the standard $295 copayment for an injection. Injections 
fall within the Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and 
Ambulatory Surgical Centers 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 waive the copayment for an injection 
provided on December 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the occlusal adjustment-complete (D9952) provided on 
March 21, 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 this service is not a covered benefit under 
your contractual 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 service provided is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the occlusal 
adjustment-complete (D9952) provided on March 21, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a sleep study provided on February 16, 
2022. 
 
You asked the Plan to waive the copayment for a sleep study. You say that you were told a different copayment 
amount for this test. The Plan denied your request. The Plan says the copayment applied was 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). Your contract with the Plan clearly says that you must pay a $275 
copayment for outpatient diagnostic tests.  
 
You have been asked to pay a $275 copayment for a sleep study. A sleep study falls within the Outpatient 
Diagnostic Tests and Therapeutic Services and Supplies 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 waive 
the copayment for a sleep study provided on February 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an additional periapical x-ray (D0230) provided on April 12, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the processing of this claim. 
The Plan denied your request. The Plan says your benefit for periapical x-rays has already 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for periapical x-rays was exhausted on date of service April 12, 2022. Therefore, we 
decided that the Plan does not have to pay for an additional periapical x-ray (D0230) provided on April 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for audiologic function test on January 04, 
2022. 
 
You asked the Plan to waive the copayment for audiologic function test. You say that you disagree with 
amount and believe you should have been charged $0. The Plan denied your request. The Plan says the cost-
sharing you are 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). Your contract with the Plan clearly says that you must pay a $25 
copayment for Medicare-covered exam for hearing services. Diagnostic hearing and balance evaluations 
performed by your provider to determine if you need medical treatment are covered as outpatient care when 
furnished by a physician audiologist, or other qualified provider. 
 
 
 
 
 You have been asked to pay a $25 copayment for audiologic function test. Audiologic function test falls within 
the Hearing 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 waive the copayment for audiologic function 
test on January 04, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99053 billed on November 10, 2021. 
 
You asked the Plan to pay for procedure code 99053. You say that the claim is correctly coded for the level 
billed. You say that medical records were submitted for review and the claim should be reconsidered for 
payment. The Plan denied your request. The Plan says procedure code 99285 has been overturned. The Plan 
also says procedure code 99053 remains denied as bundled services are 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. 
 
We find that CPT code 99053 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99053 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of procedure code 99053 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 99053 billed on November 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for maxillary complete dentures (D5110) and mandibular partial 
denture (D5214) provided on February 1, 2022. 
 
You asked the Plan to pay for the dental services. You say that you need new dentures to eat properly. The Plan 
denied your request. The Plan says your benefit for the requested items or services has already 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested items or services was exhausted on date of service May 4, 2021. 
Therefore, we decided that the Plan does not have to pay for maxillary complete dentures (D5110) and 
mandibular partial denture (D5214) provided on February 1, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for two additional units of radiopharmaceutical localization of 
tumor (78830) billed for date of service, February 23, 2022. You asked the Plan to pay for two additional units 
of code 78830. You say that the provided records support these services as billed. The Plan denied your 
request. The Plan says this service can only be billed once per day per Medicare regulations. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 78830 is one (1). The MAI value for this code is 2. You billed three total 
units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage 
of two additional units of code 78830 have not been met. Therefore, we decided that the Plan does not have to 
pay for two additional units of radiopharmaceutical localization of tumor (78830) billed for date of service, 
February 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown (D2740), core buildup, including any pins when 
required (D2950), two extractions (D7140 x2), complete mandibular denture (D5120), two periodontal scalings 
and root planings (D4342 x2), and resin-based composite of one surface (D2391) provided from March 3, 
2022, to March 24, 2022. 
 
  You asked the Plan to pay for the crown, core buildup, extractions, complete mandibular denture, scalings and 
planings, resin-based composite of one surface. You say that the treating provider is in-network with the Plan. 
The Plan denied your request. The Plan says the crown, core buildup, extractions, complete mandibular 
denture, and scalings and planings are not covered expenses under your dental plan. The Plan also says that 
your resin-based composite benefit has been satisfied and the frequency limitation has been exceeded. 
 
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, crown (D2740), core buildup, 
including any pins when required (D2950), simple extraction (D7140), complete mandibular denture (D5120), 
and periodontal scaling and root planing (D4342) are not among those covered under this benefit. The contract 
says that restorations are limited to two (2) procedure codes per calendar year. The record shows that you 
received three resin-based composites on March 24, 2022, two of which were covered by the Plan, and your 
restorations benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the crown 
(D2740), core buildup, including any pins when required (D2950), two extractions (D7140 x2), complete 
mandibular denture (D5120), two periodontal scalings and root planings (D4342 x2), and resin-based 
composite of one surface (D2391) provided from March 3, 2022, to March 24, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service March 20, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 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 70450 
is a column II code to column I code 70496. 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 code 70450 billed for date of service March 20, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for EGD balloon dilation provided on 
December 22, 2021. 
 
You asked the Plan to waive the copayment for EGD balloon dilation. You say that you didn't know the 
procedure was being done until afterwards it should be covered. The Plan denied your request. The Plan says 
the copayment applied 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). Your contract with the Plan clearly says that you must pay $250 
copayment for Medicare covered surgery at an outpatient hospital facility.  
 
 
 
 
 
 You have been asked to pay $250 copayment for EGD balloon dilation. EGD balloon dilation falls within the 
Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical 
Centers 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 waive the copayment for EGD balloon dilation 
provided on December 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental cleaning (D1110) and the periodic oral evaluation 
(D0120) provided on April 11, 2022. 
 
You asked the Plan to pay for the dental 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 dental services were received from 
an out-of-network provider and are not covered by your supplemental 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. 
 
The record shows that you received the dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the services provided are not covered under this benefit 
when received from an out-of-network provider. Therefore, we decided that the Plan does not have to pay for 
the dental cleaning (D1110) and the periodic oral evaluation (D0120) provided on April 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bilateral facet joint injections. 
 
You asked the Plan to pre-approve the facet joint injections. You say that it is felt that this treatment is 
medically indicated for the enrollee's condition. The Plan denied your request. The Plan says since this appeal 
was not filed until after the enrollee's coverage with the plan ended, this cannot be covered. 
 
Please note: We reviewed the Plans argument and Medicare rules. We find that the Plan is incorrect in its 
rationale that coverage cannot be extended for this service due to the appeal being requested after coverage 
with the Plan ended. Any service that is requested while the enrollee is active with the Plan would potentially 
be coverable by the Plan if an appeal finds the denial was incorrect. As such, we performed a clinical review to 
determine if coverage criteria were met.  
 The Plan follows Medicare rules. Medicare rules say that facet joint interventions are covered when the criteria 
listed in the Medicare rules section of this letter are met.  
 
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 facet joint injections. Our reviewer 
says that the documentation does not support that the LCD criteria are met. Our physician reviewer found the 
enrollee is a 60-year-old woman with diagnoses of lumbosacral radiculopathy, spondylosis without 
myelopathy, and chronic pain syndrome. The enrollee was evaluated on May 5, 2022, for left thoracic pain and 
low back pain. The treatment plan included a home exercise program, medications, and medial branch block. 
On June 16, 2022, the enrollee was evaluated for follow-up of lumbosacral radiculopathy. The enrollee 
reported that the pain was made better with medications and rest. 
 
The documentation does not support that the enrollee's symptoms were present for a minimum of 3 months 
with documented failure to respond to noninvasive conservative care management. In addition, it is 
documented that the enrollee has lumbosacral radiculopathy. 
 
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 facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bilateral facet joint injections.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an MRI provided on April 18, 2022. 
 
You asked the Plan to waive the copayment for an MRI. You say that you should only have a $40 copayment 
for this visit. The Plan denied your request. The Plan says the copayment applied was 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). Your contract with the Plan clearly says that you must pay a $275 
copayment for outpatient diagnostic tests.  
 
You have been asked to pay a $275 copayment for an MRI. An MRI falls within the Outpatient Diagnostic 
Tests and Therapeutic Services and Supplies 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 waive the copayment 
for an MRI provided on April 18, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70544 billed for date of service March 28, 
2022. 
 You asked the Plan to pay for procedure code 70544. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70544 is bundled into payment for 
code 70551. 
 
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 70544 
is a column II code to column I code 70551. 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 code 70544 billed for date of service March 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a battery charger (E2366), a power seat elevation 
system (E2300), a large calf panel (E0995), a cup holder (K0108), a USB charger port (K0108), and a remote 
joystick replacement (E2374). 
 
You asked the Plan to pre-approve a battery charger, a power seat elevation system, a large calf panel, a cup 
holder, a USB charger port, and a remote joystick replacement. You say that you would like the Plan to 
reconsider their denial. The Plan denied your request. The Plan says a battery charger, a power seat elevation 
system, a large calf panel, a cup holder, a USB charger port, and a remote joystick replacement are not covered. 
 
The Plan must follow Medicare rules.  Medicare rules say that wheelchair accessories are covered when 
specific criteria are met. 
 
We looked at the file and Medicare rules. There is no separate billing for the battery charger (E2366), large calf 
panel (E0995), or remote joystick replacement (E2374), as these are column II codes that cannot be separately 
approved. 
 
The rules also say that for equipment to be covered, it must primarily serve a medical purpose. Medicare 
specifically excludes coverage of power seat elevation systems coded as E2300 as not primarily medical in 
nature. Furthermore, the cup holder and USB charger port do not serve a purpose that is primarily medical in 
nature. These items are available to the general public and would be helpful even to those who are not sick or 
injured.  
 
Therefore, we decided that the Plan does not have to pre-approve a battery charger (E2366), a power seat 
elevation system (E2300), a large calf panel (E0995), a cup holder (K0108), a USB charger port (K0108), and a 
remote joystick replacement (E2374).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an epidural steroid injection provided on February 18, 2022. 
 
You asked the Plan to pay for an epidural steroid injection. You say that you needed this injection to relieve 
severe pain in your back that radiates down to your legs and to the top of your feet and it is difficult to walk. 
The Plan denied your request. The Plan says under Medicare guidelines, your request is not medically 
necessary because you do not have records demonstrating that you meet the Medicare coverage criteria. 
 
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 an epidural steroid injection provided 
on February 18, 2022 have been met. There are no medical records to confirm that Medicare coverage criteria 
have been met. Therefore, we decided that the Plan does not have to pay for an epidural steroid injection 
provided on February 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided on June 1, 2021. 
 
You asked the Plan to pay for a lumbar-sacral orthosis. You say that the item at issue was a medical necessity 
for the enrollee. The Plan denied your request. The Plan says rules for payment for DMEPOS have not been 
met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
 
  The record does not contain a valid proof of delivery for the supplies provided in this case. Therefore, we 
decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided on June 1, 2021.