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

 
We decided that the Plan does not have to pay more for periodic oral evaluation - established patient (D0120), 
intraoral - periapical first radiographic image (D0220), prophylaxis - adult (D1110), and intraoral - periapical 
each additional radiographic image (D0230) provided October 19, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay more for the dental services. You say that you were not aware that the provider is 
OON. 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. 
Additionally, the Plan provided documentation showing that one intraoral x-ray was covered on the same date 
of service, October 19, 2021. The additional intraoral x-rays exceed the Plans frequency limit and are not 
covered. Therefore, we decided that the Plan does not have to pay more for periodic oral evaluation - 
established patient (D0120), intraoral - periapical first radiographic image (D0220), prophylaxis - adult 
(D1110), and intraoral - periapical each additional radiographic image (D0230) provided October 19, 2021, by 
an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional payment for the surgical placement of implant 
body: endosteal implants (D6010), extractions, erupted tooth requiring removal of bone and/or sectioning of 
tooth, and including elevation of mucoperiosteal flap if indicated (D7210), bone replacement grafts for ridge 
preservation - per site (D7953), and guided tissue regeneration - resorbable barrier, per site (D4266) provided 
March 21, 2022. 
 
You asked the Plan to provide additional payment for the endosteal implants, tooth extractions, bone 
replacement grafts and guided tissue regeneration. You say that these services were medically necessary. The 
Plan denied your request. The Plan says you have used your full dental allowance and no further payment is 
due. 
 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 endosteal 
implant, tooth extraction, bone replacement graft and guided tissue regeneration up to $1,500 every year. 
 
We looked at the file and Medicare rules. The Plan provided documentation showing that at the time the claim 
was processed you had $1,265 remaining in your dental allowance. This amount was applied to your claim. 
Therefore, we decided that the Plan does not have to provide additional payment for the surgical placement of 
implant body: endosteal implants (D6010), extractions, erupted tooth requiring removal of bone and/or 
sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210), bone replacement 
grafts for ridge preservation - per site (D7953), and guided tissue regeneration - resorbable barrier, per site 
(D4266) provided March 21, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service March 31, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says procedure code 99100 is considered bundled 
and 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 procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service March 31, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 75716 billed for date of service May 31, 
2022. 
 You asked the Plan to pay for procedure code 75716. You say that the enrollee had multiple exams on this date 
and the records support that these services were reported correctly. The Plan denied your request. The Plan says 
payment for code 75716 is bundled into the payment for code 37225. Although a modifier was used for 
separate payment of this service, the medical records do not support the use of this modifier as these services 
were not separate and distinct from one another. 
 
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 75716 
is a column II code to column I code 37225; however, 75716 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 procedure code 75716. Our reviewer says that the records 
provided do not support the billing of the 59 modifier for separate payment of this service. Our reviewer found 
that the procedure report describes intervention performed, and in this case, this would include diagnostic 
angiograms and/or venograms. Therefore, this procedure cannot be verified as billed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 75716 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 75716 billed for date of service May 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the facial/oral photographic images provided by an out of 
network (OON) dental office on May 16, 2022, coded as D0350 x 4. 
 
You asked the Plan to pay for the dental photographic images. You say that you do not understand why the 
imaging you were provided has not been covered. The Plan denied your request. The Plan says it was decided 
that payment could be made for the periodontal care provided. The photographic images, however, are not 
covered by the 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 facial/oral photographic images provided by an out of network (OON) dental office on May 16, 2022, coded as 
D0350 x 4.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the subsequent hospital care (99232), initial 
hospital care (99223) virtual check-in (G2012) telehealth visit (99443) provided January 24, 2022 to April 7, 
2022. 
 
You asked the Plan to waive the copayment for the inpatient services and telehealth visits. You say that you are 
being charged $100 for your visits to the emergency room. You were admitted to the hospital each visit. You 
are being billed $213.06 which you do not feel you owe. The Plan denied your request. The Plan says the claim 
was reprocessed and the correct cost share has been applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is $203 deductible and $20 copay for each Medicare covered primary care doctor visit (including telehealth services and urgently needed services, which applies to categories Inpatient 
hospital care and Physician/Practitioner services, including doctors office visits.  
 
The item or service you asked the Plan to waive the copayment for falls within the benefit categories Inpatient 
hospital care and Physician/Practitioner services, including doctors office visits. The Plan has followed 
Medicare rules by clearly disclosing in the contract that there is $203 deductible and $20 copay for each 
Medicare covered primary care doctor visit (including telehealth services and urgently needed services, which 
applies to Inpatient hospital care and Physician/Practitioner services, including doctors office visits. This cost 
sharing is a contractual obligation that had not been met at the time the telehealth visits was received on 
January 24, 2022 to April 7, 2022. Therefore, we decided that the Plan does not have to waive the copayment 
for the subsequent hospital care (99232), initial hospital care (99223) virtual check-in (G2012) telehealth visit 
(99443) provided January 24, 2022 to April 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 80307 billed for date of service April 11, 
2022. 
 
You asked the Plan to pay for procedure code 80307. You say that these services were necessary and are 
supported in the medical record. The Plan denied your request. The Plan says they have agreed to pay for code 
G0481; however, the records provided do not support the billing of code 80307. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 80307 is drug test(s), presumptive, any number of drug 
classes, any number of devices or procedures; by instrument chemistry analyzers, chromatography, and mass 
spectrometry either with or without chromatography, includes sample validation when performed, per date of 
service. 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 procedure code 80307. Our reviewer says that the reported 
code is not supported in the medical record. Our reviewer found that the records provided do not document the 
use of procedure code 80307, and therefore this service cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 80307 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 80307 billed for date of service April 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electrical connection between the wheelchair 
controller and two or more motors (E2311), an expandable controller (E2377), a harness (E2313) and an 
attendant control (E2331). 
 
You asked the Plan to pre-approve wheelchair accessories. You say that you are requesting reconsideration of 
the medical necessity of all the components of this wheelchair required by the enrollee to meet her medical, 
functional and mobility needs throughout the day in her home. The Plan denied your request. The Plan says the 
enrollee does not meet coverage criteria for the requested accessories. 
 
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 wheelchair accessories. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found Provided records document that the enrollee has 3/5 to 5/5 upper extremity strength 
and is independent with feeding and toileting thus indicating she has adequate upper extremity strength and 
function to operate the wheelchair's power options with their own switches. As stated in Medicare's Local 
Coverage Determination (LCD): Wheelchair Options/Accessories - L33792, an attendant control is not covered 
in addition to a patient-operated drive control system. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of wheelchair accessories have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an electrical connection between the wheelchair controller and two or more 
motors (E2311), an expandable controller (E2377), a harness (E2313) and an attendant control (E2331).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral - periapical first radiographic image (D0220) for 
teeth 29 and 31 provided June 9, 2022. 
 
You asked the Plan to pay for the dental services. You say that you cannot afford the cost of the services. The 
Plan denied your request. The Plan says your benefit for the requested item or service 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 Plans 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 item or service was exhausted on date of service June 9, 2022. Therefore, 
we decided that the Plan does not have to pay for the intraoral - periapical first radiographic image (D0220) for 
teeth 29 and 31 provided June 9, 2022.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve one crown. We decided that the Plan does not have to pre-approve 
the remaining two requested crowns.  
 
You asked the Plan to pre-approve crowns - porcelain fused to predominantly base metal (D2751) for teeth 13, 
14 and 15. You say that the crowns are medically necessary. The Plan says that you do not meet criteria for 
coverage of the crowns. 
 
We decided that the Plan has to pre-approve one crown.  
 
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. Specifically, we requested the clinical criteria used by the Plan to review 
coverage of the crowns. The requested information was not received. Therefore, we decided that the Plan has to 
pre-approve one crown.  
 
We also decided that the Plan does not have to pre-approve the remaining two requested crowns. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service will be exhausted with the one approved crown. Therefore, 
we decided that the Plan does not have to pre-approve the remaining two requested crowns. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services (22854) provided on January 12, 2022. 
 
You asked the Plan to pay for code 22854. You say that the medical records support the billing of code 22854. 
The Plan denied your request. The Plan says the medical records do not support the billing of code 22854. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 22854 is Insertion of intervertebral biomechanical 
device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation for device anchoring (eg, screws, 
flanges), when performed, to vertebral corpectomy(ies) (vertebral body resection, partial or complete) defect, in 
conjunction with interbody arthrodesis, each contiguous defect (List separately in addition to code for primary 
procedure). 
 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 code 22854. Our reviewer says that the medical records do 
not support the billing of code 22854. Our reviewer found the documentation submitted was reviewed, and the 
records do not support the billing of code 22854. The operative report does not describe insertion of 
intervertebral biomechanical device and therefore, cannot be verified. The operative report documents 
"preparation of the end-plates and fusion with a cage and metal plates in the vertebral bodies above and below 
was performed and dictated separately". In this case, this procedure was not performed and documented by the 
billing provider, and therefore cannot be confirmed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 22854 have not been met. Therefore, we decided that the Plan does not 
have to pay for the surgical services (22854) provided on January 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a white (resin) filling on tooth #12 received on May 6, 2022. 
 
You asked the Plan to pay for the services. You say that you feel that the amount paid out of pocket was 
excessive. 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 Plans coverage rules apply in this case. The Plan covers generally the 
less expensive version of most dental treatments. 
 
The file shows that you received a white filling. Therefore, the plan correctly paid up to the amount for the 
silver filling, and you correctly owe the remainder of the balance. Based on this information, we decided that the Plan's rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for a white (resin) filling on tooth #12 received on May 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve electronic connection between wheelchair controller and 
two or more power seating system motors (E2311).  
You asked the Plan to pre-approve the upgraded electronic. You say that you are requesting man appeal for the 
denial. The Plan denied your request. The Plan says this is not medically necessary as there is no medical need 
to control the approved power options through the joystick. 
 
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 the upgraded electronic. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee feeds themself and does most of their bathing. Strength is 3+-4/5 at 
elbows. Hands and wrists are 4/5. The enrollee has the strength to operate more than one switch. 
 
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 upgraded electronic have not been met. Therefore, we decided that the Plan 
does not have to pre-approve electronic connection between wheelchair controller and two or more power 
seating system motors (E2311).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pontic (D6245) provided by a participating provider on 
January 10, 2022. 
 
You asked the Plan to pay for a pontic. You say that you were not aware that these services were not covered. 
The Plan denied your request. The Plan says the rendered dental work 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. 
 
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 a pontic 
(D6245) provided by a participating provider on January 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cone beam CT capture (D0364) and an incomplete 
endodontic therapy (D3332) provided by a participating provider on May 19, 2022. 
 
You asked the Plan to pay for a cone beam CT capture and an incomplete endodontic therapy. You say that 
these services were medically necessary. The Plan denied your request. The Plan says the rendered dental 
services are not covered 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 a cone 
beam CT capture (D0364) and an incomplete endodontic therapy (D3332) provided by a participating provider 
on May 19, 2022.