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

 
We decided that the Plan does not have to pay for the coronectomy (D7251) and unspecified preventive 
services (D1999 x 2) provided on November 29, 2021. 
 
You asked the Plan to pay for the dental services. You say that you contacted your plan to make sure this 
procedure would be covered before you made the appointment. You say that you were advised as long as the 
service was completed by an oral surgeon it would be covered in full. You also say that you expect this to be 
covered. The Plan denied your request. The Plan says the denied services are not listed as covered. 
 
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 coronectomy and unspecified 
preventive services are not among those covered under this benefit. Therefore, we decided that the Plan does 
not have to pay for the coronectomy (D7251) and unspecified preventive services (D1999 x 2) provided on 
November 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a porcelain/ceramic crown for tooth #29. 
 
You asked the Plan to pre-approve the crown. You say that this is medically necessary. The Plan denied your 
request. The Plan says the tooth does not show large decay requiring replacing a significant amount of the 
tooth. 
 
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 crown 
when the services are medically necessary and reasonable.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the crown. Our reviewer says that the 
requested crown is not medically reasonable or necessary. Our physician reviewer found a review of the 
documentation indicates that tooth #29 does not appear to have significant coronal breakdown due to caries or 
fracture to warrant a crown restoration. Also, there was no narrative indicating why a crown restoration was 
required for restoration. The documentation provided does not meet the criteria for coverage for a crown 
restoration (D2740) for tooth #29. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the crown have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a porcelain/ceramic crown for tooth #29.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a telehealth visit provided on November 3, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the telehealth visit. You say that you did not know that a prior authorization was 
required before the service was rendered. The Plan denied your request. The Plan says the rendering provider is 
an out-of-network provider and there was no referral from an in-network provider or an approved 
authorization. Also, the service rendered was not urgent or emergent. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a telehealth visit provided on November 3, 2021, 
by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system with electronics and an 
expandable controller with harness. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation system is non-covered and 
an expandable controller is used to control multiple power options. 
 
We looked at the file and Medicare rules. The requested power seat elevation system with electronic 
connection is non-covered. The expandable controller with harness is not needed to control the approved power 
options. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system with 
electronics and an expandable controller with harness.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76700 billed for date of service January 11, 
2022. 
 
You asked the Plan to pay for procedure code 76700. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76700 is bundled into payment for 
code 93976. 
 
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 76700 
is a column II code to column I code 93976. 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 76700 billed for date of service January 11, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for eyewear provided on April 7, 2021. 
 
You asked the Plan to pay for the eyewear. The Plan denied your request. The Plan says on April 6, 2021 the 
Plan processed reimbursement of frame and lens services exhausting the members benefits. 
 
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear 
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan 
covers these services 1 per calendar year. 
 We looked at the file and the Plan's rules. The file shows that the Plan processed reimbursement of frame and 
lens services provided on April 6, 2021. Your eyewear benefit has been exhausted. Therefore, we decided that 
the Plan does not have to pay for eyewear provided on April 7, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ultrasound of the breast (76642) 
provided on November 23, 2021. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that this was a frightening procedure, 
and you would like your Plan to cover the full cost of this service to relieve the additional stress. The Plan 
denied your request. The Plan says this claim was processed correctly, and your copayment was assessed in 
accordance with your contract. 
 
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 $150 
copayment for radiological diagnostic services.  You have been asked to pay a $91.10 copayment for the ultrasound. An ultrasound falls within the radiological 
diagnostic 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 the ultrasound of the 
breast (76642) provided on November 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on November 
29, 2021. 
 
You asked the Plan to pay for the dental service. You say that you were advised by a plan representative that 
the provider in this case was in network. You also say that this should be covered. The Plan denied your 
request. The Plan says a limited oral evaluation is covered once per plan year. The Plan also says that the 
frequency limit 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage and a limited oral evaluation is covered 
once per plan year, the frequency limit has been exceeded. The record shows that the Plan paid for a limited oral 
evaluation that you received on November 15, 2021. Therefore, we decided that the Plan does not have to pay 
for the limited oral evaluation (D0140) provided on November 29, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on September 21, 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 the services were not billed correctly. 
 
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 these 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 the laboratory services rendered on September 21, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for needle electromyography (95861-26-XU) provided on March 
26, 2021. 
You asked the Plan to pay for needle electromyography. You say that these services were reported correctly 
and should be paid. The Plan denied your request. The Plan says there is insufficient information to support a 
second unit of 95861 on the date in question. 
 
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 needle electromyography (95861-26-
XU) provided on March 26, 2021. have been met. Specifically, no medical records were submitted for review. 
CPT code has an MUE of 1 and an MAI of 3, which allows for additional units to be billed if they are 
supported in the medical record. Without medical records, this service cannot be verified. Therefore, we 
decided that the Plan does not have to pay for needle electromyography (95861-26-XU) provided on March 26, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient therapy services rendered by the out-of-
network (OON) provider from April 26, 2021, through April 30, 2021. 
 
You asked the Plan to pay for these 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 services were rendered by an out of 
network provider, without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. 
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the outpatient therapy services rendered by the out-of-network (OON) provider 
from April 26, 2021, through April 30, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the rhythm electrocardiogram (ECG) report (93042) 
provided on September 19, 2021. 
 
You asked the Plan to pay for the ECG report. You say that these services were billed correctly. The Plan 
denied your request. The Plan says a National Correct Coding Initiatives (NCCI) Procedure to Procedure (PTP) 
edit exists between 99291 and 93042. This PTP edit has a modifier indicator of 0, meaning modifiers 
associated with NCCI are not allowed to bypass the edit. 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 93042 
is a column II code to column I code 99291. This code pair does not allow for a 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 rhythm electrocardiogram (ECG) report (93042) provided on September 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Evaluation and Management services provided on December 
7, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for Evaluation and Management services. You say that you would like to request 
reconsideration for payment. The Plan denied your request. The Plan says the provider is out-of-network and it 
was determined these services were not urgent or emergent. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for Evaluation and Management services provided on 
December 7, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal scaling and root planing for the upper right 
quadrant (D4341) and comprehensive periodontal exam (D0180) provided on December 9, 2021, and 
December 14, 2021. 
 
You asked the Plan to pay for the periodontal services. You say that these services were necessary, and you 
could not find an available in-network dentist within a reasonable distance from you. The Plan denied your 
request. The Plan says you previously had periodontal scaling and root planing provided for the upper right 
quadrant in March of 2021, which was covered by the Plan at that time. This service is covered once per 
quadrant every two plan years.  Therefore, the periodontal scaling and root planing exceeds the frequency limitations of your benefit. In 
addition, the comprehensive periodontal exam is not listed as a covered service under any condition. 
 
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 does not cover 
services that are not listed in the dental benefits chart section of the contract. The Plan covers periodontal 
scaling and root planing (deep cleaning) (D4341) for one procedure per quadrant every two plan years, not to 
exceed four unique quadrants every two plan years. 
 
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 or are requested in a frequency that exceeds what is covered by this 
benefit. Documentation supports that you had periodontal scaling and root planing provided for this same 
quadrant within the same calendar year. Therefore, we decided that the Plan does not have to pay for the 
periodontal scaling and root planing for the upper right quadrant (D4341) and comprehensive periodontal exam 
(D0180) provided on December 9, 2021, and December 14, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient mental health stay provided 
from July 14, 2021, to July 16, 2021. 
 
You asked the Plan to waive the copayment for an inpatient mental health stay. You say that your post-
traumatic stress disorder (PTSD) was triggered by a fire alarm malfunction, that caused multiple trips to the 
emergency room. You also say that you received this bill from the hospital in January 2022. The Plan denied 
your request. The Plan says you have been charged the correct cost sharing amount. 
 
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 $395 
copayment each day for days 1-4 each time you are admitted for an in-network inpatient mental health stay. The contract also says there is a $0 copayment for additional days after day 4 up to 90 days. There is 
 
The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay a 
total of $790, which is a $395 copayment for each day of a two-day inpatient mental health stay from July 14, 
2021, to July 16, 2021 ($395 copayment x 2 days = $790). There is no charge for additional days after day 4 up 
to 90 days. There is no charge for the day of discharge. An inpatient mental health stay falls within the 
Inpatient Mental Health Care 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 inpatient 
mental health stay provided from July 14, 2021, to July 16, 2021.  
 
Your complaint about not receiving the hospital bill until January 2022 is not a valid appeal for medical 
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not 
permit us to make a decision about these types of complaints.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable cage system. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
clinical effectiveness has not been demonstrated in peer-reviewed literature. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
The file shows that an expandable cage system was requested in the setting of lumbar decompression and 
fusion services. 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 requested 
services. Our physician reviewer found that the use of the expandable cage is not medically needed in this 
surgery. It is also experimental at this time. Therefore, the request is not considered 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an expandable cage system.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services coded as 99053 provided on August 22, 2021. 
 
You asked the Plan to pay for the medical services. You say that you would like this claim reprocessed based 
on the medical documentation. The Plan denied your request. The Plan says no separate payment can be made 
for this service based on Medicare billing coding regulations. 
 
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 99053 is service(s) provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service. 
 
We looked at the file and Medicare rules. In this case, this code has a Status Code of "B" under the Physician 
Fee Schedule. This indicates that payment for covered services are always bundled into payment for other 
services not specified. Based on this information, we decided that Medicare rules for coverage of the medical 
services have not been met. Therefore, we decided that the Plan does not have to pay for the medical services 
coded as 99053 provided on August 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental periapical radiographs and partial dentures provided 
from April 21, 2021, to October 27, 2021. 
 
You asked the Plan to pay for dental services. You say that you understood that if the dentist was not in-
network, you could still be reimbursed for the allowed amount of treatment. The Plan denied your request. The 
Plan says the denial of payment for these services is correct, because periapical radiographs and partial 
dentures are not covered by the Plan's 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 pay for dental 
periapical radiographs and partial dentures provided from April 21, 2021, to October 27, 2021.