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

 
We decided that the Plan does not have to pay more for the periodic oral evaluation, prophylaxis and bitewings 
x-rays provided on November 28, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you are appealing the denial. 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 the periodic oral evaluation, prophylaxis and 
bitewings x-rays provided on November 28, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for chemotherapy treatment provided on 
January 6, 2023, and January 20, 2023. 
 
You asked the Plan to waive the cost share for chemotherapy treatment. You say that you should not have to 
pay anything for the services rendered. The Plan denied your request. The Plan says this cost sharing was 
charged correctly. 
 
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 20% 
coinsurance for Medicare Part B prescription drugs.   
You have been asked to pay a total cost share of $5,432.38 for chemotherapy treatment. The total includes 
$4,842.38 coinsurance for Medicare Part B drugs and therapeutic services, and a $590 copayment for 
outpatient hospital services. Medicare Part B drugs and therapeutic services fall within the Medicare Part B 
prescription drugs benefit category. Outpatient hospital services fall within the outpatient hospital 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 cost share for chemotherapy treatment provided 
on January 6, 2023, and January 20, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).  
You asked the Plan to pre-approve a continuous glucose monitor (CGM). You say that you would like to 
request reconsideration of the denied authorization. The Plan denied your request. The Plan says the criteria for 
approval have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin or 
have a history of problematic hypoglycemia Based on this information, we decided that Medicare rules for 
coverage of a continuous glucose monitor (CGM) have not been met.  Therefore, we decided that the Plan does 
not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient hospital services provided on December 9, 
2022.  
 
You asked the Plan to pay for the outpatient hospital services. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as 
billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. The file shows the claim was billed without the G0 condition code 
which caused procedure codes G0463 and G0402 to deny. Therefore, we decided that the Plan does not have to 
pay for the outpatient hospital services provided on December 9, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an outpatient surgery provided on October 
03, 2022. 
 
You asked the Plan to waive the coinsurance for an outpatient surgery. You say that you are disputing the share 
cost. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 10% 
coinsurance for Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and 
Ambulatory Surgical Centers. 
 
You have been asked to pay 10% coinsurance for an outpatient surgery. This item/service falls 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 coinsurance for an outpatient 
surgery provided on October 03, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve  mandibular partial denture (D5214). 
 
You asked the Plan to pre-approve the dental services. You say that this should be covered. 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 1, 2021. Therefore, 
we decided that the Plan does not have to pre-approve  mandibular partial denture (D5214).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 Mis Reader. 
 
You asked the Plan to pre-approve the Dexcom G6 Mis Reader. You say that the enrollee needs this reader to 
monitor her blood glucose daily. The Plan denied your request. The Plan says the enrollee is not on insulin or 
does not have documentation of history of problematic hypoglycemia, 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin or 
have a history of problematic hypoglycemia.  Based on this information, we decided that Medicare rules for 
coverage of the Dexcom G6 Mis Reader have not been met.  Therefore, we decided that the Plan does not have 
to pre-approve a Dexcom G6 Mis Reader.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the neuromonitoring services provided on June 14, 2021, 
billed with 95927. 
 
You asked the Plan to pay for the services as billed. You say that the billed codes are supported.  The Plan 
denied your request. The Plan says the services described by code 95927 are not documented.  
 
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 95927 is Short-latency somatosensory evoked potential 
(SSEP) study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; 
in the trunk or head. 
 
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 the services as billed. Our reviewer says that the 
documentation does not support the billed code.  Our reviewer found the procedure report does not include 
documentation of SSEP, stimulation of any/all peripheral nerves or skin sites, recording from central nervous 
system, in trunk or head. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services as billed have not been met. Therefore, we decided that the Plan 
does not have to pay for the neuromonitoring services provided on June 14, 2021, billed with 95927.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a continuous glucose monitor (CGM). You say that you would like to 
request reconsideration of the denied authorization. The Plan denied your request. The Plan says only the 
preferred brand products listed in the EOC are covered.  
 
The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including 
non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in 
clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits.  
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for a continuous glucose monitor (CGM). Therefore, we decided that the Plan does not have to pre-approve a 
continuous glucose monitor (CGM).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 16 additional physical therapy visits. 
 
You asked the Plan to pre-approve physical therapy visits.. You say that your doctor supports the need for more 
physical therapy. The Plan denied your request. The Plan says 4 additional physical therapy visits are not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 physical therapy visits. Our reviewer 
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the 
enrollee's condition. Our physician reviewer found you have shown very modest response to 65 physical 
therapy visits and are very independent in the home exercise program. An additional 12 visits before re-
evaluation are reasonable as there is little evidence that physical therapy is impacting your function. Therefore, 
additional visits are not medically necessary for your condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of physical therapy visits. have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 16 additional physical therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter (K0800). 
 
You asked the Plan to pre-approve the power scooter. You say that the power scooter is medically necessary. 
The Plan denied your request. The Plan says this equipment is being requested for use outside the home, and is 
non-covered. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home.  Therefore, we decided that the Plan does 
not have to pre-approve a power scooter (K0800).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the cervical medial 
branches (64634, 64633). 
 
You asked the Plan to pre-approve RFA of the cervical medial branches. You say that the services are 
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 
has not been met.  
The Plan follows Medicare rules. Medicare rules say that the thermal radiofrequency destruction of cervical, 
thoracic, or lumbar paravertebral facet joint (medial branch) nerves are considered medically reasonable and 
necessary for patients who meet specific criteria: 
 
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 RFA of the cervical medial branches. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee 
needs two separate sets of diagnostic medial branch blocks (MBBs), each of which must provide at least 80% 
pain relief for the expected duration of the local anesthetic used. Only one set of MBBs was performed and 
only 70% pain relief was achieved. This does not meet the LCD criteria and therefore, the request is deemed 
not medically reasonable and 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 RFA of the cervical medial branches have not been met. Therefore, we decided 
that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the cervical medial branches 
(64634, 64633).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an extra-oral  2D projection radiographic image created 
using a stationary radiation source, and detector (D0250) provided on December 13, 2022. 
 
You asked the Plan to pay for the extra-oral  2D projection radiographic image. You say that the business 
office told you that you had to pay and then will get reimbursed by the Plan. The Plan denied your request. The 
Plan says this service is not covered under the benefit package. 
 
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 an 
extra-oral  2D projection radiographic image created using a stationary radiation source, and detector (D0250) 
provided on December 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composite-four or more surfaces or involving 
an incisal angle (anterior) for tooth number 9 (D2335) provided on February 15, 2023. 
 
You asked the Plan to pay for this dental item. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says your benefit for the dental item provided 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 item provided was exhausted on date of service June 21, 2022.   
 
 
 
Specifically, the Plans contract states that coverage is provided for restorative services which include amalgam 
and anterior composite resin fillings once per tooth every twenty four months. You previously received this 
dental item for tooth number 9 on June 21, 2022, less than twenty four months prior, which was paid for by the 
Plan. Therefore, you have exhausted the allowable benefit for this dental item. Therefore, we decided that the 
Plan does not have to pay for the resin-based composite-four or more surfaces or involving an incisal angle 
(anterior) for tooth number 9 (D2335) provided on February 15, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve osseous surgery (D4260, D4261), bone replacement 
graft (D4263 x 2) and guided tissue regeneration (D4266 x 2). 
 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing the denial. The Plan 
denied your request. The Plan says these services are not covered under 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 Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
osseous surgery (D4260, D4261), bone replacement graft (D4263 x 2) and guided tissue regeneration  
(D4266 x 2).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SNF care provided from October 1, 2021, through October 8, 
2021. 
 
You asked the Plan to pay for SNF care. You say that a claim should be reprocessed. The Plan denied your 
request. The Plan says the claim was denied as timely filing. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for SNF care was filed on November 12, 2021, which was rejected. The 
corrected claim was not submitted until October 10, 2022. This means that more than one calendar year from 
the date of service had passed before the corrected claim was filed. Therefore, we decided that the Plan does 
not have to pay for SNF care provided from October 1, 2021, through October 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87150, 87481, 87653, 87798 and 87641 
billed for date of service October 21, 2022. 
 
You asked the Plan to pay for procedure codes 87150, 87481, 87653, 87798 and 87641. You say that these 
services are supported in the medical records. The Plan denied your request. The Plan says these services are 
not supported for separate billing in this case. 
 
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 87150, 87481, 87653, 87798 and 87641 are column II codes to 
column I codes 87801 and 87500. Codes 87481 and 87653 have not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met for codes 87481 and 
87653. However, codes 87150, 87798 and 87641 were each 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 codes 87150, 87798 and 87641. Our reviewer says 
that the XU modifier is not supported with these services. Our reviewer found the laboratory report does not 
include documentation to support a separate service for each of these codes. Therefore, these services cannot be 
verified as separate/repeat procedures. 
 
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 codes 87150, 87481, 87653, 87798 and 87641 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes 87150, 87481, 87653, 87798 and 
87641 billed for date of service October 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation - established patient (D0120), 
intraoral - periapical first radiographic image (D0220), prophylaxis - adult (D1110) and re-cement or re-bond 
crown (D2920), provided on May 17, 2022, and June 17, 2022. 
 
You asked the Plan to pay for the dental services. You say that are requesting to be refunded as this was fault of 
the dentist. The Plan denied your request. The Plan says your benefit for the requested services $1,000 dollar 
limit was met. 
 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 services was exhausted on dates of service May 10, 2022, and June 1, 
2022. Therefore, we decided that the Plan does not have to pay for a periodic oral evaluation - established 
patient (D0120), intraoral - periapical first radiographic image (D0220), prophylaxis - adult (D1110) and re-
cement or re-bond crown (D2920), provided on May 17, 2022, and June 17, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a cataract surgery provided on January 03, 
2023. 
 
You asked the Plan to waive the copayment for a cataract surgery. You say that you are disputing the share 
cost. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 $350 
copayment for Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers. 
 
You have been asked to pay a $350 copayment for a cataract surgery. This item/service 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 a cataract surgery provided on 
January 03, 2023.