Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the EEG (95822) provided on March 30, 2022. 
 
You asked the Plan to pay for the EEG (95822). You say that the services are medically necessary and were 
requested by the in-network surgeon. You say that the claim has been properly coded, and the claim should be 
reprocessed. The Plan denied your request. The Plan says procedure code 95937 has been approved and 
procedure code 95822 is not supported. 
 
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 95822 is electroencephalogram (EEG); recording in coma 
or sleep only. 
 
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 EEG (95822). Our reviewer says that procedure code 
95822 is not supported. Our reviewer found that the medical records provided indicate that the EEG performed 
was intraoperative, which does not meet the definition described by procedure code 95822. Therefore, this 
procedure 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 the EEG (95822) have not been met. Therefore, we decided that the Plan does 
not have to pay for the EEG (95822) provided on March 30, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 101 additional one-way trips. 
 
You asked the Plan to pre-approve 101 additional one-way trips. You say that you have rehabilitation sessions 
five days a week for three months, plus three doctors appointments. The Plan denied your request. The Plan 
says your benefit plan does not cover more than 50 one-way trips per plan year. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of up to 50 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. The record shows that as of June 20, 2023, 
you have already used 25 trips. The Plan has approved 25 additional trips, and your maximum allowed of 50 
trips has been met. Based on this information, we decided that you have exhausted the Plan maximum benefit 
for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve 101 
additional one-way trips.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service November 4, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that the records show the procedure should be 
covered. 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 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
99100 billed for date of service November 4, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 20930 and 20936 billed for date of service 
December 30, 2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says procedure codes 
20930 and 20936 are 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 codes 20930 and 20936 have a status indicator of B on the Physician Fee Schedule. 
This means that procedure codes 20930 and 20936 are not separately payable. Based on this information, we 
decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have 
to pay for procedure codes 20930 and 20936 billed for date of service December 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral complete series of radiographic images (D0210) 
provided on March 14, 2023. 
 
You asked the Plan to pay for the dental service. You say that you went to a new provider, and they told you 
that they could not get your old dental x-rays. 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 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 item or service was exhausted on the date of service of August 2, 2022. 
Therefore, we decided that the Plan does not have to pay for the intraoral complete series of radiographic 
images (D0210) provided on March 14, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve extractions (D7210 x16), and inhalation of nitrous oxide 
(D9230). 
 
You asked the Plan to pre-approve the dental services. You say that the services are medically necessary. The 
Plan denied your request. The Plan says your benefit for the extractions has been exhausted with the approval 
of 8 extractions. Additionally, inhalation of nitrous oxide is not a covered benefit. 
 
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 item or service was exhausted with the Plan's approval for 8 extractions. 
Additionally, inhalation of nitrous oxide is not a covered benefit. Therefore, we decided that the Plan does not 
have to pre-approve extractions (D7210 x16), and inhalation of nitrous oxide (D9230).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481 and 87653 billed for date of service 
May 16, 2022. 
 
You asked the Plan to pay for procedure codes 87481 and 87653. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says payment for codes 87481 and 
87653 are bundled into payment for code 87801. 
 
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 
87481 and 87653 are column II codes to column I code 87801. This claim has not been billed with an 
appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes 87481 and 87653 billed for 
date of service May 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the treatment of root canal obstruction (D3331) provided on 
March 22, 2023. 
 
You asked the Plan to pay for the dental services. You say that you are appealing the denial. The Plan denied 
your request. The Plan says this service is not a covered benefit under your dental plan.  

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 the 
treatment of root canal obstruction (D3331) provided on March 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service February 7, 
2023. 
 
You asked the Plan to pay for procedure code 99100. You say that medical records were provided. 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 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
99100 billed for date of service February 7, 2023.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a porcelain/ceramic crown (D2740) and core buildup, including 
any pins when required (D2950). 
 
You asked the Plan to pre-approve a porcelain/ceramic crown (D2740) and core buildup, including any pins 
when required (D2950). You say that your dentist requested to crown your four front lower teeth, that are weak 
and worn, to make them strong and save them. You also say that these crowns will help you to eat properly, 
since you currently eat with your side teeth. The Plan denied your request. The Plan says that this service does 
not meet the criteria for benefits. 
 
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, the Plan has not provided us with any medical records from their 
contracted dentist or any other documentation to support their reasons for denial. Without this information, the 
Plan has not substantiated their denials Therefore, we decided that the Plan has to pre-approve a 
porcelain/ceramic crown (D2740) and core buildup, including any pins when required (D2950).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 2D oral/facial photographic image (D0350). 
 
You asked the Plan to pre-approve 2D oral/facial photographic image (D0350). You say that you have a dental 
coverage of 5,000 dollars. You also say that for more than 1 year, you have had an implant that, since that piece 
is missing, the lower teeth are turning forward. The Plan denied your request. The Plan says this service is not 
included on your dental plan coverage. 
 
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 pre-approve 2D 
oral/facial photographic image (D0350).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99203), hot or cold packs therapies  
(97010 x 3), x-ray exam of the cervical spine (72040), and the mechanical traction therapies (97012 x 3) 
provided from March 10, 2023, through March 22, 2023. 
 
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 these services are not a covered benefit.  
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.   
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the office visit (99203), hot or cold packs therapies (97010 x 3), x-ray 
exam of the cervical spine (72040), and the mechanical traction therapies (97012 x 3) provided from March 10, 
2023, through March 22, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a neck/spine x-ray (CPT 72040), an x-ray of jaw 
(CPT 70100), a swallowing function x-ray (CPT 74230), diagnostic radiology procedures of the head and neck 
(CPT 70310) and an upper gastrointestinal tract x-ray (CPT 74240) provided on January 17, 2023. 
 
You asked the Plan to pay for a neck/spine x-ray (CPT 72040), an x-ray of jaw (CPT 70100), a swallowing 
function x-ray (CPT 74230), diagnostic radiology procedures of the head and neck (CPT 70310) and an upper 
gastrointestinal tract x-ray (CPT 74240). You say that the services were medically necessary. The Plan denied 
your request. The Plan says that the services were performed at a nursing home (via mobile van/portable x-ray), 
which are denied as an excluded place of service. 
 
The Plan must follow Medicare rules. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a neck/spine x-ray (CPT 72040), an x-ray of jaw (CPT 70100), a swallowing function x-ray  
(CPT 74230), diagnostic radiology procedures of the head and neck (CPT 70310) and an upper gastrointestinal 
tract x-ray (CPT 74240) have not been met. Therefore, we decided that the Plan does not have to pay for a 
neck/spine x-ray (CPT 72040), an x-ray of jaw (CPT 70100), a swallowing function x-ray (CPT 74230), 
diagnostic radiology procedures of the head and neck (CPT 70310) and an upper gastrointestinal tract x-ray 
(CPT 74240) provided on January 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen (HBO) therapy (G0277 x80) and 
physician attendance and supervision of hyperbaric oxygen therapy, per session (99183 x20). 
 
You asked the Plan to pre-approve HBO therapy and physician attendance. 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 program reimbursement for HBO therapy will be 
limited to that which is administered in a chamber (including the one man unit) and is limited to certain 
conditions. 
 
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 HBO therapy and physician attendance. 
Our reviewer says that the services are not medically necessary Our physician reviewer found the first month of 
HBO therapy was approved. However, sessions beyond that duration are not supported as there needs to be a 
wound assessment showing benefit to consider additional session approval. Although the enrollee meets 
criteria for coverage, this request for the remaining sessions is not medically necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of HBO therapy and physician attendance have not been met. Therefore, we 
decided that the Plan does not have to pre-approve hyperbaric oxygen (HBO) therapy (G0277 x80) and 
physician attendance and supervision of hyperbaric oxygen therapy, per session (99183 x20).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377) with harness (E2313) 
and electronic connection (E2311) for a power wheelchair, as well as a largest extension tube, footplate 
assembly and footplate extension coded K0108. The Plan does not have to pre-approve a reflector kit. 
 
You asked the Plan to pre-approve an expandable controller with harness and electronic connection, and a 
largest extension tube, footplate assembly and footplate extension, as well as a reflector kit. You say that the 
requested items are a medical necessity for the enrollee. The Plan denied your request. The Plan says the 
requested items are not medically necessary or do not serve a primarily medical purpose. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that for equipment to be covered, it must primarily serve a 
medical purpose. 
 
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 an expandable controller with harness 
and electronic connection, and a largest extension tube, footplate assembly and footplate extension. Our 
reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the expandable controller is not medically necessary as the enrollee has adequate 
upper body strength to manage standard power drives. The footrest and legrest accessories are miscoded as 
they have a more appropriate Healthcare Common Procedure Coding System (HCPCS) code. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an expandable controller with harness and electronic connection, and a largest 
extension tube, footplate assembly and footplate extension have not been met. A reflector kit does not serve a 
purpose that is primarily medical in nature. 
  
Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2377) with 
harness (E2313) and electronic connection (E2311) for a power wheelchair, as well as a largest extension tube, 
footplate assembly and footplate extension coded K0108. The Plan does not have to pre-approve a reflector kit.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377) with harness (E2313) 
and electronic connection (E2311) for a power wheelchair. 
 
You asked the Plan to pre-approve an expandable controller with harness and electronic connection. You say 
that the requested items are a medical necessity for the enrollee. The Plan denied your request. The Plan says 
the requested items are not medically necessary. 
 
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 an expandable controller with harness 
and electronic connection. Our reviewer says that the requested items are not considered medically reasonable 
and necessary in this case. Our physician reviewer found that the enrollee has adequate upper body strength to 
manage standard power drives. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an expandable controller with harness and electronic connection have not been 
met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2377) with 
harness (E2313) and electronic connection (E2311) for a power wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system (E2300). 
 
You asked the Plan to pre-approve wheelchair accessory. You say that you disagree with the denial and request 
reconsideration. The Plan denied your request. The Plan says the requested accessory is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
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 power seat elevation system (E2300).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 84479 billed for date of service February 20, 
2023.  You asked the Plan to pay for procedure code 84479. You say that the services were rendered in good faith. 
The Plan denied your request. The Plan says payment for code 84479 is bundled into payment for code 84439. 
 
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 84479 is a column II code to column I code 84439 with a modifier 
indicator of 0. The column II code is therefore not payable. 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 84479 
billed for date of service February 20, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for an immediate upper denture (D5130), and to pay for an 
immediate lower denture (D5140), the extractions (D7140) for tooth #21, #22, #12, #25, #26, and #27, and 
alveoloplasty (D7310) on all 4 quadrants provided on March 9, 2023. 
 
You asked the Plan to pay more for the dental services. You say that the dentures and the extractions should be 
covered, and you would like the Plan to reimburse you for the dental services. The Plan denied your request. 
The Plan says your annual dental maximum benefit for the year 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 the Plan paid $1,500 for the dental services on March 9, 2023; therefore, your annual dental maximum 
benefit for the year of 2023 was exhausted on the date of service of March 9, 2023. Therefore, we decided that 
the Plan does not have to pay more for an immediate upper denture (D5130), and to pay for an immediate 
lower denture (D5140), the extractions (D7140) for tooth #21, #22, #12, #25, #26, and #27, and alveoloplasty 
(D7310) on all 4 quadrants provided on March 9, 2023.