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

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation, intraoral x-rays, and 
gingival irrigation (D0150, D0210, D0230, D4921) provided on December 6, 2022, to December 22, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. Coverage for the gingival irrigation services denied correctly as they do not fall within 
your 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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service March 1, 2021. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation, intraoral x-rays, 
and gingival irrigation (D0150, D0210, D0230, D4921) provided on December 6, 2022, to December 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician services provided on October 21, 2022. 
 
You asked the Plan to pay for the physician services. You say that you were informed that the services would 
be covered. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the physician services 
provided on October 21, 2022.
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 to monitor 
the sugar in their diet and control the diabetes. The Plan denied your request. The Plan says a continuous 
glucose monitor is covered under Medicare only if a member with diabetes is on insulin several times a day. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 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 a Dexcom G6 Mis Reader have been 
met. Specifically, the information provided was not sufficient to support approval for medical necessity. The 
following information was not provided and/or clarified, one of the following: if the enrollee  requires multiple 
(three or more) daily doses of insulin, treatment with a continuous subcutaneous insulin infusion pump, and 
frequent daily adjustments of insulin based on blood glucose testing results. Therefore, we decided that the 
Plan does not have to pre-approve a Dexcom G6 Mis Reader.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve physical therapy. You say that you disagree with the denial of your physical 
therapy of the feet. The Plan denied your request. The Plan says the enrollee must get their care from network 
providers usually; the plan wont cover care from a provider who doesnt work with the health plan. This 
means that the enrollee will have to pay the provider in full for the services furnished from providers outside of 
the network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
physical therapy to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 47999 billed for date of service November 1, 
2022. 
 
You asked the Plan to pay for procedure code 47999. You say that the services at issue have been billed 
correctly. The Plan denied your request. The Plan says the records do not support the services billed. 
 
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 47999 is: Unlisted procedure, biliary tract. 

 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 47999. Our reviewer says that procedure 
code 47999 does not meet criteria for payment. Our reviewer found that the procedure does not describe an 
unlisted procedure of the biliary tract. No unlisted biliary tract procedure was included in the documentation or 
documentation to support an unlisted procedure. The procedure cannot be verified in the report. 
 
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 47999 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 47999 billed for date of service November 1, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 29827, 29823, and 29826 billed for 
September 20, 2022. 
 
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 procedure codes 29827, 29823, and 29826 are 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 29827 is arthroscopy, shoulder, surgical; with rotator cuff 
repair. The definition of code 29823 is arthroscopy, shoulder, surgical; debridement, extensive, 3 or more 
discrete structures (eg, humeral bone, humeral articular cartilage, glenoid bone, glenoid articular cartilage, 
biceps tendon, biceps anchor complex, labrum, articular capsule, articular side of the rotator cuff, bursal side of 
the rotator cuff, subacromial bursa, foreign body[ies]). The definition of code 29826 is arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty, with coracoacromial ligament (ie, 
arch) release, when performed (List separately in addition to code for primary procedure). 
 
We find that CPT codes 29827, 29823, and 29826 are not supported in the medical record. Specifically, there is 
no documentation of increased procedural services of a surgical shoulder arthroscopy, with rotator cuff repair, 
to support code 29827. There is no documentation of a surgical shoulder arthroscopy with extensive 
debridement to support code 29823. There is no documentation of a surgical shoulder arthroscopy with 
decompression of subacromial space with a partial acromioplasty, with or without coracoacromial ligament 
(arch) release to support code 29826. 
 
Based on this information, we decided that Medicare rules for coverage of these services have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes 29827, 29823, and 29826 billed 
for September 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiographic/surgical implant index, by report (D6190) 
provided on January 17, 2023. 
 
You asked the Plan to pay for dental services. You say that you were unaware that a pre-authorization was 
required for the services received. You say that the providers office should have known to get a pre-
authorization. The Plan denied your request. The Plan says this service is not covered under your 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. Radiographic/surgical implant 
index, by report (D6190) is not covered under the Plans dental benefits. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D6190 is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
radiographic/surgical implant index, by report (D6190) provided on January 17, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 81345 provided on September 22, 2022. 
 
You asked the Plan to pay for procedure code 81345. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the claim for this molecular pathology 
testing did not include the required unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of procedure code 81345 
have been met. Therefore, we decided that the Plan has to pay for procedure code 81345 provided on 
September 22, 2022.  
 
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 pay for the dental services (D4921) on November 18, 2022. 
 
You asked the Plan to pay for the dental service (D4921). You say that you would like to request 
reconsideration of the denied claim. The Plan denied your request. The Plan says the dental service (D4921) 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 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 dental 
services (D4921) on November 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87486 and 87496 billed for date of service 
August 25, 2020. 
 
You asked the Plan to pay for procedure codes 87486 and 87496. You say that these services were necessary 
and are supported in the medical record. The Plan denied your request. The Plan says the payment for codes 
87486 and 87496 is included in the payment for code 87150. Although code 87486 was billed with a modifier 
for separate payment, the modifier is not supported in the medical record. 
 
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 87486 and 87496 are both column II codes to column I code 87150; 
however, 87486 was billed with a modifier. Code 87496 has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met for code 87496. 
 
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 87486. Our reviewer says that modifier XU 
is not supported with code 87486. Our reviewer found the laboratory report does not support an unusual non-
over lapping service to meet the criteria for modifier XU. 
 
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 87486 and 87496 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 87486 and 87496 billed for date of service August 25, 
2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on August 8, 2022. 
 You asked the Plan to pay for ambulance services. The Plan denied your request. The Plan says Original 
Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for ambulance services provided on August 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections. 
 
You asked the Plan to pre-approve facet joint injections. You say that the requested facet joint injections are 
medically necessary. The Plan denied your request. The Plan says the requested facet joint injections do not 
meet the Medicare LCD coverage criteria. 
 
The Plan follows Medicare rules.  
 
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 facet joint injections. Our reviewer says 
that the requested facet joint injections are not considered medically necessary in this case. Our physician 
reviewer found that in this case, the documentation does not show moderate to severe axial back pain of at least 
three months duration with a documented failure to respond to conservative care. The review has determined  
the requested facet joint injections do not meet the Medicare LCD coverage criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97010 billed for date of service November 
30, 2022. 
 
You asked the Plan to pay for procedure code 97010. You say that you had authorization on file for this date of 
service. The Plan denied your request. The Plan says procedure code 97010 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 97010 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 97010 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 97010 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 97010 billed for date of service November 30, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87634 billed for date of service October 27, 
2022. 
 
You asked the Plan to pay for procedure code 87634. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 87634 is bundled into payment for code 87798. 
 
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 87634 
is a column II code to column I code 87798. This claim has not been billed with an appropriate modifier to 
bypass the edit. The -59 modifier is not supported as a separate and distinct procedural service. 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 87634 billed for date of service October 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture treatments (97810 x 7) provided from  
June 9, 2022, through October 13, 2022. Additionally, the Plan does not have to waive the copayments for the 
chiropractic manipulative treatments (98940 x 60) provided from April 4, 2022, through October 13, 2022. 
 
You asked the Plan to pay for the acupuncture treatments. Additionally, you asked the Plan to waive the 
copayments applied to the chiropractic manipulative treatments provided. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says you have 
exhausted the allowable benefit for the acupuncture services provided. Additionally, the copayments have been 
applied correctly to the chiropractic manipulative treatments provided. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
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 $10 
copayment for each chiropractic specialists office visit.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the additional acupuncture services provided have not been met. Specifically, Medicare rules allow for 20 
acupuncture visits per year. The Plan recently approved payment for 20 acupuncture visits provided; therefore, 
you have exhausted the allowable benefit for these services. Additionally, you were asked to pay $600  
($10 copayment x 60 visits) for the chiropractic manipulative treatments provided. 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. The Plan issued payment for the chiropractic 
services at the maximum allowable fee per service with the deduction of the applicable copayments. Therefore, 
we decided that the Plan does not have to pay for the acupuncture treatments (97810 x 7) provided from June 9, 
2022, through October 13, 2022. Additionally, the Plan does not have to waive the copayments for the 
chiropractic manipulative treatments (98940 x 60) provided from April 4, 2022, through October 13, 2022.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cataract surgery services (66984).

You asked the Plan to pre-approve cataract surgery. You say that the requested services are a medical necessity for the enrollee. The Plan denied your request. The Plan says the requested services are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met.

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 cataract surgery have been met.
Specifically, no medical records establishing the medical necessity of the requested services have been provided for review. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pre-approve cataract surgery services (66984).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97010 billed for date of service November 
30, 2022. 
 
You asked the Plan to pay for procedure code 97010. You say that these services were pre-approved for three 
visits. The Plan denied your request. The Plan says they have agreed to pay for the other therapy services; 
however, procedure code 97010 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 97010 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 97010 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 97010 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 97010 billed for date of service November 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99053 billed for date of service September 
14, 2022. 
 
You asked the Plan to pay for procedure code 99053. You say that the claim should be paid. The Plan denied 
your request. The Plan says procedure code 99053 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 99053 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99053 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99053 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99053 billed for date of service September 14, 2022.