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

 
We decided that the Plan does not have to pay more for the intraoral-periapical first radiographic images 
(D0220 x 3), periodic oral evaluation (D0120), dental cleaning (D1110), bitewing x-rays-four radiographic 
images (D0274), and the topical application of fluoride varnish (D1206) provided on August 14, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. 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. Additionally, you have exhausted the allowable benefit for the intraoral x-rays provided.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
  
 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Additionally, you have exhausted the allowable benefit for the intraoral x-rays provided in this case. 
Specifically, the Plans contract states that one intraoral x-ray is covered per calendar year. On this day, you 
received three intraoral x-rays, in which one was paid for by the Plan. Therefore, you have exhausted the 
allowable benefit for this service. Therefore, we decided that the Plan does not have to pay more for the 
intraoral-periapical first radiographic images (D0220 x 3), periodic oral evaluation (D0120), dental cleaning 
(D1110), bitewing x-rays-four radiographic images (D0274), and the topical application of fluoride varnish 
(D1206) provided on August 14, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the screening cytopathology, cervical or vaginal (G0145) 
provided July 27, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that you are asking for reconsideration of paying 
the $69.18. You are on a fixed income and cannot pay it. 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).  

You have been asked to pay $69.18 for the laboratory services. These rules say that enrollees are eligible for 
coverage of Pap tests and pelvic exams once every 24 months. Based on review of the file, this service was 
provided less than 24 months prior to the visit at issue in this case. The records show that the Plan had paid for 
procedure code G0145 on July 10, 2022, for date of service June 30, 2022. This item/service falls within the 
Cervical and vaginal cancer screening 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 pay for the screening 
cytopathology, cervical or vaginal (G0145) provided July 27, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 6, 2023, billed with 
codes 81279, 81321, 81339 and 81345. 
 
You asked the Plan to pay for the genetic testing billed. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says panel testing should be billed using one CPT code on 
the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code.  

We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
June 6, 2023, billed with codes 81279, 81321, 81339 and 81345.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services (Bimatoprost 0.01% drop 2.5 ml 
drop bottle) performed from February 18, 2023, to February 20, 2023. 
 
You asked the Plan to pay for the services. You say that you are appealing the partial adjustment recoupment. 
The Plan denied your request. The Plan says the itemized bill was received, and a review was completed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
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. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the medical records does not 
include sufficient documentation to confirm the medication and charges submitted. The enrollee was 
administered Bimatoprost 0.01% drop 2.5ml drop bottle per physician order Bimatoprost 0.01%, for 1 drop 
each eye at night. Since the medication is in a multi-dose bottle, billing an additional bottle is not support in the 
medical record. One bottle for 18 days of treatment is appropriate. The enrollee would not require additional 
bottles.  
 
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 have not been met. Therefore, we decided that the Plan does not 
have to pay for inpatient hospital services (Bimatoprost 0.01% drop 2.5 ml drop bottle) performed from 
February 18, 2023, to February 20, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 52352 and 52332 provided on July 20, 
2023. 
 
You asked the Plan to pay for procedure codes 52352 and 52332. 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 supported. 
 
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 procedure codes 52352 and 52332 
have been met. In this case, the documentation submitted for review did not include a procedure report to 
verify the services billed. Therefore, we decided that the Plan does not have to pay for procedure codes 52352 
and 52332 provided on July 20, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a partial mandibular denture (D5226) provided on June 20, 
2023. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for this. The Plan 
denied your request. The Plan says your annual dental allowance amount 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 July 20, 2023. The Plan processes claims as they are received. The claim for July 20, 2023, was processed prior to the claim for June 
20, 2023. Therefore, we decided that the Plan does not have to pay for a partial mandibular denture (D5226) 
provided on June 20, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomographic (CT) scan of blood vessels and 
grafts of the heart with contrast. 
 
You asked the Plan to pre-approve the CT scan. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet the criteria for approval. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
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 CT scan. Our reviewer says that the 
CT scan is not medically necessary. Our physician reviewer found the stress test performed was negative for 
ischemia. Clinical guidelines for the use of a CT scan have not been met based on review of the submitted 
clinical documentation. As a result, at this time the CT imaging would not be considered 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 the CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a computed tomographic (CT) scan of blood vessels and grafts of the heart with contrast.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cone beam computed tomography (CT) scan (D0364), 
retreatment of previous root canal therapy - molar for tooth #3 (D3348), and intraorifice barrier for tooth #3 
(D3911). 
 
You asked the Plan to pre-approve a cone beam CT scan, retreatment of previous root canal therapy - molar for 
tooth #3, and intraorifice barrier for tooth #3. You say that the services are necessary. The Plan denied your 
request. The Plan says the requested cone beam CT scan is not a covered benefit. Retreatment of previous root 
canal therapy and intraorifice barrier are not covered when not billed in conjunction with a root canal 
procedure. 
 
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 a 
cone beam computed tomography (CT) scan (D0364), retreatment of previous root canal therapy - molar for 
tooth #3 (D3348), and intraorifice barrier for tooth #3 (D3911).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950) 
provided on June 27, 2023. 
 
You asked the Plan to pay for this dental service. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says this service 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 service provided is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the core buildup, 
including any pins when required (D2950) provided on June 27, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6530. 
 
You asked the Plan to pre-approve the compression stockings. You say that you were told your gradient 
compression stockings 18-30mmhg, CPT A6530, would be covered. You also say that you then received a call 
from the provider stating they weren't covered and had you known this you would not have made the 
appointment to get measured and have them ordered. The Plan denied your request. The Plan says gradient 
compression stockings as noncovered under the surgical dressing benefit.  
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6530.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept basivertebral nerve ablation. 
 
You asked the Plan to pre-approve the Intracept basivertebral nerve ablation. You say that the enrollee's 
primary problem is chronic low back pain due to degenerative disc disease that has resulted in the development 
of vertebrogenic pain identified by degenerative endplates changes frequently known by the eponym modic on 
their magnetic resonance imaging (MRI). The Plan denied your request. The Plan says the Intracept 
basivertebral nerve ablation is 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 the Intracept basivertebral nerve 
ablation. Our reviewer says that the Intracept basivertebral nerve ablation is not medically necessary. Our 
physician reviewer found that there is no MRI showing only modic changes without facet degenerative joint 
disease. Also, the pain is not clear, and the coverage criteria has not been met. 
 
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 Intracept basivertebral nerve ablation have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the Intracept basivertebral nerve ablation.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve arthroscopy of the knee. 
 You asked the Plan to pre-approve arthroscopy of the knee. You say that the enrollee is experiencing 
mechanical symptoms and limitation of their ability to perform daily activities. The Plan denied your request. 
The Plan says the procedure requested does not meet the criteria necessary for approval. 
 
The Plan must follow Medicare rules. Medicare rules say that the requested procedure is not considered 
reasonable or necessary.  
 
We looked at the file and Medicare rules. The rules say an arthroscopic debridement of the knee is not 
reasonable or necessary. Based on this information, we decided that Medicare rules for coverage of arthroscopy 
of the knee have not been met. Therefore, we decided that the Plan does not have to pre-approve arthroscopy of 
the knee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for guided tissue regeneration and bone replacement graft 
(D7953, D4267) provided on June 26, 2023. 
 
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 the 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, 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 guided 
tissue regeneration and bone replacement graft (D7953, D4267) provided on June 26, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on September 1, 2023. 
 
You asked the Plan to pay for the lab services. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for 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 the lab 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 lab services provided on September 1, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is necessary. The Plan denied your request. 
The Plan says IRF care is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical, and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. While the medical records support a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. There is not a 
reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. Medically necessary care can be provided in a different 
level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown - porcelain/ceramic (D2740) provided on June 27, 
2023. 
 
You asked the Plan to pay for the crown - porcelain/ceramic. You say that at some point you were advised that 
crowns would be covered, but the claim was denied. The Plan denied your request. The Plan says coverage is 
provided for only stainless steel crowns. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested service is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the crown - 
porcelain/ceramic (D2740) provided on June 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup (D2950) for tooth #3, #4, #28, and #29 
provided on July 12, 2023. 
 
You asked the Plan to pay for the dental services. You say that the providers office presented you with a dental 
printout and you thought it was approved by the Plan. The Plan denied your request. The Plan says the denial 
of payment for these services is correct because the core buildup is not covered by the Plan. Also, it was 
confirmed that neither you nor the provider contacted the Plan prior to verify the proper 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 pay for the core 
buildup (D2950) for tooth #3, #4, #28, and #29 provided on July 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacroiliac joint injection. 
 
You asked the Plan to pre-approve a sacroiliac joint injection. 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 sacroiliac joint injections (SIJI) will be considered 
medically reasonable and necessary when certain requirements are met. 
 
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 a sacroiliac joint injection. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found only one test is 
documented. Therefore, the request does not meet the criteria and at this point, 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 a sacroiliac joint injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a sacroiliac joint injection.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for fillings (D2391, D2330) provided on July 7, 2023. 
 
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 the dental services were received from an out-of-
network provider and are not covered by your supplemental 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. 
 
 
  The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for fillings (D2391, D2330) provided on July 7, 2023.