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

 
We decided that the Plan does not have to pay for core build-ups (D2950) provided on May 19, 2023. 
 
You asked the Plan to pay for D2950. You say that these services should be covered. The Plan denied your 
request. The Plan says the denied dental service is not a covered dental 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 core 
build-ups (D2950) provided on May 19, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2740) for tooth #14 provided on March 2, 2023. 
 
You asked the Plan to pay for the dental service. You say that you were unaware that the tooth in question had 
been worked on 2 years ago and needed repairing again. 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 the Plan paid for a crown (D2740) for tooth #14 on December 21, 2020; therefore, your benefit for the 
requested item or service was exhausted on the date of service of December 21, 2020. Therefore, we decided 
that the Plan does not have to pay for a crown (D2740) for tooth #14 provided on March 2, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound therapy (97035), electric stimulation therapy 
(97014), and the x-ray exam of the lumbosacral spine (72100) provided from April 17, 2023, through May 8, 
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 ultrasound therapy (97035), electric stimulation therapy (97014), and 
the x-ray exam of the lumbosacral spine (72100) provided from April 17, 2023, through May 8, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the thorax. 
 
You asked the Plan to pre-approve the CT scan. You say that the records provided support medical necessity. 
The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
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 
service is not medically necessary. Our physician reviewer found the enrollee is considered high risk due to 
smoking history. The 2 small nodules mentioned are less than 6 mm in diameter. According to the Fleischner 
Society guidelines, the surveillance period for a high-risk patient with 2 nodules each less than 6 mm in 
diameter is a 12 month repeat CT. 
 
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 tomography (CT) scan of the thorax.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung 
cancer screening. 
 
You asked the Plan to pre-approve the requested LDCT scan. You say that the enrollee meets criteria for 
coverage of the scan. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung 
cancer screening for enrollees who meet all the criteria described in the Medicare rules section of this letter.  
 
We reviewed the file and the Medicare rules. We find that the enrollee does not have a smoking history of at 
least 20 pack-years. Therefore, we decided that the Plan does not have to pre-approve a low dose computed 
tomography (LDCT) scan for lung cancer screening.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care services provided on March 19, 2022. 
 You asked the Plan to pay for the critical care services. You say that the services were medically necessary. 
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 critical care services provided on March 19, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the procedure codes A7035, A7034, A7032, A7038, A7037 
rendered on August 9, 2022. 
 You asked the Plan to pay for the procedure codes A7035, A7034, A7032, A7038, A7037. You say that that 
you have made corrections to the claim and ask that it be reprocessed. 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 the procedure codes A7035, A7034, A7032, A7038, A7037 
rendered on August 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a comprehensive oral evaluation, intraoral x-ray, 
bitewing x-ray, panoramic x-ray, 2D oral/facial photographic image, and pulp vitality tests (D0150, D0220, 
D0230, D0274, D0330, D0350, D0460 and D1110) provided on May 9, 2023. 
 
You asked the Plan to pay more for the dental services. You say that the services should be covered as you 
disagree with the charges. 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 a comprehensive oral evaluation, intraoral x-
ray, bitewing x-ray, panoramic x-ray, 2D oral/facial photographic image, and pulp vitality tests (D0150, 
D0220, D0230, D0274, D0330, D0350, D0460 and D1110) provided on May 9, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for an apicoectomy (D3410), a bone replacement graft 
(D4263), diagnostic service consultation (D9310), and inhalation of nitrous oxide (D9230), provided on April 
27, 2023, to May 4, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you disagree with these charges. 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 an apicoectomy (D3410), a bone 
replacement graft (D4263), diagnostic service consultation (D9310), and inhalation of nitrous oxide (D9230), 
provided on April 27, 2023, to May 4, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine. 
 
You asked the Plan to pre-approve the MRI. You say that the records provided support medical necessity. The 
Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found neuro exam was negative. Referral to 
neurology has been made but no notes of in the records. No report from plain films of the lumbar spine. Patient 
has no back pain. The medical necessity of the requested MRI lumbar spine has not been established in the 
submitted records. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve magnetic resonance imaging (MRI) of the lumbar spine.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital services provided on April 18, 2023. 
 You asked the Plan to pay for the hospital services. You say that the services were medically necessary. 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 hospital services provided on April 18, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial nursing facility care provided on November 11, 
2021. 
 
You asked the Plan to pay for the initial nursing facility care. You say that the claim was filed timely. The Plan 
denied your request. The Plan says the claim was filed untimely without good cause on February 3, 2023. 
 
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 initial nursing facility care was not filed until February 3, 2023. This means 
that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the initial nursing facility care provided on November 11, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a psychiatric evaluation provided on August 19, 2022. 
 You asked the Plan to pay for the psychiatric evaluation. You say that the hospital staff is responsible for 
obtaining authorization. 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 a psychiatric evaluation provided on August 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 1, 2022, billed with 
codes 87481, 87491, 87500, 87563, 87640, 87641, 87653, and 87798. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing should be paid as billed.  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 testing for multiple pathogens by nucleic 
acid 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 1, 2022, billed with codes 87481, 87491, 87500, 
87563, 87640, 87641, 87653, and 87798.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 93923 and 95924 rendered on December 27, 
2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. 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 the denied codes is: 
 
CPT 93923: 
 
Complete bilateral noninvasive physiologic studies of upper or lower extremity arteries, 3 or more levels (eg, for lower extremity: ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries 
plus segmental blood pressure measurements with bidirectional Doppler waveform recording and analysis, at 3 
or more levels, or ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus 
segmental volume plethysmography at 3 or more levels, or ankle/brachial indices at distal posterior tibial and 
anterior tibial/dorsalis pedis arteries plus segmental transcutaneous oxygen tension measurements at 3 or more 
levels), or single level study with provocative functional maneuvers (eg, measurements with postural 
provocative tests, or measurements with reactive hyperemia) 
 
CPT 95924: 
 
Testing of autonomic nervous system function; combined parasympathetic and sympathetic adrenergic function 
testing with at least 5 minutes of passive tilt 
 
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 procedure report does not 
include documentation of the procedures billed. 
 
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 procedure codes 93923 and 95924 rendered on December 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial hospital services provided on April 21, 2023, 
billed with code 99222. 
 
You asked the Plan to pay for the initial hospital care. You say that Medicare pays for this code in the 
emergency department (ED) place of service. The Plan denied your request. The Plan says this code cannot be 
paid in POS 23.  
 
The Plan must follow Medicare rules. Medicare rules say that services provided to registered inpatients should 
be billed with the inpatient hospital POS code.  
 
 We looked at the file and Medicare rules. The records do not support that the enrollee was in the ED when 
these services were rendered. The progress note indicates that the enrollee was in the medical intensive care 
unit (MICU), which would be an inpatient hospital POS. Based on this information, we decided that Medicare 
rules for coverage of the initial hospital care have not been met. Therefore, we decided that the Plan does not 
have to pay for the initial hospital services provided on April 21, 2023, billed with code 99222.
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 admission to an IRF is medically necessary. The 
Plan denied your request. The Plan says the enrollee does not meet all the requirements for admission to an 
IRF.  
 
 
 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 does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  There are no 
complex nursing or rehabilitation needs. 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 record supports a need for physical therapy and/or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. 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.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on November 21, 2022, billed 
with codes 36246 and 75710. 
 
You asked the Plan to pay for the services as billed. You say that these services are supported and should be 
paid.  The Plan denied your request. The Plan says the codes are included with the main procedure. 
 
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 36246 is selective catheter placement into the arterial 
system; for the initial second order abdominal, pelvic, or lower extremity artery branch, within a vascular 
family. The definition of 75710 is angiography for a unilateral extremity with radiological supervision and 
interpretation. 
 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 these codes are 
not supported.  Our reviewer found the procedure report documents catheter placement and extremity 
angiography; however, the intervention performed is more comprehensive and includes these other services. 
 
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 medical services provided on November 21, 2022, billed with codes 36246 and 
75710.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on May 
15, 2023. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you should not be charged 
for a pacemaker check. 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 $25 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $25 copayment for a specialist office visit. This item/service falls within the 
physician/practitioner services, including doctors office visits 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 specialist office visit provided on May 15, 2023.