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

 
We decided that the Plan does not have to pay for procedure code 87493 and 87641 billed for date of service 
March 10, 2023. 
 
You asked the Plan to pay for the billed services. You say that the coding and diagnoses are approved by 
Medicare. The Plan denied your request. The Plan says the billed services cannot be verified. 
 
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 87493 is infectious agent detection by nucleic acid (DNA 
or RNA); Clostridium difficile, toxin gene(s), amplified probe technique. The CPT Code Manual definition of 
code 87641 is infectious agent detection by nucleic acid (DNA or RNA); Staphylococcus aureus, methicillin 
resistant, amplified probe technique. 
 
The file shows that a wound panel test was provided. We find that CPT codes 87493 and 87641 are not 
supported in the medical record. Based on this information, we decided that Medicare rules for coverage of the 
billed services have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
87493 and 87641 billed for date of service March 10, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87496, 87498, 87502, and 87532 billed for 
date of service January 31, 2023. 
 
You asked the Plan to pay for the billed services. You say that the testing was medically necessary. The Plan 
denied your request. The Plan says only one code should be submitted for all targets.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the panel testing was not billed with a single code as required. Based on this information, we 
decided that Medicare rules for coverage of the billed services have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure codes 87496, 87498, 87502, and 87532 billed for date of service 
January 31, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on August 3, 2022. 
 
You asked the Plan to pay for the dental services. You say that you thought the provider was in network. 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 dental services provided on August 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99203) provided on May 16, 2023. 
 
You asked the Plan to pay for this 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.  
 
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 service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit (99203) provided on May 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal scaling and root planing (D4341) on 3 
quadrants provided on January 17, 2023, and January 23, 2023 . 
 
You asked the Plan to pay for the dental services. You say that you went to the dentist for a checkup, and you 
were not told that the Plan would not cover the visit. The Plan denied your request. The Plan says your benefit 
for the requested items or services 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 the periodontal scaling and root planing (D4342) for the same 3 quadrants on February 
9, 2021, and February 15, 2021; therefore, your benefit for the requested items or services was exhausted on 
the dates of service of February 9, 2021, and February 15, 2021. Therefore, we decided that the Plan does not 
have to pay for the periodontal scaling and root planing (D4341) on 3 quadrants provided on January 17, 2023, 
and January 23, 2023 .
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88374 billed for date of service March 9, 
2023.  
 
You asked the Plan to pay for procedure code 88374. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the number of units billed exceeds the 
maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 88374 is 5. The MAI value for this code is 3. You billed 8 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
medically necessary. Based on this information, we decided that Medicare rules for coverage of procedure code 
88374 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 88374 
billed for date of service March 9, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from August 10, 2023, 
forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from August 10, 2023, forward. You say that the 
services at issue were medically necessary. The Plan denied your request. The Plan says the services at issue 
were not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric care from August 
10, 2023, forward. Our reviewer says that the enrollee does not meet the criteria for treatment in an acute 
inpatient mental health treatment beyond the date in question of August 10, 2023, forward. Our physician 
reviewer found the enrollee did not require inpatient mental health treatment beyond August 10, 2023, as she 
was not a danger to herself or others and did not have any delusions, auditory or visual hallucinations. It did not 
appear that active treatment was taking place beyond the date in question. It did not appear that the services for 
the dates in question were reasonably expected or medically necessary to improve the enrollees condition or 
for the purpose of diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care from August 10, 2023, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from August 10, 
2023, forward.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic radiographic image (D0330) provided on May 
5, 2023. 
 
You asked the Plan to pay 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 your benefit for the requested item or service has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service June 2, 2021. Therefore, 
we decided that the Plan does not have to pay for a panoramic radiographic image (D0330) provided on May 5, 
2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87899 and 87900 billed for date of service 
August 26, 2022. 
 
You asked the Plan to pay for the billed services. You say that the test was ordered based on medical necessity. 
The Plan denied your request. The Plan says the billed codes 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 87899 is infectious agent antigen detection by 
immunoassay with direct optical (i.e., visual) observation; not otherwise specified. The CPT Code Manual 
definition of code 87900 is infectious agent drug susceptibility phenotype prediction using regularly updated 
genotypic bioinformatics. 
 
We find that CPT codes 87899 and 87900 are not supported in the medical record. The medical records do not 
include the codes as billed. Based on this information, we decided that Medicare rules for coverage of the 
billed services have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 
87899 and 87900 billed for date of service August 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and the 
panoramic radiographic image (D0330) provided on April 7, 2023. 
 
You asked the Plan to pay 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 your benefit for the services provided 
has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  
 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the services provided was exhausted on date of service January 18, 2023. Specifically, 
the Plans contract states that a comprehensive oral evaluation and a panoramic radiographic image are covered 
once every three years. A panoramic radiographic image is not covered when received within three years of an 
intraoral-complete series of radiographic images. You previously received a comprehensive oral evaluation and 
an intraoral-complete series of radiographic images on January 18, 2023, less than three years prior, which 
were paid for by the Plan. Therefore, you have exhausted the allowable benefit for the services provided in this 
case. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) 
and the panoramic radiographic image (D0330) provided on April 7, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc. 
 
You asked the Plan to pre-approve Synvisc . You say that this is medically necessary. The Plan denied your 
request. The Plan says based on Medicare guidelines and the information we have about your condition, you 
don't meet all the requirements for additional treatment. The requirements are: (1) Your last injection was at 
least six months ago. And (2) after the last injection you have less pain so you're able to function better. Based 
on the information available to us, you do not meet the following: Your last injection was at least six months 
ago. After the last injection you have less pain so you're able to function better. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Synvisc. Our reviewer says that service is not medically necessary. Our physician reviewer found the enrollee had a Synvisc-One injection in April 2023 which provided minimal relief. The review has determined that the documentation does not support that Synvisc-One is medically reasonable or necessary for the enrollee. The documentation does not support that the Synvisc-One is safe and effective for the enrollee. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Synvisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Synvisc.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for porcelain/ceramic crowns (D2740) for teeth numbers 27 and 
28 provided on October 11, 2022. 
 
You asked the Plan to pay for porcelain/ceramic crowns (D2740) for teeth numbers 27 and 28. You say that 
you are appealing with supporting records. The Plan denied your request. The Plan says your dental plan does 
not cover services to treat the effects of tooth wear. 
 
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 porcelain/ceramic crowns (D2740) for 
teeth numbers 27 and 28 have been met. The record shows the Plan requested medical records several times. 
The medical records, including x-rays and provider narrative, were not received. Therefore, we decided that the 
Plan does not have to pay for porcelain/ceramic crowns (D2740) for teeth numbers 27 and 28 provided on 
October 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an abutment supported crown (D6059). 
 
You asked the Plan to pre-approve an abutment supported crown. You say that the service is necessary. The 
Plan denied your request. The Plan says the requested 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 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 an 
abutment supported crown (D6059).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for a determination of refractive state (92015) provided on April 
4, 2023. 
 
You asked the Plan to pay for a determination of refractive state (92015). You say that the provider should 
have told you that the insurance would not cover this test for a determination of refractive state (92015) before 
the test was done. The Plan denied your request. The Plan says that it was confirmed that the services received 
were not for a routine eye examination, but rather for an eye condition according to the providers diagnosis. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when they are part of a routine eye examination. 
 
We looked at the file and the Plan's rules. The Plan rules say that Original Medicare does not cover routine eye 
examinations (eye refractions) for eyeglasses/contacts. The Plan rules also say that the Plan covers one routine 
vision examination per year (including eye refraction for eyeglasses/contact lenses). The record shows that this 
was a medical/diagnostic examination and refraction. Based on this information, we decided that the Plan's 
rules for coverage of a determination of refractive state (92015) have not been met. Therefore, we decided that 
the Plan does not have to pay for a determination of refractive state (92015) provided on April 4, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on May 22, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you did 
not call 911 and you should not be responsible for the bill. You also say that the only thing the ambulance crew 
did was help you get up and no transportation was provided. 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 Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on May 22, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on May 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture treatments (97813, 97814) provided from 
January 19, 2023, through February 3, 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 the services at issue are not payable as the 
provider is not enrolled in the Medicare program.  
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
A review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the acupuncture treatments (97813, 
97814) provided from January 19, 2023, through February 3, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services billed with codes 81225, 91335, 981241, and 
81291 provided on September 21, 2021. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the denial. 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 the lab services billed with codes 81225, 91335, 981241, and 81291 provided 
on September 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on January 24, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were unaware that this dentist was out-of-
network. 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 dental services provided on January 24, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder test (0012M) provided on January 30, 2023. 
 
You asked the Plan to pay for the Cxbladder test. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for CxBladder are non-
covered. 
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the Cxbladder test have not been met. Therefore, we decided that 
the Plan does not have to pay for the Cxbladder test (0012M) provided on January 30, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on April 4, 2023. 
 
You asked the Plan to pay for the dental services. You say that you are retired and 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 annual dental allowance amount was exhausted on date of service February 8, 2023. Therefore, we 
decided that the Plan does not have to pay for dental services provided on April 4, 2023.