Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture treatments (97810 x 2, 97811 x 2) provided 
from June 17, 2022, to June 22, 2022. 
 
You asked the Plan to pay for the acupuncture services. You say that your claims were denied incorrectly, and 
you have not reached your benefit limit. The Plan denied your request. The Plan says your benefit for the 
requested item or service has already been exhausted. 
 
  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.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, your benefit for acupuncture services has already 
been exhausted. Therefore, we decided that the Plan does not have to pay for the acupuncture treatments 
(97810 x 2, 97811 x 2) provided from June 17, 2022, to June 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87640, 87641, 87651, and 87798, billed for 
date of service September 1, 2023. 
 You asked the Plan to pay for procedure codes 87640, 87641, 87651, and 87798. The Plan denied your request. 
The Plan says payment for codes 87640, 87641, 87651, and 87798, is bundled into payment for code 87801. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that codes 
87640, 87641, 87651, and 87798 are column II codes to column I code 87801. This claim has not been billed 
with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have 
not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 87640, 87641, 
87651, and 87798, billed for date of service September 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0463 provided on September 14, 2023, by 
an out-of-network (OON) provider.  
 
You asked the Plan to pay for procedure code G0463. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent 
nor urgent and prior authorization was not obtained to provide out-of-network care. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for procedure code G0463 provided on September 14, 
2023, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit (99213) provided on May 9, 2023, 
by an out-of-network (OON) provider.  
 You asked the Plan to pay for the outpatient office visit. You say that you are requesting this claim be 
reprocessed and paid due to the enrollee's circumstances. The Plan denied your request. The Plan says the 
services are not authorized because the treating provider is a non-network provider who does not work with the 
enrollees health plan, and the enrollee self-directed for care. The Plan also says the enrollee's primary care 
provider did not refer for services, and no medical necessity for an OON provider, such as an urgent or 
emergency situation, has been documented. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the outpatient office visit (99213) provided on 
May 9, 2023, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cone beam CT capture and interpretation with limited 
field of view  less than one whole jaw (D0364), and pulp vitality tests (D0460) provided on August 9, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were charged incorrectly for the services 
rendered. You also say that you believe the dental office charged the incorrect codes. The Plan denied your 
request. The Plan says these services are 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. 
 
 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the cone beam 
CT capture and interpretation with limited field of view  less than one whole jaw (D0364), and pulp vitality 
tests (D0460) provided on August 9, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prefabricated abutment (D6056) for teeth 29 and 30, and 
abutment supported porcelain fused to metal crown (D6059) for teeth 29 and 30. 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing with supporting records. 
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 with the authorization of 
prefabricated abutment (D6056) for teeth 19 and 20, and abutment supported porcelain fused to metal crown 
(D6059) for teeth 19 and 20 on November 1, 2023. Therefore, we decided that the Plan does not have to pre-
approve prefabricated abutment (D6056) for teeth 29 and 30, and abutment supported porcelain fused to metal 
crown (D6059) for teeth 29 and 30.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 1 standard power wheelchair (K0814). 
 
  You asked the Plan to pre-approve a Group 1 standard power wheelchair. You say that you believe your life 
quality can be increased with this wheelchair since you would be able to get out of your home without being 
worried about falling due to the weakness in your legs. The Plan denied your request. The Plan says a required 
home assessment to evaluate the feasibility of a power mobility device in your living environment has yet to be 
completed. 
 
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. Medicare rules also say that prior to or at the time of delivery of a POV or PWC, the supplier or 
practitioner must perform an on-site evaluation of the beneficiarys home to verify that the beneficiary can 
adequately maneuver the device that is provided. 
 
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 Group 1 standard power wheelchair 
have been met. Specifically, a home assessment which is required for coverage was not submitted with this 
case. Therefore, we decided that the Plan does not have to pre-approve a Group 1 standard power wheelchair 
(K0814).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bitewing x-rays-four radiographic images (D0274) 
provided on August 30, 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 your benefit for the service 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 service provided was exhausted on date of service February 15, 2023.  
  
 
Specifically, the Plans contract states that one set of bitewing x-rays are covered per plan year. You previously 
received this service on February 15, 2023, less than one year prior, which 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 for the bitewing x-rays-four radiographic images (D0274) provided on August 30, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 very heavy duty powered operated vehicle 
(scooter) (K0808). 
 
You asked the Plan to pre-approve a group 2 very heavy duty powered operated vehicle (scooter). 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 power mobility devices are covered when specific 
criteria 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 group 2 very heavy duty powered 
operated vehicle (scooter). Our reviewer says that the services are not medically necessary. Our physician 
reviewer found provided records in this case do not document that you have a personal mobility deficit that 
impairs participation in mobility related activities of daily living such as toileting, feeding, grooming and 
bathing in customary locations within the home. Based on the medical records provided there is no 
documentation that your mobility deficit cannot be helped by the use of a walker, cane or manual wheelchair. 
There is no documentation that you can safely operate a power mobility device. Records do not document your 
home provides adequate access between rooms, maneuvering space, and surfaces for the operation of the 
scooter that is being request. Records do not document you have a weight of 428  600 pounds to meet criteria 
for the very heavy duty powered operated vehicle.  
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 group 2 very heavy duty powered operated vehicle (scooter) have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a group 2 very heavy duty powered 
operated vehicle (scooter) (K0808).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99070 billed for date of service August 4, 
2023. 
 
You asked the Plan to pay for procedure code 99070. You say that this should be paid for. The Plan denied 
your request. The Plan says procedure code 99070 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 99070 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99070 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99070 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99070 billed for date of service August 4, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dispensing fee, of a monaural hearing aid, any type 
(D5241) provided on July 26, 2023. 
 
You asked the Plan to pay for the dispensing fee. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says the dispensing fee is not payable as the 
hearing aid in this case was rendered by an out-of-network provider.  
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case.  
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the dispensing fee applied have not been met. Specifically, the Plans contract states that hearing 
aids/services are only covered when rendered by the Plans select hearing aid provider. However, the hearing 
aid in this case was rendered by an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for the dispensing fee, of a monaural hearing aid, any type (D5241) provided on July 26, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a consultation provided on August 3, 2023. 
 
You asked the Plan to pay for a consultation. You say that this was medically necessary. The Plan denied your 
request. The Plan says this is not a covered service. 
 
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 a 
consultation provided on August 3, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prophylaxis - adult (D1110) provided on August 31, 
2023. 
 
You asked the Plan to pay for the prophylaxis - adult. You say that the benefits guide does not specify the 
frequency of service for routing dental services. You also say that you would like your $120 refunded and 
would like a clear, easy way to find information about dental benefits on the patient portal. The Plan denied 
your request. The Plan says your benefit for the requested 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 service was exhausted on dates of service February 16, 2023, and May 25, 
2023. Therefore, we decided that the Plan does not have to pay for the prophylaxis - adult (D1110) provided on 
August 31, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 24-hour in-home personal care. 
 
You asked the Plan to pre-approve the custodial care services. You say that you are appealing the denied 
services. The Plan denied your request. The Plan says the requested services are not covered by Medicare or 
the Plan. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the custodial care services have not been met. Specifically, we find that the services at issue in this 
case are considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve 24-
hour in-home personal care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics.  
 
You asked the Plan to pre-approve foot orthotics. You say that because of a surgery you experience pain in 
your foot and the orthotics are medically necessary. The Plan denied your request. The Plan says this item is 
not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
  Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home delivered meals. 
 
You asked the Plan to pre-approve home delivered meals. You say that meal preparation is a challenge as your 
strength, while continuing to heal, is at a low level. You also say your spouse has been diagnosed with 
osteoarthritis in the right knee. The Plan denied your request. The Plan says the member has received the 
maximum benefit for 2023. 
 The Plan must follow Medicare rules. Medicare rules say that meals may be offered as a supplemental benefit 
immediately following surgery or an inpatient hospital stay, or for a chronic condition, for a temporary period.  
 
We looked at the file and Medicare rules. The record shows the benefit for this service was exhausted from 
June 8, 2023, to June 29, 2023. Based on this information, we decided that Medicare rules for coverage of 
home delivered meals have not been met. Therefore, we decided that the Plan does not have to pre-approve 
home delivered meals.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for complete denture- maxillary (D5110) and mandibular partial 
denture (D5214) provided on August 21, 2023. 
 
You asked the Plan to pay for complete denture- maxillary and mandibular partial denture. You say that this 
should be covered. The Plan denied your request. The Plan says this is not a covered service. 
 
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 complete 
denture- maxillary (D5110) and mandibular partial denture (D5214) provided on August 21, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal scaling and root planing (D4341) provided on 
September 6, 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 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 March 7, 2023. 
Therefore, we decided that the Plan does not have to pay for periodontal scaling and root planing (D4341) 
provided on September 6, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing (0359U) provided on July 27, 2023. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this 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 pay for the testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there was no documentation provided indicating why the enrollee could not undergo prostate biopsy. 
The review has determined that the requested testing in this case was 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 the testing have not been met. Therefore, we decided that the Plan does not have 
to pay for the testing (0359U) provided on July 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an occlusal guard (D9944) provided on September 18, 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 an 
occlusal guard (D9944) provided on September 18, 2023.