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

 
We decided that the Plan has to pay for core buildup, including any pins when required (D2950) provided on 
January 6, 2023. 
 
You asked the Plan to pay for the core buildup. You say that  buildup was indicated due to more than 50% of 
the tooth structure indicating need for a new stable foundation for #9 unit on the enrollees bridge #6-9. This 
information was indicated in the narrative of the claim and on the clinical note. The Plan denied your request. 
The Plan says that based on submitted documents the benefits are not recommended. 
 
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 Plan covers the core build 
up when the services are medically necessary and reasonable. 
 
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 core build up. Our reviewer says that the 
core buildup, including any pins when required was medically necessary. Our physician reviewer found the 
documentation indicates that old crowns on teeth #'s 6 and 9 were removed due to recurrent caries. 50% of the 
coronal structure of tooth #9 was compromised due to the caries. A core buildup is medically reasonable and 
necessary to provide adequate support and retention for a new crown.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the core buildup have been met. Therefore, we decided that the Plan has to pay 
for core buildup, including any pins when required (D2950) provided on January 6, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on August 26, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that you are requesting reconsideration of the denied 
claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the genetic testing 
provided on August 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an apicoectomy, bone graft, retrograde filling, guided tissue 
regeneration, surgical procedure for isolation, unspecified endodontic procedure, gingival irrigation, palliative 
treatment of dental pain, and drugs or medicaments dispensed in the office for home use provided on May 19, 
2023, to June 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 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 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 pay for an 
apicoectomy, bone graft, retrograde filling, guided tissue regeneration, surgical procedure for isolation, 
unspecified endodontic procedure, gingival irrigation, palliative treatment of dental pain, and drugs or 
medicaments dispensed in the office for home use provided on May 19, 2023, to June 6, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150) and a 
panoramic x-ray (D0330). 
 
You asked the Plan to pre-approve the evaluation and x-ray. You say that the requested dentures are medically 
necessary. 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 Plan's 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 items or services were exhausted on date of service August 23, 2023. 
Therefore, we decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150) and 
a panoramic x-ray (D0330).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87801, 87150, 87481, 87641, 87653 and 
87798 billed for date of service February 8, 2023. 
 
You asked the Plan to pay for procedure codes 87801, 87150, 87481, 87641, 87653 and 87798. You say that 
these services were necessary and are supported as billed. The Plan denied your request. The Plan says these 
services are not supported in the medical record. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, we have confirmed that code 87150, 87481, 87641, 87653 and 87798 is a column II code to 
column I code 87500 and/or 87801; however, 87150, 87481, 87641, 87653 and 87798 was billed with a 
modifier.  
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for procedure codes 87801, 87150, 87481, 87641, 87653 and 
87798. Our reviewer says that these codes are not supported in the medical record. Our reviewer found the 
provider reported three units of code 87801; however, this is a panel code and only one unit of service is 
allowable, as this procedure is for multiple organisms. This code is not supported with the number of units 
reported. In addition, codes 87150, 87481, 87641, 87653 and 87798 were each reported with modifier XU. 
However, the laboratory report does not include documentation to support that these services were unusual 
non-overlapping services with the primary procedures. Therefore, the XU modifier cannot be verified, and 
these codes are not supported for separate reporting. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 87801, 87150, 87481, 87641, 87653 and 87798 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes 87801, 87150, 87481, 
87641, 87653 and 87798 billed for date of service February 8, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory testing provided on March 17, 2023. 
 
You asked the Plan to pay for the laboratory testing. You say that you are requesting reconsideration of the 
denied claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the laboratory testing 
provided on March 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on July 11, 2022. 
 
You asked the Plan to pay for laboratory services. You say that the services should be covered. The Plan denied 
your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for laboratory services 
provided on July 11, 2022.
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 you need this level of care.  The Plan denied your 
request. The Plan says the medical records do not show a need for IRF care.  
 
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 enrollee has 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 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. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 73564 and 99214 billed for date of service 
April 18, 2023. 
 
You asked the Plan to pay for procedure codes 73564 and 99214. You say that you have billed the services at 
issue correctly. The Plan denied your request. The Plan says the provided records do not support the services 
billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 73564 is: Radiologic examination, knee; complete, 4 or 
more views. The definition of code 99214 is: Office or other outpatient visit for the evaluation and 
management of an established patient, which requires a medically appropriate history and/or examination and 
moderate level of medical decision making. When using time for code selection, 30-39 minutes of total time is 
spent on the date of the encounter. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for procedure codes 73564 and 99214. Our reviewer says that 
procedure codes 73564 and 99214 do not meet criteria for payment. Our reviewer found that for code 73564, 
the procedure report documents "Radiographs of both knees obtained today in clinic reviewed, shows 
tricompartmental osteoarthritic changes bilaterally." There is insufficient documentation to confirm that 
procedure 73564 has been performed to include complete and 4 or more views. For code 99214, the medical 
record submitted does not support the procedure code billed. Modifier 25 is not supported, as evaluation 
service provided is related to the procedure performed. Additionally, a moderate level of medical decision 
making is not supported. The documentation supports a low level of medical decision making. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 73564 and 99214 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 73564 and 99214 billed for date of service April 18, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the specialist office visit and x-ray 
provided on May 16, 2023. 
 
You asked the Plan to waive the copayments for the specialist office visit and x-ray. You say that you are 
appealing the copayments for these services. 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 $30 
copayment for in-network specialist office visits. Your contract with the Plan also clearly says that you must pay a $50 copayment for in-network x-rays provided in a physicians office. 
 
You have been asked to pay a $30 copayment for the specialist office visit. This item/service falls within the 
physician/practitioner services benefit category. You have also been asked to pay $6.81, which is less than the 
standards $50 copayment for the x-ray. This item/service falls within the outpatient diagnostic tests and 
therapeutic services benefit category. You have been asked to pay a total of $36.81 ($30 copayment + $6.81 
copayment = $36.81). 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 copayments for the specialist office visit and x-
ray provided on May 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cone beam computed tomography (CT) capture and 
interpretation (D0367), a surgical stent (D5982), radiographic/surgical implant index (D6190), and a 
therapeutic parenteral drug (D9610). 
 
You asked the Plan to pre-approve a cone beam CT capture and interpretation, a surgical stent, 
radiographic/surgical implant index, and a therapeutic parenteral drug. You say that these services are 
necessary. The Plan denied your request. The Plan says the requested services are not covered 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 pre-approve a 
cone beam computed tomography (CT) capture and interpretation (D0367), a surgical stent (D5982), 
radiographic/surgical implant index (D6190), and a therapeutic parenteral drug (D9610).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for incision and drainage of abscess provided on March 28, 
2023. 
 
You asked the Plan to pay for incision and drainage of abscess. You say that this service is supported in the 
records. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for incision and drainage of 
abscess provided on March 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95937 billed for date of service March 14, 
2023. 
 
You asked the Plan to pay for procedure code 95937. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says the provided records do not support the code reported. 
 
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 95937 is: Neuromuscular junction testing (repetitive 
stimulation, paired stimuli), each nerve, any 1 method. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for procedure code 95937. Our reviewer says that procedure 
code 95937 does not meet criteria for payment. Our reviewer found the procedure report documents "TO4 
95937 - Neuromuscular Junction Test (TO4)"; however, these are two different procedures. The neuromuscular 
transmission (NMT) module automatically determines the current needed for the supramaximal stimulus and 
maintains this current throughout the procedure. Train-of-four (TO4) is used as the default stimulation mode. 
Four supramaximal stimuli are generated at 0.5 second intervals.  Train-of-four monitoring is considered 
integral to intraoperative neuromonitoring and/or administration of anesthesia and, therefore, is not separately 
reportable. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 95937 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 95937 billed for date of service March 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a programming device evaluation (in person) with iterative 
adjustment of the implantable device provided on May 08, 2023. 
 
You asked the Plan to pay for a programming device evaluation (in person) with iterative adjustment of the 
implantable device. You say that the services should be covered. The Plan denied your request. The Plan says 
that unauthorized, out-of-network care is not covered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a programming device 
evaluation (in person) with iterative adjustment of the implantable device provided on May 08, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (26990, 27048, 35703, 64712) provided on 
January 9, 2023. 
 
You asked the Plan to pay for the surgical services. You say that these services were medically necessary. The 
Plan denied your request. The Plan says the billed codes are not supported by the documentation. 
 
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 CPT codes 26990, 27048, 35703 and 64712 are not supported in the medical record. Specifically, 
code 26990 is included in code 27048 which was also billed. Codes 27048, 35703, & 64712 were billed with 
an inappropriate modifier. Based on this information, we decided that Medicare rules for coverage of the 
surgical services have not been met. Therefore, we decided that the Plan does not have to pay for surgical 
services (26990, 27048, 35703, 64712) provided on January 9, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the guided tissue regeneration (D4266) for tooth #11 
and #12. 
  
You asked the Plan to pre-approve the dental services. You say that it is medically necessary to have the 
implants installed and they are on the list of codes of treatment. The Plan denied your request. The Plan says 
the denial of authorization for these services is correct, because the guided tissue regeneration is not covered by 
the Plan. 
 
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 the 
guided tissue regeneration (D4266) for tooth #11 and #12.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on November 01, 2022. 
 
You asked the Plan to pay for psychotherapy. You say that the services should be covered. The Plan denied 
your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for psychotherapy provided 
on November 01, 2022.