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

 
We decided that the Plan does not have to pay for an office or other outpatient visit (procedure code 99215) 
performed on December 13, 2022. 
 
You asked the Plan to pay for an office or other outpatient visit (procedure code 99215). You say that 
procedure code 99215 is appropriate based on the services performed. The Plan denied your request. The Plan 
says the service at issue in this case are not supported by the medical records. 
 
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 99215 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 high level of medical decision making. When using time for code selection, 40-54 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 an office or other outpatient visit (procedure code 99215). 
Our reviewer says that the services at issue in this case were not supported by the medical records. Our 
reviewer found the documentation does not show medical decision making of high complexity. The 
documentation does not show the amount of time spent caring for the patient. As such, the billing of CPT 
99215 is not supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an office or other outpatient visit (procedure code 99215) have not been met. 
Therefore, we decided that the Plan does not have to pay for an office or other outpatient visit (procedure code 
99215) performed on December 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110). 
 
You asked the Plan to pre-approve the dental service. You say that your previous denture failed, and it needs to 
be redone. 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 partial upper denture (D5211) on April 27, 2021; therefore, your benefit for the 
requested item or service was exhausted on the date of service of April 27, 2021. Therefore, we decided that 
the Plan does not have to pre-approve a complete upper denture (D5110).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endodontic therapy, of an anterior tooth (excluding final 
restoration) (D3310 x 2). 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says the requested services are not covered under the 
supplemental dental policy.  
 
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 pre-approve endodontic 
therapy, of an anterior tooth (excluding final restoration) (D3310 x 2).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for  ambulance transport services to the physicians office 
provided on July 24, 2023. 
 
You asked the Plan to pay for  the ambulance transport services. You say that the services were medically 
necessary to save the enrollee from going home and then back to the physicians office. The Plan denied your 
request. The Plan says the services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when 
they meet certain origin and destination requirements. A doctors office is not a covered destination.  
 
The services you have asked the Plan to pay for are ambulance transport services to a doctors office. 
Therefore, we decided that the Plan does not have to pay for  ambulance transport services to the physicians 
office provided on July 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation, extraction, and fixed partial 
denture sectioning (D7210, D9120, D0150) provided on July 21, 2023, to July 24, 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 comprehensive oral evaluations 
has already been exhausted. Coverage for the fixed partial denture sectioning denied correctly as it does not fall 
within your dental benefit. Additionally, the cost-sharing for the extraction applied correctly as you received 
the services 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. Though the Plan offers a 
dental benefit in excess of Medicare coverage, certain limitations apply. The record shows your benefit for 
comprehensive oral evaluations was exhausted on date of service March 29, 2023 (D0150). Coverage for the 
fixed partial denture sectioning denied correctly as it does not fall within your dental benefit. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment for the extraction. This cost sharing is a contractual obligation you agreed to pay when you enrolled in 
the Plan Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation, 
extraction, and fixed partial denture sectioning (D7210, D9120, D0150) provided on July 21, 2023, to July 24, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete denture - maxillary (D5110). 
 
You asked the Plan to pre-approve the complete denture. You say that you have a complex dental situation in 
which you feel this provider is best suited to complete your denture. The Plan denied your request. The Plan 
says dental services from an out-of-network prosthodontist provider is 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. 
 
You are requesting dental services from an out-of-network prosthodontist provider. Though the Plan offers a 
dental benefit in excess of Medicare coverage, the requested service is not covered under this benefit when 
received from an out-of-network prosthodontist provider. Therefore, we decided that the Plan does not have to 
pre-approve a complete denture - maxillary (D5110).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the external mobile cardiovascular telemetry provided on 
June 09, 2023. 
 
You asked the Plan to pay for the external mobile cardiovascular telemetry. 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 external mobile 
cardiovascular telemetry provided on June 09, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye refraction (92015) provided on July 14, 2023. 
 
You asked the Plan to pay for the eye refraction. You say that you do not think you owe for this service since 
the explanation of benefits says you owe nothing. The Plan denied your request. The Plan says the Evidence of 
Coverage provides that refractive determination is non-covered for eyeglasses/contacts. 
 
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.  
 
 
 
 We looked at the file and the Plan's rules. Specifically, the record shows that this refraction was provided with 
a medical eye examination. Medicare does not cover eye refractions provided with medical eye exams. Based 
on this information, we decided that the Plan's rules for coverage of the eye refraction have not been met. 
Therefore, we decided that the Plan does not have to pay for the eye refraction (92015) provided on July 14, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intraosseous radiofrequency ablation of the 
basivertebral nerve. 
 
You asked the Plan to pre-approve intraosseous radiofrequency ablation of the basivertebral nerve. You say 
that it is medically necessary. The Plan denied your request. The Plan says that there is not enough research to 
show that intraosseous radiofrequency ablation of the basivertebral nerve improves net health outcomes in 
patients with vertebrogenic back pain. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve intraosseous radiofrequency ablation of 
the basivertebral nerve. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found there is no magnetic resonance imaging (MRI) showing only modic changes without facet degenerative joint disease (DJD) or stenosis. The cause of 
pain is not clear.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of intraosseous radiofrequency ablation of the basivertebral nerve have not been 
met. Therefore, we decided that the Plan does not have to pre-approve intraosseous radiofrequency ablation of 
the basivertebral nerve.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).  
You asked the Plan to pre-approve a CGM. You say that a CGM is medically necessary for the enrollee. The 
Plan denied your request. The Plan says the medical criteria for a CGM have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin. 
Based on this information, we decided that Medicare rules for coverage of a CGM have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture services provided on June 27, 2023. 
 You asked the Plan to pay for the acupuncture services. The Plan denied your request. The Plan says that 
acupuncture is only covered for chronic low back pain. 
 
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, the enrollee's diagnosis is cervicalgia, and 
acupuncture is only covered for chronic low back pain. Therefore, we decided that the Plan does not have to 
pay for the acupuncture services provided on June 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an unspecified restorative procedure (D2999), and an 
unspecified oral surgery procedure (D7999). 
 
You asked the Plan to pre-approve D2999 and D7999. You say that you need this dental work. The Plan denied 
your request. The Plan says the requested dental 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 an 
unspecified restorative procedure (D2999), and an unspecified oral surgery procedure (D7999).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel provided on 
January 20, 2023, and billed with codes 87481, 87653, 87798, and 87801. 
 
You asked the Plan to pay for the urine PCR panel. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this testing should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a single panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the urine PCR panel have not been met. Therefore, we decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel 
provided on January 20, 2023, and billed with codes 87481, 87653, 87798, and 87801.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for transportation services (99999) from April 27, 2023, to May 
18, 2023. 
 
You asked the Plan to pay for transportation services (99999). You say that you were previously kept waiting 
on two consecutive occasions and was unable to keep your two appointments on those occasions. You also say 
that because of that, you needed a person to take you to the hospital, wait for you, and return you home. The 
Plan denied your request. The Plan says the invoice is not from an official entity. The Plan also says the service 
provider does not have registration with the commissioner of health or a national provider identifier (NPI). 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. Medicare rules say that plans can require enrollees to 
get care from network providers. For that reason, the Plans coverage rules apply in this case. The Plan covers 
routine transportation when the services are obtained with an in-network provider.  
 
We looked at your request, the records in the case file, and the rules. The record shows that there was no 
authorization for services with the provider. The record also shows that services were not received from an in-
network provider. Based on this information, we decided that the Plans rules for coverage of routine 
transportation have not been met. Therefore, we decided that the Plan does not have to pay for transportation 
services (99999) from April 27, 2023, to May 18, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 continuous glucose monitor (CGM).  
You asked the Plan to pre-approve a CGM. You say that this is necessary because the enrollee has prediabetes. 
The Plan denied your request. The Plan says the medical criteria for a CGM have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin. 
Based on this information, we decided that Medicare rules for coverage of a CGM have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 2 continuous glucose 
monitor (CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips (A0100). 
 
You asked the Plan to pre-approve the additional trips. You say that you feel the additional transportation trips 
should be covered. The Plan denied your request. The Plan says the record shows you have exhausted all of 
your allowed 48 one-way trips.  
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 48 trips per year.  
 
We looked at your request, the records in the case file, and the rules. You asked the Plan to pre-approve 
additional routine transportation trips. Based on this information, we decided that you have exhausted the Plan 
maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to 
pre-approve additional routine transportation trips (A0100).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for guided tissue regeneration, deep sedation/general anesthesia, 
therapeutic parenteral drugs 9D6106, D9222, D9223, D9612) provided on May 30, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for guided 
tissue regeneration, deep sedation/general anesthesia, therapeutic parenteral drugs D6106, D9222, D9223, 
D9612) provided on May 30, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical placement of implant body: endosteal implant 
tooth #14 (D6010) provided on May 2, 2023. 
 
You asked the Plan to pay for the surgical placement of implant body. You say that this is your third dental 
implant and the first two were denied, appealed and then approved. You also say that the first two implants 
were covered under your medical plan and the third should be covered as the first two. The Plan denied your 
request. The Plan says the service is not eligible for coverage by Medicare or under the medical benefit. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
 
 
 The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for the surgical placement of implant 
body: endosteal implant tooth #14 (D6010) provided on May 2, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the endodontic therapy (D3332) for tooth #14. 
 
You asked the Plan to pre-approve the dental service. You say that you have severe pain in your tooth and the 
dental procedure is necessary. The Plan denied your request. The Plan says the denial of authorization for this 
service is correct, because the endodontic therapy 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 Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
endodontic therapy (D3332) for tooth #14.