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

 
We decided that the Plan does not have to pay for procedure code 99348 provided on March 3, 2023. 
 
You asked the Plan to pay for procedure code 99348. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as 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 99348 is Home or residence visit for the evaluation and 
management of an established patient, which requires a medically appropriate history and/or examination and 
low level of medical decision making. When using total time on the date of the encounter for code selection, 30 
minutes must be met or exceeded. 
 
We find that CPT code 99348 is not supported in the medical record. Specifically, the records show that the 
services were provided in the enrollee's residence. The place of service used on the claim is incorrect. Based on 
this information, we decided that Medicare rules for coverage of procedure code 99348 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 99348 provided on March 3, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapy services (97112, 97110, 97116) provided on 
February 27, 2023. 
 
You asked the Plan to pay for the therapy services. You say that these services were medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as 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. 
 
We find that CPT code 97112, 97110, & 97116 is not supported in the medical record. Specifically, diagnosis 
codes R26.9 (Unspecified abnormalities of gait and mobility) and R27.0 (Ataxia, unspecified) have an exclude 
note and cannot be billed together. Based on this information, we decided that Medicare rules for coverage of 
the therapy services have not been met. Therefore, we decided that the Plan does not have to pay for therapy 
services (97112, 97110, 97116) provided on February 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on March 29, 2023. 
 
You asked the Plan to pay for the dental services. You say that you needed this dental work. 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 March 29, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services (G0151, G0152, G0299, Q5001) 
provided on November 24, 2022, to December 23, 2022. 
 
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 NOA was not received timely. As such, this 
final claim was correctly denied.  
 The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is October 25, 2022. The NOA was not received by the Plan until December 
29, 2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services (G0151, 
G0152, G0299, Q5001) provided on November 24, 2022, to December 23, 2022.
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 October 19, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you would 
like the services to be reconsidered. 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 October 19, 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 October 19, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous vertebral augmentation (PVA) for 
osteoporotic vertebral compression fracture at 5 levels. 
 
You asked the Plan to pre-approve PVA for osteoporotic vertebral compression fracture at 5 levels. You say 
that this service is medically necessary. The Plan denied your request. The Plan says the fractures are more 
than 12 weeks old. Additionally, the enrollee has more than three fractures.  
 
The Plan follows Medicare rules. Medicare rules say that PVA, PVP or PKP is covered in patients with acute 
(less than 6 weeks) or subacute (6-12 weeks) osteoporotic VCF (T1  L5) by recent (within 30 days) advanced 
imaging. 
 
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 PVA for Osteoporotic Vertebral 
Compression Fracture at 5 levels. Our reviewer says that criteria for coverage are not met for this service. Our 
physician reviewer found that there is no trial of fracture bracing and the imaging does not show that the 
fracture is acute. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PVA for Osteoporotic Vertebral Compression Fracture at 5 levels have not been 
met. Therefore, we decided that the Plan does not have to pre-approve percutaneous vertebral augmentation 
(PVA) for osteoporotic vertebral compression fracture at 5 levels.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on January 23, 
2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on January 23, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for dental services provided on June 2, 2022, to November 
2, 2022. 
 
You asked the Plan to pay more for the dental services. You say that this should be covered. The Plan denied 
your request. The Plan says you are responsible for any charged amount above the Plans cost-sharing amount 
when your services are received from an out-of-network provider.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to pay more for dental services provided on June 2, 2022, to 
November 2, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox. 
 
You asked the Plan to pre-approve the medication. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the requested treatment order of Botox is not medically necessary. 
 
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 the medication. Our reviewer says that 
the requested use of Botox is not medically necessary. Our physician reviewer found that the requested dose of 
600 units of Botox every 3 months exceeds the Food and Drug Administration (FDA) recommended maximum 
dose of 400 units in a 3-month interval. The review has determined that the requested use of Botox is FDA 
approved for the enrollees diagnosis, however, the maximum cumulative dose should not exceed 400 Units, in 
a 3-month interval. 
 
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Botox.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on December 15, 2022. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. 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 December 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on August 30, 2022. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. 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 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visit and treatment to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve office visit and treatment to be provided by an OON provider. You say that 
the services are necessary. The Plan denied your request. The Plan says there are in-network providers that are 
able to provide these services. Therefore, coverage criteria have not been met. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
office visit and treatment to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a cleaning, filling, core buildup services, and the 
topical application of fluoride varnish (D2950, D1206, D1110, D2394) provided on February 14, 2022 to 
November 1, 2022. 
 
You asked the Plan to pay more 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 you are responsible for any charged 
amount above the Plans cost-sharing amount when your services are received from an out-of-network 
provider. Coverage for the core buildup services and the topical application of fluoride 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. You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Coverage for the core buildup services and the topical application of fluoride denied correctly as they do not 
fall within your dental benefits. Therefore, we decided that the Plan does not have to pay more for a cleaning, 
filling, core buildup services, and the topical application of fluoride varnish (D2950, D1206, D1110, D2394) 
provided on February 14, 2022, to November 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation - problem focused (D0140) 
provided on January 19, 2023. 
 
You asked the Plan to pay for the limited oral evaluation - problem focused. The Plan denied your request. The 
Plan says your benefit for the limited oral evaluation - problem focused 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 dates of service May 13, 2022, 
December 19, 2022, and February 16, 2023. Therefore, we decided that the Plan does not have to pay for a 
limited oral evaluation - problem focused (D0140) provided on January 19, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation - established patient (D0120), 
prophylaxis - adult (D1110), crown - porcelain/ceramic (D2740), and core buildup, including any pins when 
required (D2950) provided on February 13, 2023. 
 
You asked the Plan to pay for the dental services represented by codes D0120, D1110, D2740 and D2950. You 
say that you contacted member service on January 30, 2023, prior to your appointment and was advised you 
had out-of-network dental coverage. 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 a periodic oral evaluation - established patient (D0120), prophylaxis - adult (D1110), crown - 
porcelain/ceramic (D2740), and core buildup, including any pins when required (D2950) provided on February 
13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composite - two surfaces, posterior (D2392 
x3) provided on February 21, 2023. 
 
You asked the Plan to pay for the resin-based composite - two surfaces, posterior. You say that you understand 
that you have used your $1,000 available maximum annual limit. You also say that you were expecting to 
receive the contracted discounted rate for the services rendered that is negotiated between the plan and your 
provider. The Plan denied your request. The Plan says your benefit for the resin-based composite - two 
surfaces, posterior $1,000 dollar limit was met.  
 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 resin-based composite - two surfaces, posterior was exhausted on date of service 
February 8, 2023. Therefore, we decided that the Plan does not have to pay for the resin-based composite - two 
surfaces, posterior (D2392 x3) provided on February 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 78730 provided on December 8, 2022. 
 
You asked the Plan to pay for procedure code 78730. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim was not billed with a valid primary procedure. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 78730 
is an add-on code and has not been billed with an appropriate primary procedure code. 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 code 78730 provided on December 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral imaging (D0210), and three additional 2D oral 
imaging (D0350) provided on March 13, 2023. 
 
You asked the Plan to pay for the dental services. You say that you needed this dental treatment. 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 13, 2023. One 
D0350 was approved and paid. The additional three D0350 have been denied. Panoramic imaging was provided on March 13, 2023. Therefore, we decided that the Plan does not have to pay for intraoral imaging 
(D0210), and three additional 2D oral imaging (D0350) provided on March 13, 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 January 19, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you should 
not have to pay for the ambulance service. 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 January 19, 2023. 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 January 19, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited dental exam (D0191) provided on February 22, 
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.  
 
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 service provided is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the limited dental 
exam (D0191) provided on February 22, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 99309 provided on December 5, 2022. 
 
You asked the Plan to pay for procedure code 99309. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that if more than one evaluation and management 
(face-to-face) service is provided on the same day to the same patient by the same physician or more than one 
physician in the same specialty in the same group, only one evaluation and management service may be 
reported. 
 
We looked at the file and Medicare rules. The E/M service in question was provided on the same day as E/M 
service (99309) provided by a different provider in a different group practice. This means that more than one 
E/M service is payable. Therefore, we decided that the Plan has to pay for procedure code 99309 provided on 
December 5, 2022.  
 
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.