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

 
We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) 
provided on June 20, 2023. 
 
You asked the Plan to pay for the limited oral evaluation. You say that you had two molars extracted from the 
upper left quadrant and then waited three to four months for your gums to heal so you could get a partial. You 
also say that you needed this partial to be able to chew your food. The Plan denied your request. The Plan says 
your benefit for the limited oral evaluation 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 service was exhausted on date of service January 18, 2023, and July 19, 
2023. The Plan has provided evidence that the service which denied took place before service D0140 you 
received on July 19, 2023, for which the plan paid. The plan received the claim for service D0140 you received 
on July 19, 2023, on July 20, 2023, and processed it on July 25, 2023. The plan received the claim for service 
D0140 you received on June 20, 2023, on July 26, 2023. At this point, the plan had already paid for two units 
of service D0140 for the 2023 plan year. Therefore, we decided that the Plan does not have to pay for the 
limited oral evaluation - problem focused (D0140) provided on June 20, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the treatment of root canal obstruction; non-surgical 
access (D3331). 
 
You asked the Plan to pre-approve the treatment of root canal obstruction. You say that there are no 
endodontists within 100 miles of your address. You also say that the plan indicated that an exception would be 
made to allow the services at the in-network level of benefits. The Plan denied your request. The Plan says the 
treatment of root canal obstruction; non-surgical access is not a covered expense under your dental 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 service is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
treatment of root canal obstruction; non-surgical access (D3331).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infectious agent detection by nucleic acid (DNA or 
RNA); neisseria gonorrhoeae, amplified probe technique (87591) provided September 22, 2022. 
 
You asked the Plan to pay for the laboratory testing. You say that the records describe the services rendered 
and need for medical necessity. The Plan denied your request. The Plan says procedure code 87591 has not met 
the associated diagnosis code. 
 
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 laboratory testing. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee is being followed for opiate use disorder. The medical notes indicate there is no 
recommendation for sexually transmitted infection (STI) testing. The notes supplied do not suggest there were 
any symptoms, pregnancy or behaviors to suggest that STI screening with a test for gonorrhea was indicated. 
 
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 laboratory testing have not been met. Therefore, we decided that the Plan 
does not have to pay for the infectious agent detection by nucleic acid (DNA or RNA); neisseria gonorrhoeae, 
amplified probe technique (87591) provided September 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81345-GZ provided on March 21, 2023. 
 
You asked the Plan to pay for procedure code 81345-GZ. 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 state that items submitted with a GZ modifier shall be 
denied automatically and will not be subject to complex medical review. 
 
We find that CPT code 81345 is not supported in the medical record. Specifically, this service includes the GZ 
modifier, which means that this service does not meet the criteria for Medicare coverage. Based on this 
information, we decided that Medicare rules for coverage of the services described by procedure code(s) 81345 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 81345-GZ 
provided on March 21, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from November 1, 2023, 
forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from November 1, 2023, forward. You say that 
the services at issue were medically necessary. The Plan denied your request. The Plan says the services at 
issue were not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve inpatient psychiatric care from 
November 1, 2023, forward. Our reviewer says that the enrollee does not meet the criteria for treatment in an 
acute inpatient mental health treatment beyond the date in question of November 1, 2023, forward. Our 
physician reviewer found the enrollee did not require inpatient mental health treatment beyond November 1, 
2023, as he was not a danger to himself or others and did not have any delusions, auditory or visual 
hallucinations. It did not appear that active treatment was taking place beyond the date in question. It did not 
appear that the services for the dates in question were reasonably expected or medically necessary to improve 
the enrollees condition or for the purpose of diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care from November 1, 2023, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from November 1, 
2023, forward.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the core buildup (D2950) for tooth #12 and #29. 
 
You asked the Plan to pre-approve the dental services. You say that the requested dental services are medically 
necessary. The Plan denied your request. The Plan says the denial of authorization for these services is correct, 
because the core buildup 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 
core buildup (D2950) for tooth #12 and #29.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the core buildups (D2950 x 6). 
 
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 the criteria for coverage have not been met. 
 
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. The Plan covers the dental 
services when the services are medically necessary and reasonable. The Plan's rule for coverage of a core 
buildup states the procedure is covered when there is insufficient retention for a separate extracoronal 
restorative procedure. 
 
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 dental services. Our reviewer says 
that the request is not medically necessary. Our physician reviewer found that the information in the appeal was 
reviewed. Included was a narrative from the dental provider, and x-rays of the teeth in question. After 
reviewing the information, D2950 is not the correct code for what the provider is desiring to do. Recurrent 
decay must be removed and filled. When a restorative material is placed in order to eliminate caries, undercuts, 
or to yield a more ideal form, an alternative code should be used. From the x-rays it cannot determined whether 
there is an existing buildup that needs to be replaced. X-rays or photos after the crown has been removed would 
be required. A core buildup (D2950) is used when there is insufficient sounds tooth structure left to support a 
crown. Therefore, D2950 is not medically reasonable or necessary for teeth numbers 6, 7, 8, 9 and 10. 
 
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 dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the core buildups (D2950 x 6).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service June 13, 
2023. 
 
You asked the Plan to pay for procedure code 76705. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment for code 76705 is bundled into 
payment for code 93976. 
 
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 76705 
is a column II code to column I code 93976. 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 code 76705 billed for date of service June 13, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a laparoscopic cholecystectomy (47562). 
 
You asked the Plan to pre-approve a laparoscopic cholecystectomy. You say that this is medically necessary. 
The Plan denied your request. The Plan says records do not show documentation of gallbladder disease, 
including symptoms of pain, fever, or sonographic evidence of gallstones. 
 
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 a laparoscopic cholecystectomy. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found on October 2, 2023, the enrollee underwent an ultrasound of the abdomen 
which showed no evidence of gallstones. 
 
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 laparoscopic cholecystectomy have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a laparoscopic cholecystectomy (47562).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 83789 and G0480 billed for date of service 
June 22, 2023.  

You asked the Plan to pay for the billed services. You say that the testing is needed for possible opioid abuse. 
The Plan denied your request. The Plan says the billed codes are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Medicare rules say that providers performing 
validity testing on urine specimens utilized for drug testing should not separately bill the validity testing. 
 
In this case, the CPT Code Manual definition of code G0480 is definitive drug testing of 1-7 drug classes. We 
find that CPT code G0480 is not supported in the medical record. The records show that a standard toxicology 
panel was provided. The records do not show that the test was individualized based on the enrollee's clinical 
history. Blanket orders are not a covered benefit. We find that the testing described by code 83789 is 
considered specimen validity testing which is not separately payable. Based on this information, we decided 
that Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure codes 83789 and G0480 billed for date of service June 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 96138 billed for date of service April 25, 
2023. 
 
You asked the Plan to pay for procedure code 96138. You say that you were not informed you would lose your 
established doctors and you should be reimbursed. The Plan denied your request. The Plan says payment for 
code 96138 is bundled into payment for code 99214. 
 
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 96138 
is a column II code to column I code 99214. 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 code 96138 billed for date of service April 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genicular nerve block (64454).

You asked the Plan to pre-approve genicular nerve block. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.

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 genicular nerve block. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found genicular nerve blocks and genicular nerve radiofrequency ablation are considered
investigational and not medically necessary for the treatment of chronic knee pain, including, but not limited to any of the following: degenerative joint disease; osteoarthritis of the knee; as a treatment prior to knee replacement; as a treatment following knee replacement; or as a treatment for individuals who are not candidates for knee replacement surgery. The review has determined that the requested genicular nerve block of the left knee is not medically reasonable or 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 genicular nerve block have not been met. Therefore, we decided that the Plan does not have to pre-approve genicular nerve block (64454).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for cataract surgery on June 22, 2023. 
 
You asked the Plan to waive the cost share for cataract surgery. You say that you had this surgery 10 years ago 
and since it's the same provider then it should not have a cost share. 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 $275 
copay, your $1,000 plan deductible, for each Medicarecovered outpatient surgery at an outpatient hospital 
facility. There is a deductible of $672.40 and based on the allowed amount of the claim, $78.87 was applied as 
the enrollee's copayment [$672.40 + $78.87 = $751.27]. 
 
You have been asked to pay a $751.27 cost share for cataract surgery. This item/service falls within the 
outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 
benefit category. 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 cost share for cataract surgery on June 22, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional retainer crown for tooth #19 (D6740). 
 
You asked the Plan to pre-approve 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 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 item or service was exhausted with the Plan's overturn. Therefore, we 
decided that the Plan does not have to pre-approve an additional retainer crown for tooth #19 (D6740).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided by a chiropractor (99213), 
chiropractic treatment to regions other than spine (98943) and therapeutic exercises (97110) provided on June 
15, 2023. 
 
You asked the Plan to pay for the chiropractic services. You say that the enrollee has out-of-network coverage 
so the provider should be compensated. The Plan denied your request. The Plan says these chiropractic services 
are excluded from coverage. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The record show that the services at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit provided by a chiropractor (99213), chiropractic treatment to 
regions other than spine (98943) and therapeutic exercises (97110) provided on June 15, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown for tooth #15 (D2740). 
 
You asked the Plan to pre-approve 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 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 item or service was exhausted on date of service April 5, 2023, and June 
21, 2023. Therefore, we decided that the Plan does not have to pre-approve a crown for tooth #15 (D2740).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endosteal implants (D6010), and therapeutic parental 
drug administration (D9610). 
 
You asked the Plan to pre-approve D6010 and D9610. You say that the enrollee needs these implants. The Plan 
denied your request. The Plan says the denied 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 
endosteal implants (D6010), and therapeutic parental drug administration (D9610).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99222 provided on November 18, 2022. 
 
You asked the Plan to pay for procedure code 99222. You say that the medical records support the billing of 
code 99222.  The Plan denied your request. The Plan says the medical records do not support the billing of 
code 99222. 
 
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 99222 is Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and medical decision making of moderate complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) 
requiring admission are of moderate severity. Typically, 50 minutes are spent at the bedside and on the patient's 
hospital floor or unit. 
 
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 99222. Our reviewer says that the medical 
records do not support the billing of code 99222. Our reviewer found the documentation supports a 
comprehensive exam, but not a comprehensive history or medical decision making of moderate complexity. 
 
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 99222 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99222 provided on November 18, 2022.