Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (83516, 86038, 86039, 86146, 86147, 86200, 
86225, 86235, 86376, 86431, 86800, 88184, 88185, 88187) provided January 24, 2022. 
 
You asked the Plan to pay for the lab services. You say that the 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 codes 83516, 86038, 86039, 86146, 86147, 86200, 86225, 86235, 86376, 86431, 86800, 
88184, 88185, & 88187 are not supported in the medical record. Specifically, if a single laboratory procedure 
produces multiple reported results, only a single procedure code should be reported. Multiple unbundled codes 
were billed. Based on this information, we decided that Medicare rules for coverage of the lab services have 
not been met. Therefore, we decided that the Plan does not have to pay for lab services (83516, 86038, 86039, 
86146, 86147, 86200, 86225, 86235, 86376, 86431, 86800, 88184, 88185, 88187) provided January 24, 2022.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the home health services provided to the enrollee from 
November 1, 2021 to November 30, 2021. 
 
You asked the Plan to pay for home health services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, the required 
RAP claim was not submitted for this episode. Therefore, we decided that the Plan does not have to pay for the 
home health services provided to the enrollee from November 1, 2021 to November 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture - cast metal framework with 
resin denture bases (including retentive/clasping materials, rests and teeth) (D5213) and mandibular partial 
denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) 
D5214. 
 
You asked the Plan to pre-approve a partial upper and lower denture. You say that you need these dentures. 
The Plan denied your request. The Plan says your x-rays show bone loss around the remaining teeth that would 
not support the partials. The teeth remaining have a poor prognosis for partial dentures. 
 
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 a partial 
upper and lower denture 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 pre-approve a partial upper and lower denture. 
Our reviewer says that the partial dentures are not medically reasonable and necessary. Our physician reviewer 
found that the provided x-rays reveal significant bone loss around all the abutment teeth in the range of about 
50%, including #6, 12, 14 (25% bone remaining), 21,22, 28 and 29.  The use of a tooth supported prosthesis 
requires that the supporting teeth are sufficiently encased in bone so to be able to withstand functional forces 
on itself and a percentage of the teeth being replaced.  When there is significant bone loss around the 
supporting abutments, a tooth supported prosthesis is not indicated or reasonable. The Plan limits tooth 
supported partial dentures to those cases where all the supporting abutment teeth have adequate bone support 
remaining, generally above 50.  In this case there are multiple periodontally involved teeth that would 
compromise the long-term prognosis of a partial denture.  As such, the criteria for metal based partial dentures 
would not be met for either the upper or lower appliances. 
 
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 a partial upper and lower denture have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a maxillary partial denture - cast metal framework with resin denture 
bases (including retentive/clasping materials, rests and teeth) (D5213) and mandibular partial denture - cast 
metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) D5214.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral x-rays (D0210), 2D oral/facial photographic images 
(D0350 x 4), cone beam imaging (D0367), additional periapical x-rays (D0230 x 5), gingival irrigation (D4921 
x 2), and topical application of fluoride varnish (D1206) provided on February 22, 2022. 
 
You asked the Plan to pay for intraoral/periapical x-rays, imaging, irrigation, and fluoride varnish. You say that 
you disagree with the denial of dental services. The Plan denied your request. The Plan says intraoral x-rays (D0210), 2D oral/facial photographic images (D0350), cone beam imaging (D0367), additional periapical x-
rays (D0230), gingival irrigation (D4921), and topical application of fluoride varnish (D1206) are not covered 
by your supplemental 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 intraoral 
x-rays (D0210), 2D oral/facial photographic images (D0350 x 4), cone beam imaging (D0367), additional 
periapical x-rays (D0230 x 5), gingival irrigation (D4921 x 2), and topical application of fluoride varnish 
(D1206) provided on February 22, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the urgent care office visit (99215), and 
the computed tomography (CT) scan, of the abdomen and pelvis; with contrast material(s) (74177) provided on 
January 31, 2022. 
 
You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayments have been applied correctly to 
the services provided. 
 
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 $325 
per day for other Medicare-covered diagnostic radiology services that are not ultrasounds. Additionally, 
enrollees must pay $50 for each Medicare-covered urgent care facility visit.  
 
You have been asked to pay $350 ($300 + $50). This amount includes a $300 copayment for the Medicare-
covered diagnostic radiology service provided. This is the Plan's allowed amount for this service, which is less 
than the applicable copayment. Additionally, this amount includes a $50 copayment for the Medicare-covered 
urgent care facility office visit provided. 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 urgent 
care office visit (99215), and the computed tomography (CT) scan, of the abdomen and pelvis; with contrast 
material(s) (74177) provided on January 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance (D4910) provided on January 18, 2021. 
 
You asked the Plan to pay for periodontal maintenance. You say that you disagree with the denial of dental 
services. The Plan denied your request. The Plan says periodontal maintenance (D4910) is not covered by 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 
periodontal maintenance (D4910) provided on January 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and intraoral x-
rays (D0210) provided on February 25, 2022. 
 
You asked the Plan to pay for the dental services. You say that you have had charge issues that have prevented 
you from getting the services you need. 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 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 items or services was exhausted on date of service June 25, 2020. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and 
intraoral x-rays (D0210) provided on February 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for an outpatient hospital surgery provided on 
January 19, 2022, and two outpatient hospital visits provided on January 19, 2022, and February 10, 2022. 
 
You asked the Plan to waive the copayments for an outpatient surgery and two hospital visits. You say that you 
should not have to pay any of these copayments. The Plan denied your request. The Plan says the copayment 
applied was correct. 
 
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 $150 
copayment for outpatient surgery and $10 for a hospital visit. ($10 x 2 = $20) ($150 +$20 = $170). 
 
You have been asked to pay a $170 copayment for outpatient surgery and for two hospital visits. An outpatient 
surgery and two hospital visits fall within the Outpatient Hospital Services - Outpatient Hospital Surgery and 
Outpatient Hospital Services 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 copayments for an outpatient hospital surgery 
provided on January 19, 2022, and two outpatient hospital visits provided on January 19, 2022, and February 
10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81286, 81413, 81414, 81442, 81161, 81479) 
provided February 14, 2022. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed service. 
 
The Plan must follow Medicare rules. Medicare rules say that all diagnostic x-ray tests, diagnostic laboratory 
tests, and other diagnostic tests must be ordered by the physician who is treating the beneficiary. 
 
We looked at the file and Medicare rules. The records do not show that the primary physician ordered the tests 
at issue. Based on this information, we decided that Medicare rules for coverage of the lab services have not 
been met. Therefore, we decided that the Plan does not have to pay for lab services (81286, 81413, 81414, 
81442, 81161, 81479) provided February 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99335) provided March 9, 2022. 
 
You asked the Plan to pay for the physician services. You say that the 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. 
 
In this case, the CPT Code Manual definition of code 99335 is Domiciliary or rest home visit for the evaluation 
and management of an established patient. 
 
We find that CPT code 99335 is not supported in the medical record. Specifically, the claim was billed with 
place of service 11- office visit. The records show that this service was not provided in an office setting. Based 
on this information, we decided that Medicare rules for coverage of the physician services have not been met. 
Therefore, we decided that the Plan does not have to pay for physician services (99335) provided March 9, 
2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for domiciliary services provided on October 11, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for domiciliary services. You say that you would like to request reconsideration of 
the denied claim. The Plan denied your request. The Plan says the provider is out-of-network, and it was 
determined these services were not urgent or emergent. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for domiciliary services provided on October 11, 
2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (95718) provided June 3, 2021. 
 
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the records do not support the billed services. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
We find that 2 units of CPT code 95718 are not supported in the medical record. The medical record only 
supports 1 unit of CPT code 95718. Based on this information, we decided that Medicare rules for coverage of 
the physician services have not been met. Therefore, we decided that the Plan does not have to pay for 
physician services (95718) provided June 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on April 7, 2022. 
 
You asked the Plan to pay for the dental service. You say that you would like to be informed on the date that 
the last panoramic x-ray was taken and by which provider in the past five years. The Plan denied your request. 
The Plan says your benefit for the panoramic x-ray 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 panoramic x-ray was exhausted on date of service February 20, 2019. Therefore, we 
decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on April 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (0037U) provided December 20, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that genetic testing panels that include the FANCC 
gene are statutorily excluded service. 
 
We looked at the file and Medicare rules. This service is non-covered under Medicare rules. Based on this 
information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we 
decided that the Plan does not have to pay for lab services (0037U) provided December 20, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vabysmo for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says step therapy criteria is not met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications.  
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 drug. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found that there is no 
indication that there is no indication that the enrollee has tried and failed Bevacizumab. Based on the medical 
records provided and the Medicare-approved major drug compendia there is no indication that the plan's 
required drug(s) would likely be less effective and/or likely have adverse effects for the patient. An unsigned 
hand written statement was provided on one of the appeal documents stating the provider " does not feel 
Avastin will be as effective in treating patient's condition" but no additional information was provided to 
further explain this statement and what features of this patient's condition are present to require an exception to 
the health plan's step therapy criteria. 
 
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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Vabysmo for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay the in-network rate for the additional periapical x-ray (D0230) 
provided on March 16, 2022. 
 
You asked the Plan to pay the in-network rate for the additional periapical x-ray. You say that when you signed 
up for your plan you were advised the provider in this case is in-network. You also say that you cannot afford 
to pay this bill. The Plan denied your request. The Plan says your benefit for the additional periapical x-ray 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 additional periapical x-ray was exhausted on date of service March 16, 2022. 
Therefore, we decided that the Plan does not have to pay the in-network rate for the additional periapical x-ray 
(D0230) provided on March 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory tests provided on January 18, 2022. 
 
 You asked the Plan to pay for lab tests. You say that this enrollee was seen as a follow-up to an emergency 
room visit. The Plan denied your request. The Plan says the denial of payment for these services is correct, 
because these lab codes are not included for payment under the Federally Qualified Health Center (FQHC) 
Prospective Payment System (PPS). 
 
The Plan must follow Medicare rules. Medicare rules say that FQHCs are paid through a PPS and that the PPS 
payment is established based on specific payment codes. Codes 83036, 80050, and 80061 are not specific 
payment codes within the FQHC PPS. 
 
We looked at the file and Medicare rules. The billed codes 83036, 80050, and 80061 are not specific payment 
codes within the FQHC PPS, so are not included in the PPS payment made to the facility. Based on this 
information, we decided that Medicare rules for coverage of lab tests have not been met. Therefore, we decided 
that the Plan does not have to pay for laboratory tests provided on January 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a second diagnostic facet joint injection for the enrollee. 
 You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your 
request. The Plan says per the provider office outreach, it was confirmed that the enrollee reported 60-65% 
relief of pain with the first diagnostic facet joint injection. 
 
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 the injection. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there is a requirement for 80% pain relief from each set of diagnostic medial branch blocks. The first 
block did not achieve this, so the request is deemed 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 the injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a second diagnostic facet joint injection for the enrollee.