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

 
We decided that the Plan does not have to pay for the next generation sequence testing (NGS) panel provided 
on December 27, 2021. 
 
You asked the Plan to pay for the next generation sequence testing (NGS) panel. You say that you would like 
the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a 
covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that panels that include the FANCC gene are not 
covered.  
 
 
 
 We looked at the file and Medicare rules. Review of the file shows that the testing rendered included testing for 
the FANCC gene. This means the entire panel is not covered. Based on this information, we decided that 
Medicare rules for coverage of the next generation sequence testing (NGS) panel have not been met. Therefore, 
we decided that the Plan does not have to pay for the next generation sequence testing (NGS) panel provided 
on December 27, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the morphometric analysis services coded 88368 and 88377 
provided on April 16, 2021. 
 You asked the Plan to pay for the morphometric analysis services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services billed are not separately 
payable. 
 
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 88368 
is a column II code to column I code 81263. We have confirmed that code 88377 is a column II code to column 
I code 81263. 
 
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 the 
morphometric analysis services coded 88368 and 88377 provided on April 16, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the tissue exam (88305) provided on August 23, 2021. 
 
You asked the Plan to pay for the tissue exam. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says the documentation submitted does not support 
that the provider rendered the global service for CPT code 88305. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We find that CPT code 88305 is not supported in the medical record. Specifically, CPT code 88305 was not 
billed with a modifier to indicate that this was the professional or technical component. The documentation 
submitted does not support that the global service for CPT code 88305 was rendered by this provider. Based on 
this information, we decided that Medicare rules for coverage of the tissue exam have not been met. Therefore, 
we decided that the Plan does not have to pay for the tissue exam (88305) provided on August 23, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered on November 17, 2021 to 
December 1, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that HH PPS claims must report a 0023 revenue code line 
on which the first four positions of the HIPPS code match the code submitted on the RAP.  
 
We looked at the file and Medicare rules. The file shows that the claims were not billed with the correct 
revenue code line on the RAP. Therefore, we decided that the Plan does not have to pay for the home health 
services rendered on November 17, 2021 to December 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal maintenance (D4910) to be performed by an 
out of network dentist. 
 
You asked the Plan to pre-approve the dental service. You say that you need this service. The Plan denied your 
request. The Plan says dental services that you receive out of network are not covered. 
 
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 periodontal maintenance 
is not among those covered under this benefit when performed out of network. Therefore, we decided that the 
Plan does not have to pre-approve periodontal maintenance (D4910) to be performed by an out of network 
dentist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete 
series of intraoral x-rays (D0210) provided on January 28, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the comprehensive oral evaluation and complete series of intraoral x-rays. You 
say that you asked the receptionist if the services would be covered by the Plan, and you were told yes and that 
the entire bill would be paid by the Plan. The Plan denied your request. The Plan says services performed by an 
OON provider are not covered because your healthcare plan does not have OON benefits. The Plan also says 
that you did not contact the Plan prior to this date of service to verify benefits and provider eligibility. 
 
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, you are responsible for 100% of the 
cost for dental services rendered by an OON provider. Therefore, we decided that the Plan does not have to pay 
for the comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210) provided on 
January 28, 2022 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiologic examination, gastrointestinal tract (74230) 
transportation of portable x-ray equipment and personnel to home or nursing home, per trip to facility or 
location, (R0070) 
 
You asked the Plan to pay for the portable x-ray services. You say that this service was of medical necessity 
especially during this COVID pandemic where nursing home patients are high risk for entering the hospital or 
even in outpatient due to risk for contracting COVID and having a bad outcome. The Plan denied your request. 
The Plan says these are non-covered charges and claim/service lacks information or has submission/billing 
errors. 
 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 find that CPT codes 74230 and R0070 are not supported in the medical record. Specifically, 
74230 is a non-payable code. R0070 was billed with place of service 11 (office) which is an incorrect place of 
service. Based on this information, we decided that Medicare rules for coverage of the portable x-ray services 
have not been met. Therefore, we decided that the Plan does not have to pay for the radiologic examination, 
gastrointestinal tract (74230) transportation of portable x-ray equipment and personnel to home or nursing 
home, per trip to facility or location, (R0070)
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an opt-out provider on January 
26, 2021, to May 3, 2021. 
 
You asked the Plan to pay for dental services. You say that you were referred to this surgeon. The Plan denied 
your request. The Plan says the rendering dentist has opted-out of Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare plans may not pay for services given 
by a physician or other practitioner who has opted out of Medicare. The rules also say that a Medicare plan 
must pay for emergency or urgently needed services given by a physician or practitioner who has not signed a 
private contract with the enrollee. 
  
We confirmed that the provider has opted out of Medicare. However, the services meet the definition of 
emergent or urgently needed services. There is no evidence that the enrollee has signed a private contract with 
the provider for the services at issue. Based on this information, we decided that Medicare rules for coverage of 
dental services have been met. Therefore, we decided that the Plan does not have to pay for dental services 
provided by an opt-out provider on January 26, 2021, to May 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prefabricated abutment (D6056) and abutment supported 
porcelain/ceramic crown (D6058) provided on January 6, 2022. 
 
You asked the Plan to pay for the prefabricated abutment and abutment supported porcelain/ceramic crown. 
You say that the 2022 Evidence of Coverage is misleading, and does not list the name of the crowns that are 
covered, but only the codes. You also say that you would like to be reimbursed for these services. The Plan 
denied your request. The Plan says these services are not covered. 
 
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 the 
prefabricated abutment (D6056) and abutment supported porcelain/ceramic crown (D6058) provided on 
January 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Surgical preparation or creation of recipient site (15004) 
provided on September 30, 2021. 
 
You asked the Plan to pay for code 15004. You say that the medical records support the billing of code 15004. 
The Plan denied your request. The Plan says the medical records do not support the billing of code 15004. 
 
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 15004 is Surgical preparation or creation of recipient site 
by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar 
contracture, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet and/or multiple digits; first 100 
sq cm or 1% of body area of infants and children. 
 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 code 15004. Our reviewer says that the medical records do 
not support the billing of code 15004. Our reviewer found the case file does not contain documentation of 
excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar 
contracture. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 15004 have not been met. Therefore, we decided that the Plan does not 
have to pay for the Surgical preparation or creation of recipient site (15004) provided on September 30, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to provide in-network coverage for the inpatient care provided on August 22, 
2021, through August 25, 2021. 
 
You asked the Plan you asked the Plan to provide in-network coverage for inpatient care. You say that you 
would like the Plan to pay for the inpatient hospital services. The Plan denied your request. The Plan says that 
coinsurance is correct. 
 
The rules say that a Cost plan must disclose in writing all benefits available under the Plan. The health plan 
contract says that enrollees must pay $295 per day for days 1-6 of the admission for in-network care. 
 
You have been asked to pay $885 for inpatient care ($295/day x 3 days = $885). The inpatient care falls within 
the Inpatient hospital care benefit category. The Plan applied the 50% coinsurance to the inpatient stay since 
it was provided out of network, but the documentation supports that there was no network provider available to 
perform the necessary surgery. As such, we find that the Plan must apply the in-network cost sharing to this 
inpatient claim. This means that you do not have to pay this 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 has you asked the Plan to provide in-network coverage for the inpatient care provided on August 
22, 2021, through August 25, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve guided tissue regeneration (D4266), and removal of 
impacted tooth - completely bony (D7240 x 2). 
 
You asked the Plan to pre-approve guided tissue regeneration. You say that you need your wisdom teeth 
removed. You say that you cannot get other work done until these teeth are removed. You also say that it is 
hard for you to eat. The Plan denied your request. The Plan says guided tissue regeneration is not listed as 
covered. 
 
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 guided tissue 
regeneration not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pre-approve guided tissue regeneration (D4266), and removal of impacted tooth - completely bony (D7240 x 2).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on November 9, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening 
purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan 
does not have to pay for the laboratory services rendered on November 9, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve a core buildup (D2950) for tooth #8.
You asked the Plan to pre-approve a core buildup. You say that these crown services are necessary. The Plan denied your request. The Plan says that they have agreed to pre-approve the requested crowns (D2790); however, the core buildup is denied as it is not a covered service under your dental benefit.
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. In addition, the rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. We looked at the file and the Plan's rules. A core buildup, identified with code D2950, is listed as a covered service in the Plan's contract with a frequency of one per tooth every five plan years. No other criteria or argument for denial was provided. A crown has been pre-approved for this same tooth. Based on this information, we decided that the Plan's rules for coverage of a core buildup have been met. Therefore, we decided that the Plan has to pre-approve a core buildup (D2950) for tooth #8.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Freestyle Libre continuous glucose monitor (CGM) 
sensor for the enrollee. 
 
You asked the Plan to pre-approve CGM sensor. You say that the enrollee has problems with dexterity. The 
Plan denied your request. The Plan says that there is no evidence that the enrollee receives at least 3 insulin 
injections per day. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
CGM sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve Freestyle 
Libre continuous glucose monitor (CGM) sensor for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crowns (D2740) for tooth #'s 19 and 30 provided on 
September 8, 2021, and September 29, 2021. 
 
You asked the Plan to pay for the crowns. You say that you believe the Plan owes you $2,000 for the two 
crowns. You also say that both of these teeth had 50-year-old gold caps with failing margins, and porcelain 
replaced the gold. The Plan denied your request. The Plan says the records appear to show the filling and tooth 
are currently intact. The Plan also says that this treatment appears to be for preventive reasons and not to treat 
active dental disease. 
 
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 crowns 
when the services are medically necessary and reasonable.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the crowns. Our reviewer says that the 
crowns were not medically necessary. Our physician reviewer found both of these teeth have older crowns 
already placed on them as seen on the provided x-rays, the marginal integrity of #19 appears to be intact, and 
#30 may be slightly more questionable, but requires a clinical observation to confirm. There were no treatment 
notes included to support the contention that the crowns were not serviceable and had defective margins. Our 
reviewer found that unless there is clear radiographic evidence of decay at the margin of a crown, a clinical 
note from a provider indicating a finding of a decayed margin would be necessary. As there are no supplied 
clinical notes of the provider, there is insufficient support for the need for a replacement crown for either #19 
or #30. Our physician reviewer also found with the information provided, it cannot be found there is medical 
necessity for the replacement crowns. 
 
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 crowns have not been met. Therefore, we decided that the Plan does not 
have to pay for the crowns (D2740) for tooth #'s 19 and 30 provided on September 8, 2021, and September 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), first intraoral periapical 
x-ray (D0220), additional intraoral periapical x-ray (D0230), bitewing x-rays (D0274), prophylaxis (D1110), 
and crown (D2740) provided on August 24, 2021, and December 14, 2021 by a Medicare opt out provider. 
 
You asked the Plan to pay for the dental services. You say that you did not receive any notification from the 
Plan that the treating dentist was not in the Medicare dental network. You also say that you had no way of 
knowing that the treating provider had opted out of the Medicare network. The Plan denied your request. The 
Plan says you received these services from a provider who chose not to receive Medicare funds. 
 
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 
covered when they are received by a provider that has opted out of Medicare. Therefore, we decided that the 
Plan does not have to pay for the periodic oral evaluation (D0120), first intraoral periapical x-ray (D0220), 
additional intraoral periapical x-ray (D0230), bitewing x-rays (D0274), prophylaxis (D1110), and crown 
(D2740) provided on August 24, 2021, and December 14, 2021 by a Medicare opt out provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two gingivectomies (D4211 x2). 
 
You asked the Plan to pre-approve the gingivectomies. You say that gingivectomies are needed to access the 
cavities and restore the teeth to health. The Plan denied your request. The Plan says this service is not covered 
under the enrollee's 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve two 
gingivectomies (D4211 x2).