Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the portable oxygen concentrator (E1390), and special 
service (99199), provided on October 15, 2021. 
 
You asked the Plan to pay for the portable oxygen concentrator and special service. You say that the items are 
medically necessary. The Plan denied your request. The Plan says you purchased these items from a provider 
that is not enrolled in Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
 
 Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the portable oxygen concentrator 
(E1390), and special service (99199), provided on October 15, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the initial hospital care provided by a network physician on August 7, 
2021. 
 
You asked the Plan to pay for the initial hospital care. You say that you were ordered by your primary care 
doctor and the service was done at a network facility. The Plan denied your request. The Plan says that no prior 
authorization was obtained. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for the initial hospital care by a contract provider. The file does not show that the Plan 
provided notice that the initial hospital care would not be covered. Under Medicare rules, this means the initial 
hospital care is considered approved by the Plan. Therefore, we decided that the Plan has to pay for the initial 
hospital care provided by a network physician on August 7, 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 four periodontal scalings and root planings (D4341 x4). 
 
You asked the Plan to pre-approve the scalings and planings. You say that you need the periodontal deep 
cleanings due to the bone loss in your gums. The Plan denied your request. The Plan says this service is not 
covered under your benefit 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 four 
periodontal scalings and root planings (D4341 x4).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for infectious agent detection testing provided on September 2, 2021. 
 
You asked the Plan to pay for lab test. You say that the ordering physician determined this testing was helpful 
to make informed decisions about the enrollee's treatment regime. The Plan denied your request. The Plan says 
that the denial of payment for this testing is correct, because this testing is not covered for screening purposes. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
This testing was ordered by an in-network provider. The file does not show that the plan provided notice that 
lab test would not be covered. Under Medicare rules, this means lab test is considered approved by the plan. 
Therefore, we decided that the Plan has to pay for infectious agent detection testing provided on September 2, 
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 pay for the comprehensive oral evaluation - new or established 
patient (D0150), prophylaxis - adult (D1110), and intraoral - complete series of radiographic images (D0210) 
provided December 8, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the comprehensive exam, dental cleaning and complete series of x-rays. You say 
that you would like these services covered. The Plan denied your request. The Plan says these services are not 
covered because they were provided OON. 
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 
comprehensive exam, dental cleaning and complete series of x-rays when the services are provided by an in-
network dental provider. 
 
We looked at the file and Medicare rules. 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. Based on this information, we decided that the Plan's rules for coverage of 
the comprehensive exam, dental cleaning and complete series of x-rays have not been met. Therefore, we 
decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established patient 
(D0150), prophylaxis - adult (D1110), and intraoral - complete series of radiographic images (D0210) provided 
December 8, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on September 22, 2021. 
 
You asked the Plan to pay for the laboratory services. 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. The rules say that laboratories shall not report multiple individual CPT 
codes describing the component test results. 
 
We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT code 81479. Therefore, we decided that the Plan does not have 
to pay for the laboratory services provided on September 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hereditary cardiovascular screening genetic panel (81401, 
81403, 81404, 81405, 81406, 81407, 81408) provided March 11, 2021. 
 You asked the Plan to pay for a hereditary cardiovascular screening genetic panel. You say that this is a 
covered service. The Plan denied your request. The Plan says this is excluded from Medicare coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular 
(CV) risk assessment panels, except the basic lipid panel, for symptomatic and asymptomatic patients. 
 
We looked at the file and Medicare rules. The services at issue are a CV risk assessment panel and are not 
covered. Based on this information, we decided that Medicare rules for coverage of a hereditary cardiovascular 
screening genetic panel have not been met. Therefore, we decided that the Plan does not have to pay for a 
hereditary cardiovascular screening genetic panel (81401, 81403, 81404, 81405, 81406, 81407, 81408) 
provided March 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics. 
 
You asked the Plan to pay for foot orthotics. You say that the item is medically necessary. The Plan denied 
your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pay for foot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for assembly and operation of pump (99190 and 99191), 
autologous blood or component (86891) and red blood cells (P9022) provided on July 7, 2021. 
 
  You asked the Plan to pay for assembly and operation of pump (99190 and 99191), autologous blood or 
component (86891) and red blood cells (P9022). You say that the patient did not have a choice of Perfusion 
providers because our service was arranged directly with the surgeon and facility. You say that the claim 
should be reprocessed according to the patients in- network level benefits since the services are considered 
medically necessary. The Plan says CPT codes 99190, 99191, 86891 and P9022 are included in payment to the 
facility. 
 
The Plan must follow Medicare rules. Medicare rules say that all items and non-physician services furnished to 
inpatients must be furnished directly by the hospital or billed through the hospital under arrangements. This 
provision applies to all hospitals, regardless of whether they are subject to PPS. 
 
We find that the services are not supported in the medical record. Specifically, all items and non-physician 
services furnished to inpatients must be furnished by the hospital or billed through the hospital. Based on this 
information, we decided that Medicare rules for coverage of assembly and operation of pump (99190 and 
99191), autologous blood or component (86891) and red blood cells (P9022) have not been met. Therefore, we 
decided that the Plan does not have to pay for assembly and operation of pump (99190 and 99191), autologous 
blood or component (86891) and red blood cells (P9022) provided on July 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies (K0553), 
provided on November 20, 2021. 
 
You asked the Plan to pay for the CGM supplies. You say that the items were medically necessary. The Plan 
denied your request. The Plan says the documentation submitted did not include valid proof of delivery [or] a 
delivery ticket to indicate the specific supplies. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay 
for the continuous glucose monitor (CGM) supplies (K0553), provided on November 20, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that you need additional care. The Plan denied your 
request. The Plan says SNF care is not medically necessary, and your needs can be met at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found you do not have documented skilled nursing 
needs or documented skilled therapy needs.  Daily skilled services are not shown to be required to establish a 
maintenance program or to prevent deterioration of your condition.  Your care needs can, as a practical matter, 
be provided at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a surgical placement of implant body: endosteal implant 
(D6010) and prefabricated abutment (D6056). 
 
You asked the Plan to pre-approve the endosteal implant and prefabricated abutment. 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 pre-approve a 
surgical placement of implant body: endosteal implant (D6010) and prefabricated abutment (D6056).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the omentum removal (49255) and hernia repair (49568) 
provided on September 10, 2021. 
  You asked the Plan to pay for the omentum removal (49255) and hernia repair (49568). The Plan denied your 
request. The Plan says CPT code 49255 cannot be billed with a modifier to bypass the edit. The Plan also says 
that CPT code 49568 was not billed with an appropriate 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 49255 
is a column II code to column I code 49587. This code cannot be billed with a modifier to bypass the edit. In 
addition, CPT code 49568 was not 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 the omentum removal (49255) and hernia repair (49568) provided on September 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete series of intraoral x-rays (D0210) provided on 
November 22, 2021. 
 
You asked the Plan to pay for the complete series of intraoral x-rays. You say that you were not notified that 
the complete series of intraoral x-rays (D0210) had a limitation of frequency. You also say that you do not 
want to pay for this service and feel it is the provider's fault. The Plan denied your request. The Plan says this 
service is limited to once every three years and the benefit has been exceeded. 
 
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, you are limited to one complete (full 
mouth) or panoramic series every 36 months. The record shows that you received a panoramic x-ray (D0330) 
on August 12, 2019 and your complete (full mouth) or panoramic series benefit has been exhausted. Therefore, 
we decided that the Plan does not have to pay for the complete series of intraoral x-rays (D0210) provided on 
November 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (82310, 82728, 83540, 83550 and 
84100) provided on September 8, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like reconsideration because 
there is no contractual agreement in place which indicates that the CPT codes at issue are included in the 
dialysis rate. The Plan denied your request. The Plan says the dialysis center is responsible for laboratory 
services related to the treatment of ESRD. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the laboratory services (82310, 82728, 83540, 83550 and 84100) provided on September 8, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services provided on November 3, 2021. 
 
You asked the Plan to pay for the laboratory services. 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. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for the laboratory services by a contract provider. The file does not show that the 
plan provided notice that the laboratory services would not be covered. Under Medicare rules, this means the 
laboratory services are considered approved by the plan. Therefore, we decided that the Plan has to pay for the 
laboratory services provided on November 3, 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 pay for the problem focused limited oral evaluation (D0140) 
provided on November 22, 2021. 
 
You asked the Plan to pay for the problem focused limited oral evaluation. You say that you were not told that 
you were only allowed one visit that is covered. You also say that you cannot afford to pay this bill. The Plan 
denied your request. The Plan says this service exceeds the maximum count allowed per period. 
 
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, problem focused limited oral 
evaluation (D0140) is limited to one procedure per plan year. The record shows that you received a problem 
focused limited oral evaluation (D0140). Therefore, we decided that the Plan does not have to pay for the 
problem focused limited oral evaluation (D0140) provided on November 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unspecified preventive procedure, by report (D1999) 
provided December 21, 2021. 
 
You asked the Plan to pay for the unspecified preventative procedure. You say that you did not have x-rays 
taken during your dental visit. The Plan denied your request. The Plan says your claim has been reprocessed 
and the complete series of x-rays was voided. The unspecified preventative procedure is not covered under 
your 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 the 
unspecified preventive procedure, by report (D1999) provided December 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the paravertebral facet joint injections (64493 and 64494) 
provided on October 19, 2021. 
 
You asked the Plan to pay for the paravertebral facet joint injections (64493 and 64494). You say that you 
cannot bundle 64493 and 64494 when they were performed by a different provider for a separate procedure. 
You say that the anesthesia was paid, and the main procedures should be paid. The Plan denied your request. 
The Plan says CPT code 64493 was not billed with an appropriate modifier to bypass the edit. The Plan also 
says that CPT code 64494 is an add-on code and is eligible for payment only if it is reported with an 
appropriate 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 64493 
is a column II code to column I code 01936. Code pair edits are applicable to services performed on the same 
day. CPT code 64493 has not been billed with an appropriate modifier to bypass the edit. In addition, CPT code 
64494 is an add on code and cannot be paid if the primary procedure code is not paid. 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 paravertebral facet joint injections (64493 and 64494) provided on October 19, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for cytopathology testing provided on June 18, 2021. 
 
You asked the Plan to pay for lab test. You say that this code represents an integral part of your testing process. 
The Plan denied your request. The Plan says that the denial of payment for this testing is correct, because this 
testing is not covered for screening purposes. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
This testing was ordered by an in-network physician. The file does not show that the plan provided notice that 
lab test would not be covered. Under Medicare rules, this means lab test is considered approved by the plan. 
Therefore, we decided that the Plan has to pay for cytopathology testing provided on June 18, 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.