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

 
We decided that the Plan does not have to pre-approve vascular surgery services including angioplasty and 
atherectomy (37221, 37224, 37226, 37227, 37228, 37229, 37230, 37229, 37230, 37231). 
 
You asked the Plan to pre-approve vascular surgery services. You say that this care is medically necessary for 
the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage have not been 
met as the records do not show blockage in enrollee's legs. 
 
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 vascular surgery services. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found at issue is whether the requested authorization for angiography and revascularization 
of lower extremity arteries is medically necessary. While the patient has a history of peripheral vascular 
disease, the non-invasive studies provided are not consistent with severe disease. In summary, there is 
insufficient documentation to support the medical necessity for lower extremity angiography and 
revascularization of lower extremity arteries in this patients clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of vascular surgery services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve vascular surgery services including angioplasty and atherectomy (37221, 
37224, 37226, 37227, 37228, 37229, 37230, 37229, 37230, 37231).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for topical application of fluoride varnish (D1206) provided by a 
participating provider on January 12, 2022. 
 
You asked the Plan to pay for topical application of fluoride varnish. You say that this was medically 
necessary. The Plan denied your request. The Plan says the dental work denied is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 topical 
application of fluoride varnish (D1206) provided by a participating provider on January 12, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital discharge day management (99239) provided on 
March 5, 2021. 
 
You asked the Plan to pay for discharge day management. You say that this service was billed appropriately. 
The Plan denied your request. The Plan says this service is not supported in the medical record. 
 
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 99239 is hospital discharge day management; more than 
30 minutes. 
 
We find that CPT code 99239 is not supported in the medical record. Specifically, medical records that note the 
amount of time spent providing this service on the date in question were not provided. Based on this information, we decided that Medicare rules for coverage of discharge day management have not been met. 
Therefore, we decided that the Plan does not have to pay for hospital discharge day management (99239) 
provided on March 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the loyalty program for the dental services including a 
periodic oral evaluation (D0120), complete series of intraoral x-rays (D0210), bitewing x-rays (D0274), 
panoramic x-ray (D0330), adjunctive pre-diagnostic test (D0431), and prophylaxis (D1110) which were 
provided on June 3, 2021. 
 
You asked the Plan to pay for the loyalty program. You say that the cost of the loyalty program ($384.00) is far 
less than the $1,000.00 dental allowance offered by the Plan. The Plan denied your request. The Plan says 
reward programs are not listed as a covered service. 
 
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 
loyalty program for the dental services including a periodic oral evaluation (D0120), complete series of 
intraoral x-rays (D0210), bitewing x-rays (D0274), panoramic x-ray (D0330), adjunctive pre-diagnostic test 
(D0431), and prophylaxis (D1110) which were provided on June 3, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the portion of the hereditary cardiovascular disease panel provided on 
July 24, 2021, described by two units of code 81404-XS. 
 
You asked the Plan to pay for the portion of the panel billed with 81404. You say that this testing was 
medically necessary. The Plan denied your request. The Plan says that it was found that this testing panel was 
not validly ordered by a treating physician and is statutorily noncovered as cardiovascular screening testing. 
This means that only 5 out of the six billed line items are payable. 
 
Please note: We reviewed the Plans argument and found it is not supported. The record clearly shows that this 
was ordered by a network provider. The argument regarding screening noncoverage is not supported because 
the enrollees diagnoses indicate signs/symptoms of cardiovascular disease.  
 
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 panel by a contract provider. The file does not show that the plan provided 
notice that the portion of the panel billed with 81404 would not be covered. In addition, the Plan paid all other 
codes, and no rationale was provided to support denying only code 81404. Under Medicare rules, this means 
the portion of the panel billed with 81404 is considered approved by the plan. Therefore, we decided that the 
Plan has to pay for the portion of the hereditary cardiovascular disease panel provided on July 24, 2021, 
described by two units of code 81404-XS.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99213) rendered by the out-of-network 
(OON) provider on February 1, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the office visit (99213) rendered by the out-of-network (OON) provider on February 1, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on December 29, 2021 by an out-of-network (OON) provider.

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 rendered by an out-of-network provider without prior authorization.

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 the office visit provided on December 29, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an amalgam (D2150 and D2160), and resin-based 
composites (D2391 and D2392) provided by a participating provider on December 1, 2021, to December 15, 
2021. 
 
You asked the Plan to pay for an amalgam and resin-based composites. You say that you believe that the 
fillings should be covered. The Plan denied your request. The Plan says the rendered 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 pay for an amalgam (D2150 and D2160), and resin-based composites (D2391 and D2392) provided by a participating 
provider on December 1, 2021, to December 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and 
intraoral periapical x-rays (D0220 and D0230) provided on December 28, 2021. 
 
You asked the Plan to pay for problem focused limited oral evaluation and intraoral periapical x-rays. You say 
that you would like to appeal these services. The Plan denied your request. The Plan says these services are not 
covered expenses under your dental plan. The Plan also says that you did not contact the Plan prior to the 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, 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 
problem focused limited oral evaluation (D0140) and intraoral periapical x-rays (D0220 and D0230) provided 
on December 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the sterile needle services (A4215) provided on October 18, 
2021. 
 
You asked the Plan to pay for the sterile needle services. You say that you would like this claim reprocessed 
based on the medical records. The Plan denied your request. The Plan says no separate payment is made for 
this code. 
 
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 A4215 is needle, sterile, any size, each.  
We looked at the file and Medicare rules. In this case, the code A4215 has a Status Code of X under the 
Physician Fee Schedule indicating that this code is not in the statutory definition of physician services for fee 
schedule payment purposes. Based on this information, we decided that Medicare rules for coverage of the 
sterile needle services have not been met. Therefore, we decided that the Plan does not have to pay for the 
sterile needle services (A4215) provided on October 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay the in network rate for the limited oral evaluation (D0140), 
simple extraction (D7140), deep sedation (D9222), and unspecified adjunctive procedure (D9999) provided on 
November 24, 2021. 
 
You asked the Plan to pay the in network rate for the oral evaluation, simple extraction, deep sedation, and 
unspecified adjunctive procedure. You say that the enrollee had an appointment with an in network provider. You say that the facility suffered damage. You also say that you made an appointment for the enrollee with an 
out of network provider. The Plan denied your request. The Plan says additional payment will not be made. 
 
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 and extractions are listed as covered, 
the frequency limit of 2 per calendar year has been exceeded. The record shows that the Plan paid for 2 
extractions that you received on the date of service in this case. Additionally, the limited oral evaluation, deep 
sedation, and unspecified adjunctive procedure are not among those covered under this benefit. Therefore, we 
decided that the Plan does not have to pay the in network rate for the limited oral evaluation (D0140), simple 
extraction (D7140), deep sedation (D9222), and unspecified adjunctive procedure (D9999) provided on 
November 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the 14 additional simple extractions (D7140 x14) and 
surgical extraction (D7210) provided on December 10, 2021, and December 21, 2021. 
 
You asked the Plan to pay for the additional extractions. You say that your dental plan has a $2,000 annual 
maximum. You also say that you would like the Plan to pay the provider the $2,000 maximum and you will 
pay the rest of the balance. The Plan denied your request. The Plan says your benefits for this service have been 
satisfied and the frequency limitation 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 Plans coverage rules apply in this case. 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, extractions are limited to two 
procedure codes per calendar year. The record shows that you received five simple extractions (D7140 x5) on 
December 10, 2021, two of which were covered by the Plan, and your extractions benefit has been exhausted. 
Therefore, we decided that the Plan does not have to pay for the 14 additional simple extractions (D7140 x14) 
and surgical extraction (D7210) provided on December 10, 2021, and December 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an out-of-network provider on 
February 17, 2022. 
 
You asked the Plan to pay for dental services. You say that the Plan told you that this provider was in-network. 
The Plan denied your request. The Plan says services provided 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. The Plan covers covered 
dental services when they are provided in-network. 
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of dental services have not been met. Therefore, we decided that the Plan does not have to pay for 
dental services provided by an out-of-network provider on February 17, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Opdivo (J9299). 
 
You asked the Plan to pre-approve Opdivo. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the 
requested drug has been prescribed for an off-label and medically unsupported use. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Opdivo. Our reviewer says that the 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the 
requested use of Opdivo is not FDA-approved for the enrollees diagnosis. The use is not supported by one of the major drug compendia or by clinical research that appears in a Medicare-approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Opdivo have not been met. Therefore, we decided that the Plan does not have to 
pre-approve treatment with Opdivo (J9299).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CxBladder test provided on November 26, 2021. 
 
You asked the Plan to pay for the testing services. You say that the testing aids in the detection of Urothelial 
Carcinoma. The Plan denied your request. The Plan says the testing is non-covered. 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 testing services. Our physician reviewer 
found that the CxBladder test is considered experimental/investigational as a screening test for urothelial 
cancer. Cystoscopy, ureteroscopy, possible biopsy and upper tract imaging will still be necessary regardless of 
the results of CxBladder testing. Urinary biomarker tests such as CxBladder give significant false-negative 
results in those with urothelial cancer and are subject to false-positive results in others. Accuracy is poor for 
low-stage and low-grade tumors. Therefore, the CxBladder testing is not  medically reasonable and necessary 
to treat the enrollee.  
 
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 testing services have not been met. Therefore, we decided that the Plan does 
not have to pay for the CxBladder test provided on November 26, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pharmacogenomic testing provided on October 13, 2021. 
 
You asked the Plan to pay for the pharmacogenomic testing. You say that this testing is medically necessary to 
evaluate the best medications for this enrollee. The Plan denied your request. The Plan says there is no 
evidence that this testing was ordered by a treating physician. As such, Medicare coverage rules are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 
The file does not contain documentation of an established relationship between the enrollee and the ordering 
provider. In addition, there was no order for the testing submitted with the appeal request. Without a record 
showing that this provider is treating the enrollee and that the test results will be used in patient management, 
the criteria for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to 
pay for the pharmacogenomic testing provided on October 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the UTID panel test (87653, 87798x13, 87651, 87640, 
87556, 87481, 87150x12) provided November 23, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you are appealing as the service was 
medically necessary and you request the Plan covers the service. The Plan denied your request. The Plan says 
the service is unbundled and does not meet Medicare criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Providers/suppliers must not unbundle the 
services described by a HCPCS/CPT code. 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 UTID panel test (87653, 87798x13, 87651, 87640, 87556, 
87481, 87150x12) provided November 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction, erupted tooth requiring removal of bone 
and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210) provided 
January 5, 2022. 
 
You asked the Plan to pay for the surgical extraction. You say that you would like this service covered. The 
Plan denied your request. The Plan says this service 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 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 extraction, erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of 
mucoperiosteal flap if indicated (D7210) provided January 5, 2022.