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

We decided that the Plan does not have to waive the copayment for an eye exam on April 21, 2022.

Per your 2022 Evidence of Coverage (EOC), Chapter 4, page 126, it states you are responsible for a $20 copayment for each Medicare-covered eye exam to diagnose and treat diseases and conditions of the eye. Therefore, based on the EOC, your appeal is partial overturned, and claim number will be reprocessed with a $20 copayment no later than July 1, 2022. You say that you received a bill for the $45 copayment for your eye exam. When you made the appointment, you stated it was for your annual eye exam. The Plan denied your request. The Plan says the claim was reprocessed to apply a $20 copayment for an eye exam.

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 $20 copayment for an eye exam. 

You have been asked to pay a $20 copayment for an eye exam. An eye exam falls within the vision care 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 copayment for an eye exam on April 21, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the enrollee was approved for 
lumbar fusion surgery and will need inpatient admission after surgery. The Plan denied your request. The Plan 
says there is no documentation provided to support the expectation the enrollee will require a greater than 2 
midnight stay. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.   
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case. Our physician reviewer found the enrollee is approved for lumbar fusion surgery. The record does not 
document that the treating physician has a reasonable expectation of a length of stay spanning 2 or more 
midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Freestyle Precision Neo Blood Glucose test strips. 
 
You asked the Plan to pre-approve the test strips. You say that you feel these should be covered because you 
have already been approved for the Freestyle Libre CGM. You would like to have the strips covered as a 
backup for emergencies in case there is an issue with the sensor. The Plan denied your request. The Plan says 
claims for a BGM or related supplies, billed in addition to an approved CGMs, will be denied. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. Per the Medicare guidelines, continuous glucose monitors (CGMs) 
replace standard home blood glucose monitors (BGMs) and related supplies, including blood glucose test 
strips. Claims for a BGM or related supplies, billed in addition to an approved CGMs, will be denied. As the 
requested items are not covered by Medicare or offered as a supplemental benefit, we are unable to approve 
your request. Please note, this is included in the monthly supply list, but it needs to be picked up at the same 
time as your other CGM supplies Based on this information, we decided that Medicare rules for coverage of 
the test strips have not been met. Therefore, we decided that the Plan does not have to pre-approve the 
Freestyle Precision Neo Blood Glucose test strips.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an alignable system (L5910) for a below-knee prosthesis. 
 
You asked the Plan to pre-approve an alignable system. You say that the requested item is a medical necessity 
for the enrollee. The Plan denied your request. The Plan says that rules for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a determination of the medical necessity for 
components/additions to the prosthesis is based on the beneficiarys potential functional abilities. 
 
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 an alignable system. Our reviewer says 
that the requested item is medically reasonable and necessary in this case. Our physician reviewer found that an 
alignable system is required on an endoskeletal prosthesis in order to properly adjust the alignment of the foot, 
pylon and socket. Without the requested component, the prosthesis cannot be adjusted to the mobility needs of 
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 an alignable system have been met. Therefore, we decided that the Plan has to 
pre-approve an alignable system (L5910) for a below-knee prosthesis.  
 
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 the extractions (dental code D7140). 
 
You asked the Plan to pre-approve the extractions. You say that you are in pain and the procedure needs to be 
done. The Plan denied your request. The Plan says the enrollee's dental benefits only provide coverage for 
dental services that are rendered by a participating general dentist; therefore, these services are not covered by 
the Plan's 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. The Plan covers 1 extraction 
of a tooth per year when performed by a participating general dentist. The Plan does not cover extractions when 
performed by an oral surgeon. 
 
  We looked at this the file, the Plans rules, and Medicare rules. Extractions when performed by an oral surgeon are 
not covered by the Plan. 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 pre-approve the extractions 
(dental code D7140).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dental bridge comprised of a pontic (D6241) and 
retainer crowns (D6751) for teeth #28-#31. 
 
You asked the Plan to pre-approve a dental bridge. You say that these services are necessary. The Plan denied 
your request. The Plan says the criteria for coverage of these services are not met. 
 
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 a dental 
bridge when this service is requested to replace one front upper tooth or two adjacent lower front teeth when 
there are no other teeth missing in the arch.  
 We looked at the file and the Plans rules. The fixed bridge in this case is requested to replace tooth #30, which 
is a posterior (back) tooth. The Plans allowance for fixed bridges does not extend to the replacement of 
posterior teeth. Based on this information, we decided that the Plan's rules for coverage of a dental bridge have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a dental bridge comprised of a 
pontic (D6241) and retainer crowns (D6751) for teeth #28-#31.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periapical x-rays (D0220) provided on April 14, 2022. 
 
You asked the Plan to pay for x-rays. You say that you needed a follow-up x-ray after a new dental issue arose 
after having your initial exam. The Plan denied your request. The Plan says this service is covered by the Plan's 
dental benefits; however, your benefits for one periapical x-ray every year has 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. The Plan covers one periapical 
x-ray (D0220) every year. 
 
We looked at this case file, the Plans rules, and Medicare rules. The record shows the Plan paid for periapical 
x-rays provided on March 29,2022; therefore, the benefit for periapical x-rays has been exhausted. Therefore, 
we decided that the Plan does not have to pay for periapical x-rays (D0220) provided on April 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system, expandable controller 
with harness, and electronic connection. 
 
You asked the Plan to pre-approve 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 must follow Medicare rules. Medicare rules say that an expandable controller is used to control 
multiple power options and a power seat elevation system is not covered. 
 
We looked at the file and Medicare rules. The file shows that the expandable harness is not needed to control 
the approved power switches. The requested power seat elevation system is not covered by Medicare. Based on 
this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a power seat elevation system, expandable controller 
with harness, and electronic connection.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the digital breast tomosynthesis rendered on October 14, 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 must follow Medicare rules. The rules say that the PC and TC for diagnostic services are separately 
payable when furnished in different payment localities. 
 
We looked at the file and Medicare rules. The file shows that the PC and TC were not performed in different 
payment localities. Based on this information, we decided that Medicare rules for coverage of these services 
have not been met. Therefore, we decided that the Plan does not have to pay for the digital breast 
tomosynthesis rendered on October 14, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on June 11, 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 laboratory shall not report multiple individual CPT 
codes describing the component test results.  
 
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results 
and was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay 
for the laboratory services rendered on June 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the consultation services (D9310) provided on January 27, 2022. 
 
You asked the Plan to pay for the consultation services. You say that you disagree with the denial of dental 
services. The Plan denied your request. The Plan says consultation services (D9310) are 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 the 
consultation services (D9310) provided on January 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bone replacement graft (D7953) provided by a participating 
provider on May 27, 2021. 
 
You asked the Plan to pay for a bone replacement graft. You say that you needed these services for your overall 
health. The Plan denied your request. The Plan says D7953 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 a bone replacement graft (D7953) provided by a 
participating provider on May 27, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance routine disposable supplies (A0398) provided 
on November 22, 2021. 
 
You asked the Plan to pay for the ambulance routine disposable supplies. You say that you would like this 
claim reprocessed and approved for payment. The Plan denied your request. The Plan says ambulance supplies 
are not separately payable per Medicare rules. 
 
The Plan must follow Medicare rules. Medicare rules say that that items and services which include but are not 
limited to oxygen, drugs, extra attendants, supplies, electrocardiogram, and night differential are no longer paid 
separately for ambulance services.
 
We looked at the file and Medicare rules. In this case, no separate payment is made for the ambulance supplies. 
Based on this information, we decided that Medicare rules for coverage of the ambulance routine disposable 
supplies have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance routine 
disposable supplies (A0398) provided on November 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the amalgam (D2150) provided on March 21, 2022 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the amalgam. You say that this was an emergency because your tooth broke and 
almost half was lost. 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 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, 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 amalgam (D2150) provided on March 21, 2022 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the molecular pharmacogenetic testing coded as 81220, 
81226, 81227, 81230, 81240, 81241, 81291, 81335, 81355 and 81479 provided May 17, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that please review the attached medical records 
and consider towards payment. The Plan denied your request. The Plan says does not meet Medicare 
NCD/LCD criteria. Service is not covered by Medicare. Services do not meet coverage requirements.  
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 code 81220, 81226, 81227, 81230, 81240, 81241, 81291, 81335, 81355 and 
81479 is not supported in the medical record. Specifically, Medicare denies coverage when a laboratory assays 
two or more genes in a patient in parallel. Those two or more genes will be considered part of the same panel. 
A panel constitutes a single procedural service, so one CPT code must be submitted for the panel. Based on this 
information, we decided that Medicare rules for coverage of the laboratory services have not been met. 
Therefore, we decided that the Plan does not have to pay for the molecular pharmacogenetic testing coded as 
81220, 81226, 81227, 81230, 81240, 81241, 81291, 81335, 81355 and 81479 provided May 17, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services rendered on June 21, 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 procedure codes 15002 and 15003 are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of 15002 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, trunk, arms, legs; first 100 sq cm or 1% of body area of infants and children. The definition of 
code 15003 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, trunk, arms, legs; each additional 100 
sq cm, or part thereof, or each additional 1% of body area of infants and children (List separately in addition to 
code for primary procedure). 
 
We find that CPT codes 15002 and 15003 are not supported in the medical record. Specifically, there is no 
documentation of surgical preparation or creation of recipient site by excision of open wounds for the first 100 
sq cm to support code 15002. Given that primary code 15002 is not supported, add-on code 15003 is also not 
supported. Based on this information, we decided that Medicare rules for coverage of these services have not 
been met. Therefore, we decided that the Plan does not have to pay for the surgical services rendered on June 
21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic radiographic image (D0330) provided March 
30, 2022. 
 
You asked the Plan to pay for the panoramic x-ray. You say that this service was necessary for your dentist to 
check your gums. 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 
panoramic radiographic image (D0330) provided March 30, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on September 24, 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 laboratory shall not report multiple individual CPT 
codes describing the component test results.   
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and 
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on September 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve complete upper dentures (D5110) and complete lower 
dentures (D5120). 
 
You asked the Plan to pre-approve dentures. You say that you cannot help it if you need new dentures. The 
Plan denied your request. The Plan says these services are covered by your dental benefits; however, your 
benefit for one complete upper and lower denture (D5120, D5110) every four years. 
 
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 complete 
upper and lower dentures (D5120, D5110) once every four years. 
 
We looked at this case file, the Plans rules, and Medicare rules. The record shows the Plan paid for complete 
upper and lower dentures provided on June 1, 2021; therefore, the benefit for complete upper and lower 
dentures has been exhausted. Therefore, we decided that the Plan does not have to pre-approve complete upper 
dentures (D5110) and complete lower dentures (D5120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a revaluation (D0170) and general anesthesia (D9222 and 
D9223), provided by an out-of-network provider on July 27, 2021, to January 1, 2022. 
 
You asked the Plan to pay for a revaluation and general anesthesia. You say that you would like the Plan to pay 
for these services. The Plan denied your request. The Plan says the rendered services have been correctly 
denied. 
 
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 a 
revaluation (D0170) and general anesthesia (D9222 and D9223), provided by an out-of-network provider on 
July 27, 2021, to January 1, 2022.