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

 
We decided that the Plan does not have to pre-approve office visit services to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve office visit services. You say that this care with an OON provider is 
medically necessary. The Plan denied your request. The Plan says there are in-network providers available to 
provide the care you need. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
office visit services to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a stair glide. 
 
You asked the Plan to pre-approve a stair glide. You say that the enrollee had a home chairlift installed as she 
was unable to navigate stairs even with her supplemental oxygen. This was medically necessary equipment and 
served a definitive purpose in the enrollee's health and safety. The Plan denied your request. The Plan says this 
item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pre-approve a stair glide.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the deep sedation/general anesthesia, first 15 minutes 
(D9222) and the deep sedation/general anesthesiaeach subsequent 15 minute increment (D9223) provided on 
December 2, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services are not a covered benefit under 
your contractual policy. 
 
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 services provided in this case are 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
deep sedation/general anesthesia, first 15 minutes (D9222) and the deep sedation/general anesthesiaeach 
subsequent 15 minute increment (D9223) provided on December 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on 
January 12, 2022. 
 
You asked the Plan to pay for a comprehensive oral evaluation. You say that the services were necessary. The 
Plan denied your request. The Plan says the benefit 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 a 
comprehensive oral evaluation once every 3 plan years.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a comprehensive oral evaluation have not been met. Therefore, we decided that the Plan does not 
have to pay for a comprehensive oral evaluation (D0150) provided on January 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a second opinion consultation provided on October 28, 2021. 
 
You asked the Plan to pay for a second opinion consultation. You say that the service was necessary. The Plan 
denied your request. The Plan says the service 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 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 second 
opinion consultation provided on October 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for limited oral evaluation (D0140), pin retention (D2951 x3), 
periapical first radiographic image (D0220), and resin-based composite (D2332) provided from August 9, 2021 
to August 24, 2021, December 20, 2021 and January 6, 2022. 
 
You asked the Plan to pay for limited oral evaluation, pin retention, periapical first radiographic image, and 
resin-based composite. You say that the services provided were necessary and payment should be rendered. 
The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not 
been met. 
 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 limited 
oral evaluation (D0140), pin retention (D2951 x3), periapical first radiographic image (D0220), and resin-
based composite (D2332) provided from August 9, 2021 to August 24, 2021, December 20, 2021 and January 6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for molecular cancer genomics (CGx) testing coded as 81201, 
81317, 81405, 81407, 81408 81479, 81295 and 81298 provided May 3, 2021. 
 You asked the Plan to pay for the laboratory services. You say that you are requesting a re-determination of the 
denial and have enclosed documentation to substantiate the claim. The Plan denied your request. The Plan says 
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 codes are not supported in the medical record. Specifically, for codes 81201, 
81317, 81405, 81407, 81408, 81479: If a laboratory assays two or more genes in a patient in parallel, then 
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. Also, a procedure to Procedure (PTP) edit exists 
between 81295, 81298 and 81432. This PTP edit has a modifier indicator of 0, which indicates there are no 
modifiers that are allowed with this PTP code pair. 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 molecular cancer genomics (CGx) testing coded as 81201, 81317, 81405, 81407, 81408 81479, 81295 
and 81298 provided May 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the complete mandibular denture (D5120) provided on 
November 1, 2021. 
 
You asked the Plan to pay for the complete mandibular denture. You say that when you contacted the Plan 
about in-network providers, you were advised that this treating provider was in-network. The Plan denied your 
request. The Plan says your dental maximum has been 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.  
Though the Plan offers a dental benefit in excess of Medicare coverage, the Plan offers a $2,500 annual dental 
allowance. The record shows that you met the annual maximum benefit while this claim for the November 1, 
2021 date of service was re-processed and your annual maximum benefit has been exhausted. Therefore, we 
decided that the Plan does not have to pay more for the complete mandibular denture (D5120) provided on 
November 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infectious agent detection by nucleic acid identified with 
code 87633 provided on December 28, 2020. 
 
You asked the Plan to pay for the infectious agent detection by nucleic acid. You say that you would like the 
plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not a 
covered benefit. 
 
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 infectious agent detection by nucleic acid test at issue in this appeal 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 infectious agent detection by nucleic acid identified with code 87633 provided on 
December 28, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transluminal balloon angioplasty services coded 37249 
and the intravascular ultrasound coded 37253 provided on September 13, 2021. 
 
You asked the Plan to pay for the transluminal balloon angioplasty and the intravascular ultrasound. 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 supported by the documentation. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. We find that CPT codes 37249 and 37253 
are not supported in the medical record. Specifically, the operative report did not include documentation of a transluminal balloon angioplasty (except dialysis circuit), by open or percutaneous approach, including all imaging and radiological supervision and interpretation necessary to perform the angioplasty within the same vein, for each additional vein (listed separately in addition to code for primary procedure); therefore, code 37249 cannot be verified. The operative report did not include documentation of intravascular ultrasound (noncoronary vessel) during diagnostic evaluation and/or therapeutic 
intervention, including radiological supervision and interpretation, for each additional noncoronary vessel 
(listed separately in addition to code for primary procedure); therefore, code 37253 cannot be verified. 
Therefore, we decided that the Plan does not have to pay for the transluminal balloon angioplasty services 
coded 37249 and the intravascular ultrasound coded 37253 provided on September 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the upper partial denture (D5213) and lower partial 
denture (D5214). 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing because you need your 
teeth to eat. The Plan denied your request. The Plan says this request exceeds the Plan's benefit frequency 
limitation. 
 
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. This service is a covered 
service but is allowed once every 5 years. The records show that D5213 was rendered December 12, 2019 and 
D5214 was rendered March 24, 2020.  
 
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 at this time. Therefore, we decided that the Plan does not have to pre-
approve the upper partial denture (D5213) and lower partial denture (D5214).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81479) provided on January 12, 2021. 
 You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed based 
on the medical documentation. The Plan denied your request. The Plan says this claim has not been billed as 
required by Medicare billing regulations. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Specifically, this claim was billed with the laboratory 
POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided 
that the Plan does not have to pay for the laboratory services (81479) provided on January 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a continuous glucose monitor (CGM).
You asked the Plan to provide coverage for a continuous glucose monitor (CGM). You say that a continuous
glucose monitor (CGM) is medically necessary. The Plan denied your request. The Plan says your physician
failed to submit medical records to show all of the required coverage criteria were met at the time of the appeal.
We overturned the Plan's denial for a lack of medical records.
The Plan requested a reopen and provided documentation to show several requests were sent to your physician
requesting medical records which were not responded to.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that therapeutic
CGMs are considered medically reasonable and necessary for enrollees when all of the required criteria are
met. The medical records provided by your physician must document these criteria. Your physician failed to
provide the required medical records. Therefore, we decided that the Plan does not have to provide coverage
for a continuous glucose monitor (CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cone beam computed tomography (CT) scan (D0367). 
 
You asked the Plan to pre-approve the dental service. You say that the services is medically necessary. The 
Plan denied your request. The Plan says cone beam CT scan is 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested cone beam CT scan is 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
cone beam computed tomography (CT) scan (D0367).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an abutment supported porcelain crown (D6058), and a 
custom fabricated abutment (D6057) provided by an out-of-network provider. 
 
You asked the Plan to pre-approve an abutment supported porcelain crown and a custom fabricated abutment. 
You say that you would like the Plan to approve these services. The Plan denied your request. The Plan says 
the requested dental 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 an 
abutment supported porcelain crown (D6058), and a custom fabricated abutment (D6057) provided by an out-
of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental bridge services (D6245, D6740) for teeth #12 and 
#13. 
 
You asked the Plan to pre-approve dental services. You say that these services are necessary, and you do not 
understand how your benefit is already exhausted. The Plan denied your request. The Plan says they have 
agreed to approve and pay for bridge services and crowns as requested for teeth #2 through #11; however, the 
cost of these services will exhaust your annual dental benefit allowance and therefore the Plan will not pay for 
the services on tooth #12 and tooth #13. 
 
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 will pay up to a 
maximum of $5,000 per year for comprehensive dental care. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the documentation shows that the 
services requested will exceed the annual allowance for services covered under this benefit. Therefore, we 
decided that the Plan does not have to pre-approve dental bridge services (D6245, D6740) for teeth #12 and 
#13.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 3 home health skilled nursing services. 
 You asked the Plan to pre-approve 3 home health skilled nursing services. You say that home health services 
are medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for 
home health skilled nursing services have not been met. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 3 home health skilled nursing services. 
Our reviewer says that the documentation does not support the requested home health skilled nursing services. 
Our physician reviewer found the documentation does not support that the member requires additional skilled 
nursing services or skilled rehab services to provide treatment that is medically necessary. The member does 
not require additional skilled nursing or rehab services to effectively provide treatment, care, and/or services in 
order to improve the members condition, perform a maintenance program to maintain the members condition 
and/or prevent deterioration. The member has been medically stable without any recent exacerbations of 
chronic medical problems or hospitalizations. The requested home health services are not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 3 home health skilled nursing services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve 3 home health skilled nursing services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 76705-26 billed for date of service February 19, 2022.
You asked the Plan to pay for procedure code 76705-26. You say that the patient had multiple exams on this date of service. The Plan denied your request. The Plan says payment for code 76705-26 is bundled into payment for code 93976.
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 76705-26 is a column II code to column I code 93976. 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 procedure code 76705-26 billed for date of service February 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown (D2740) provided on November 15, 2021. 
 
You asked the Plan to pay for the crown. You say that you should not have to pay for a service you did not 
receive. The Plan denied your request. The Plan says the copayment amount you are being charged is correct. 
 
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. The record shows that you were not enrolled in the optional 
supplemental dental benefit plan on this date of service. Therefore, we decided that the Plan does not have to 
pay for the crown (D2740) provided on November 15, 2021.   
Your complaint about having been provided indecent and unfinished service is not a valid appeal for medical 
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not 
permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation - established patient (D0120), 
prophylaxis - adult (D1110), bitewings - four radiographic images (D0274) and panoramic radiographic image 
(D0330) provided February 9, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the periodic oral exam, prophylaxis, bitewings and panoramic x-rays. You say 
that you were given misinformation. 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 Plans coverage rules apply in this case. The Plan covers the periodic 
oral exam, prophylaxis, bitewings and panoramic x-rays when the services are provided by a participating 
provider.  
 
We looked at the file and Medicare rules. The services in this case were provided OON. The services were not 
provided in an emergency situation. Based on this information, we decided that the Plan's rules for coverage of 
the periodic oral exam, prophylaxis, bitewings and panoramic x-rays have not been met. Therefore, we decided 
that the Plan does not have to pay for the periodic oral evaluation - established patient (D0120), prophylaxis - 
adult (D1110), bitewings - four radiographic images (D0274) and panoramic radiographic image (D0330) 
provided February 9, 2022, by an out-of-network (OON) provider.  
 
Your complaint about potentially being provided misinformation is not a valid appeal for medical coverage. 
This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to 
make a decision about these types of complaints.