Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140) and pulp vitality test 
(D0460) provided on December 23, 2021. 
 
You asked the Plan to pay for the dental services. You say that you had a referral for a consultation. You also 
say that you do not have $119 to pay this bill. The Plan denied your request. The Plan says 1 limited oral 
evaluation is covered per plan year. The Plan says that the frequency limit has been exceeded. The Plan also 
says that pulp vitality test 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage and limited oral evaluation is covered once per plan year, the frequency limit has been exceeded. The record shows that the Plan paid for a limited 
oral evaluation that you received on December 20, 2021. Additionally, the pulp vitality test is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the limited oral 
evaluation (D0140) and pulp vitality test (D0460) provided on December 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on August 30, 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 testing is not covered.  
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, genetic screening, was requested solely for screening purposes. Medicare does 
not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for 
the laboratory services rendered on August 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visits provided from May 17, 2021, 
to January 31, 2022. 
 
You asked the Plan to waive the copayment for the office visits. You say that the services should be covered as 
you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied correctly 
based on the services provided. 
 
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 $15 
copayment for Physician/Practitioner services, including doctor's office visits.  
 
 
  You have been asked to pay a $360 copayment for 24 office visits ($15 x 24 = $360). 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 office visits provided from May 17, 2021, to January 31, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abdominal ultrasound (76705) provided on January 24, 
2022. 
 
 
 
 You asked the Plan to pay for the ultrasound. You say that the enrollee received multiple exams on the date in 
question. The Plan denied your request. The Plan says a National Correct Coding Initiatives (NCCI) Procedure 
to Procedure (PTP) edit exists between 93976 and 76705. This PTP edit has a modifier indicator of 1, meaning 
modifiers associated with NCCI are allowed. However, an appropriate modifier was not billed with this PTP 
code edit. This service was not billed as required by Medicare coding regulations. 
 
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 
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 the abdominal ultrasound (76705) provided on January 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on August 25, 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 there is no valid physician order. 
 
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.  
 
We looked at the file and Medicare rules. The file does not contain documentation of an established 
relationship between the enrollee and the ordering provider. Without a record showing that this provider is 
treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the laboratory services rendered on August 25, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided from November 11, 2020, to 
November 13, 2020, as billed with Diagnosis Related Group (DRG) 190. 
 
 You asked the Plan to pay for inpatient care billed with DRG 190. You say that these services were medically 
necessary and are supported in the record. The Plan denied your request. The Plan says DRG 190 is not 
supported as the diagnosis of acute kidney failure with tubular necrosis (N17.0) is not supported in the medical 
record. The Plan argues that DRG 192 is more appropriate in this case. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes. 
 
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 inpatient care billed with DRG 190. Our 
reviewer says that the diagnosis of acute kidney failure with tubular necrosis (N17.0) is not supported in the 
medical record. Our physician reviewer found the enrollee presented with shortness of breath and cough. 
Clinical management addressed the key conditions of chronic obstructive pulmonary disease. The clinical notes 
did not reflect that acute kidney failure with tubular necrosis impacted the clinical resource utilization. The 
review has determined that the medical records did not support the billing of acute kidney failure with tubular 
necrosis (N17.0). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient care billed with DRG 190 have not been met. Therefore, we decided 
that the Plan does not have to pay for inpatient hospital care provided from November 11, 2020, to November 
13, 2020, as billed with Diagnosis Related Group (DRG) 190.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on August 4, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the services should be covered. The Plan 
denied your request. The Plan says the enrollees claim would be covered under Original Medicare as it is 
responsible for coverage of Part B benefits starting on the date of election until the last day of the month in 
which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage 
before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the laboratory services provided on August 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pin retention (D2951) and re-cement or re-bond crown 
(D2920) for tooth #9 provided on December 27, 2021. 
 
You asked the Plan to pay for the pin retention and re-cement or re-bond crown. You say that you understand 
why these services were denied, but it is your front tooth and you constantly have problems with it. You also 
say that you are doing all you can to save what you have left without having your teeth pulled. The Plan denied 
your request. The Plan says the pin retention is not covered under your dental plan. The Plan also says that your 
benefit plan has a limit for how often a re-cement or re-bond crown is 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, pin retention (D2951) is not among 
those covered under this benefit. The contract also says that re-cementation is limited to one per tooth per year. 
The record shows that you received a re-cement or re-bond crown (D2920) on tooth #9 on January 21, 2021 
and your re-cementation benefit for tooth #9 has been exhausted. Therefore, we decided that the Plan does not 
have to pay for the pin retention (D2951) and re-cement or re-bond crown (D2920) for tooth #9 provided on 
December 27, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abdominal ultrasound (76705) provided on January 15, 
2022. 
 
You asked the Plan to pay for the ultrasound. You say that the enrollee received multiple exams on the date in 
question. The Plan denied your request. The Plan says a National Correct Coding Initiatives (NCCI) Procedure 
to Procedure (PTP) edit exists between 93976 and 76705. This PTP edit has a modifier indicator of 1, meaning modifiers associated with NCCI are allowed. However, an appropriate modifier was not billed with this PTP 
code edit. This service was not billed as required by Medicare coding regulations. 
 
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 
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 the abdominal ultrasound (76705) provided on January 15, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Orthovisc. 
 
You asked the Plan to pre-approve Orthovisc. The Plan denied your request. The Plan says you have not tried 
and failed Durolane and Gelsyn-3. 
 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We looked at the file, and Medicare rules. The Plan requires a trial of Durolane and Gelsyn-3 before they will 
approve the requested drug. The limited records provided do not show that you have tried and failed both 
Durolane and Gelsyn-3. Based on this information, we decided that Medicare rules for coverage of Orthovisc 
have not been met. Therefore, we decided that the Plan does not have to pre-approve Orthovisc.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pre-approve Signatera molecular genetic testing for the enrollee. 
 
You asked the Plan to pre-approve the testing. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this test remains unproven and can still be considered experimental and 
investigational.  
The Plan must follow Medicare rules. Medicare rules say that services are covered when they are medically 
necessary. 
 
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 the testing. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found plasma postoperative circulating tumor DNA (ctDNA) testng detects minimal residual disease (MRD) 
and identifies patients at high risk of relapse in localized colon cancer. The enrollee has stage III colon cancer, 
and is status post folfox chemotherapy. 
 
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 have been met. Therefore, we decided that the Plan has to pre-
approve Signatera molecular genetic testing for the enrollee.  
 
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 intraoral imaging (D0210) provided by a participating 
provider on January 4, 2022. 
 
You asked the Plan to pay for intraoral imaging. You say that you were not made aware that they were doing 
intraoral imaging. The Plan denied your request. The Plan says D0210 is not a covered dental benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
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 intraoral 
imaging (D0210) provided by a participating provider on January 4, 2022.
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 
January 14, 2022. 
 
You asked the Plan to pay for the complete series of intraoral x-rays. You say that your dentist contacted the 
Plan to inquire about services that would be covered. You also say that you are on a limited income and need 
help paying for this. The Plan denied your request. The Plan says this service is not a covered expense under 
your dental plan. 
 
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 
complete series of intraoral x-rays (D0210) provided on January 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair. 
 
You asked the Plan to pre-approve a power wheelchair. You say that you have rheumatoid arthritis among 
other health impairments that causes extreme difficulties when it comes to doing anything for yourself such as 
walking to the bathroom or getting to your bed. The Plan denied your request. The Plan says the records do not 
show that the enrollee meets the Medicare criteria for power wheelchairs. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 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 a power wheelchair. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the documentation does not support that the enrollee has a mobility limitation that 
significantly impairs her ability to participate in one or more mobility-related activities of daily living 
(MRADLs) such as toileting, feeding, dressing, grooming, and bathing in customary locations in the home. The 
documentation does not support that the enrollees mobility limitation cannot be sufficiently resolved by the 
use of an appropriately fitted walker. The documentation does not support that the use of a power wheelchair 
will significantly improve the enrollee s ability to participate in MRADLs and the enrollee will use it on a 
regular basis in the home.  A 4/1/22 PT Periscope assessment states that the enrollee is a functional ambulator 
and able to complete community distance ambulation with a 4WW. She can walk and move around her home 
in order to complete ADLs independently and safely. The criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a power wheelchair have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power wheelchair.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for emergency room (ER) visits provided on 
October 13, 2021, and October 18, 2021. 
 
You asked the Plan to waive the copayments for the ER visits. You say that you should not have to pay these 
charges because of COVID-19. The Plan denied your request. The Plan says you have been charged the correct 
cost sharing amount. 
 
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 $90 
copayment for each emergency room visit.  
 
The record shows that as of April 1, 2021, there are no cost share waivers are in effect. You have been asked to 
pay a $90 copayment for each ER visit on October 13, 2021, and October 18, 2021. An ER visit falls within the 
Emergency 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 copayments for emergency room 
(ER) visits provided on October 13, 2021, and October 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation feature (E2300). 
 
You asked the Plan to pre-approve a power seat elevation feature. You say that this device is medically 
necessary. The Plan denied your request. The Plan says this item is statutorily non-covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a power seat elevation feature (E2300).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for DME and supplies provided from July 31, 
2021, to December 28, 2021. 
 
You asked the Plan to waive the coinsurance for DME  and related supplies. You say that you were advised 
there would be no charge. The Plan denied your request. The Plan says the coinsurance applied correctly. 
 
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 20% 
coinsurance for Medicare-covered durable medical equipment and related supplies. 
 
 
  You have been asked to pay a total of $227.70 for DME and related supplies.  
 
Date of Service Allowed Amount Standard Cost Member Liability 
July 31, 2021 $189.74 20% $37.95 
August 30, 2021 $189.74 20% $37.95 
September 29, 2021 $189.74 20% $37.95 
October 29, 2021 $189.74 20% $37.95 
November 28, 2021 $189.74 20% $37.95 
December 28, 2021 $189.74 20% $37.95 
TOTAL: $1,138.44  $227.70 
 
DME supplies fall within the Durable medical equipment (DME) and related supplies 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 coinsurance for durable medical equipment (DME) and related supplies 
provided from July 31, 2021, to December 28, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the full Biodesix lung reflex test panel provided to the 
enrollee on September 13, 2021. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says only the tests on the panel that are most likely to be helpful can be approved. 
 
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 the various denied CPT codes are not supported in the medical record. Specifically, there are three 
remaining codes that are still denied from this panel. In this case, it is not appropriate to individually report 
each of these codes. A single code should be used. The plan has already paid for one code in this case. Based 
on this information, we decided that Medicare rules for coverage of the services have not been met.  Therefore, we decided that the Plan does not have to pay for the full Biodesix lung reflex test panel provided to 
the enrollee on September 13, 2021.