Persius/hicric huggingface dataset:
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 March 9, 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 March 9, 
2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the occupational therapy and physical therapy visits in your 
home provided from April 27, 2021, to May 22, 2021. 
 
You asked the Plan to pay for the home health services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the services were not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the occupational therapy and physical 
therapy visits in your home provided from April 27, 2021, to May 22, 2021. have been met. [ADJUDICATOR - ENTER INCOMPLETE, MISSING, OR INVALID DATA ELEMENTS]. Therefore, we decided that the 
Plan does not have to pay for the occupational therapy and physical therapy visits in your home provided from 
April 27, 2021, to May 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive evaluation (D0150) provided by a 
network provider on December 8, 2021. 
 
You asked the Plan to pay for the comprehensive evaluation (D0150). You say that you were charged for a 
cleaning although one never occurred. The Plan denied your request. The Plan says the service exceeded the 
frequency limitation in the benefit 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. 
 
The Plan also has a maximum benefit of one exam and cleaning every six months. The comprehensive 
evaluation (D0150) is not covered because the Plan paid for a comprehensive evaluation (D0150) on October 4, 
2021, which exhausted your benefit. The medical record also shows a cleaning was performed. Therefore, 
we decided that the Plan does not have to pay for the comprehensive evaluation (D0150) provided 
by a network provider on December 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220) and additional 
intraoral periapical x-ray (D0230) provided on November 23, 2021. 
 You asked the Plan to pay for the first intraoral periapical x-ray and additional intraoral periapical x-ray. You 
say that you do not understand why these services were denied. The Plan denied your request. The Plan says 
these 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 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 first 
intraoral periapical x-ray (D0220) and additional intraoral periapical x-ray (D0230) provided on November 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral - periapical first radiographic image (D0220) 
and intraoral - periapical each additional radiographic image (D0230) provided January 26, 2022. 
 
You asked the Plan to pay for the periapical x-rays. You say that the average person cannot be expected to 
know what type of x-ray is being provided. 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 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 
intraoral - periapical first radiographic image (D0220) and intraoral - periapical each additional radiographic 
image (D0230) provided January 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the replacement of missing or broken teeth, each tooth, 
(D5580) provided on December 14, 2021, by an out of network provider. 
 
You asked the Plan to pay for the dental service. You say that you would like an exception to be made. You say 
that under your previous plan you did not have to use a network provider to receive reimbursement. You also 
say that you will never make this mistake again. The Plan denied your request. The Plan says dental services 
received 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the replace missing or broken teeth is 
not among those covered under this benefit when received out of network. Therefore, we decided that the 
Plan does not have to pay for the replacement of missing or broken teeth, each tooth, (D5580) provided on December 14, 2021, by an out of network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on September 19, 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 19, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic panel testing provided on May 16, 2021. 
 
You asked the Plan to pay for genetic testing. You say that this panel is useful for patients at initial diagnosis or 
for a patient with refractory disease. The Plan denied your request. The Plan says the denial of payment for this 
testing is correct, because a panel constitutes a single procedural service so one code must be submitted for the 
panel. 
 
The Plan must follow Medicare rules. Medicare rules say that if a lab procedure produces multiple reportable 
test results, only a single procedure code shall be reported.  
 We looked at the file and Medicare rules. This testing was not billed with the appropriate coding. Based on this 
information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we 
decided that the Plan does not have to pay for genetic panel testing provided on May 16, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for diagnostic endoscopy provided on 
December 21, 2021. 
 
You asked the Plan to waive the copayment for a diagnostic endoscopy. You say that you need full coverage. 
The Plan denied your request. The Plan says the copayment has been 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 a $400 
copayment for diagnostic endoscopy.  
 
You have been asked to pay a $400 copayment for diagnostic endoscopy. Diagnostic Endoscopy falls within 
the Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory 
Surgical Centers 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 diagnostic 
endoscopy provided on December 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided by a participating 
provider on January 27, 2022. 
 
You asked the Plan to pay for a limited oral evaluation. You say that you were still having pain, and you 
needed to make another appointment. The Plan denied your request. The Plan says the benefit limit for D0140 
has already been met and 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 limited 
oral evaluation per plan year. 
 
We looked at the file and Medicare rules. Evidence was provided to show that D0140 was provided on January 
4, 2022. Based on this information, we decided that the Plan's rules for coverage of a limited oral evaluation 
have not been met. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation 
(D0140) provided by a participating provider on January 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pathology services provided on February 13, 2022. 
 
You asked the Plan to pay for the services provided. You say that the medical records provide evidence of 
medical necessity. The Plan denied your request. The Plan says the procedure code is inconsistent with the 
place of service. 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 code 85060 is a physician interpretation code. Separate payment may be made only if the 
physician interprets an abnormal smear for hospital inpatient. The claim shows the services at issue were 
provided to the enrollee as an outpatient. Based on this information, we decided that Medicare rules for 
coverage have not been met. Therefore, we decided that the Plan does not have to pay for the pathology 
services provided on February 13, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found you do not have documented skilled nursing 
needs or documented skilled therapy needs. You are not shown to have an acute decline in function. Your care 
needs, custodial and intermittent, can, as a practical matter, be provided at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on 
January 27, 2022. 
 
You asked the Plan to pay for the dental service. You say that you only went in for a cleaning. You say that you 
were not happy with your previous dentist. You say that cleaning is a covered service. You also say that you 
are getting a bill for $70 for D0150. The Plan denied your request. The Plan says a comprehensive oral 
evaluation is covered once every 3 plan years. The Plan also says that the frequency limit 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 and a comprehensive oral evaluation is 
covered once every 3 plan years, the frequency limit has been exceeded. The record shows that the Plan paid 
for a comprehensive oral evaluation that you received on July 6, 2021. Therefore, we decided that the Plan does 
not have to pay for the comprehensive oral evaluation (D0150) provided on January 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care services provided on October 29, 2021. 
 
You asked the Plan to pay for the services provided. You say that no changes are required. The Plan denied 
your request. The Plan says the billed code cannot be verified. 
 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 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. We find that CPT code 99291 is not supported in 
the medical record. Specifically, the records do not document the amount of time spent for the services 
provided. Based on this information, we decided that Medicare rules for coverage  of the services at issue have 
not been met. Therefore, we decided that the Plan does not have to pay for the critical care services provided on 
October 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a tooth extraction (D7140) provided by an out-of-network 
provider on September 19, 2019. 
 
You asked the Plan to pay for a tooth extraction. You say that you think the Plan should be paying for this. The 
Plan denied your request. The Plan says this was denied due to an untimely filing. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a tooth 
extraction when the services are medically necessary and reasonable.  
 
We looked at the file and Medicare rules. The rendering dentist is out-of-network. Based on this information, 
we decided that the Plan's rules for coverage of a tooth extraction have not been met. Therefore, we decided 
that the Plan does not have to pay for a tooth extraction (D7140) provided by an out-of-network provider on 
September 19, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for molecular pathology testing coded as 81275,81276, 81301 
provided April 8, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that based on the information provided in this 
appeal, you request for reconsideration of this determination and cover the Tempus Gene Panel test at the in-network benefit level. The Plan denied your request. The Plan says the records do not support the service 
billed. The services do not meet Medicare NCD/LCD 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. 
 
In this case, we find that CPT codes are not supported in the medical record. Specifically, if one laboratory 
procedure evaluates multiple genes using a next generation sequencing procedure, the laboratory shall report 
only one unit of service of one genomic sequencing procedure, molecular multianalyte assay, multianalyte 
assay with algorithmic analysis, or proprietary laboratory analysis CPT code. If no CPT code accurately 
describes the procedure performed, the laboratory may report CPT code 81479 (Unlisted molecular pathology 
procedure) with one unit of service. If a single procedure is performed, only one HCPCS/CPT code with one 
unit of service may be reported for the procedure. 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 pathology testing coded as 81275,81276, 81301 provided April 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on November 30, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says this claim has denied correctly.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Medicare rules say that specimen validity testing 
is not covered separately. 
 
The services at issue in this case are for the purpose of specimen validity testing. 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 laboratory services provided on November 30, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that this is medically necessary. The Plan denied 
your request. The Plan says that the clinical value and effectiveness of bone marrow aspirate in the setting of 
spinal fusion surgery have not been demonstrated in the peer-reviewed literature. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. There is a lack of 
large volume, long-term peer-reviewed outcome studies to support the use of bone marrow aspirate for this 
enrollee's medical condition. There is no compelling rationale presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception to guidelines. Our physician reviewer found that 
the enrollee's condition does not meet criteria for coverage of these services. 
 
We looked at this physician's review, the file, and Medicare rules. 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 bone marrow aspirate for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computerized tomography (CT) scan on 
February 10, 2022. 
 
You asked the Plan to waive the copayment for a computerized tomography (CT) scan. You say that you would 
like to appeal the cost share. The Plan denied your request. The Plan says based on a review of the claim the 
total cost share should be $295 and not $310. 
 
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 $295 
copayment for a computerized tomography (CT) scan.  
 
You have been asked to pay a $295 copayment for a computerized tomography (CT) scan. A computerized 
tomography (CT) scan falls within the Outpatient diagnostic tests and therapeutic services and 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 copayment for a computerized tomography (CT) scan on 
February 10, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Physical Therapy provided on January 6, 2022 to January 31, 
2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for Physical Therapy. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 Physical Therapy provided on January 6, 2022 to 
January 31, 2022 by an out-of-network (OON) provider.