Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the iron binding capacity testing provided on November 18, 
2021, billed with code 83550. 
 You asked the Plan to pay for the billed code. You say that this should be paid. The Plan denied your request. 
The Plan says all testing was approved for payment except for 83550. This cannot be separately paid on the 
same date as 84466. 
 
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 83550 
is a column II code to column I code 84466 with a modifier indicator of 0. The column II code is therefore not 
payable. 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 iron binding capacity testing provided on November 18, 2021, billed with 
code 83550.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that criteria for admission to the IRF setting have not 
been met. The enrollee's ongoing skilled therapy and nursing needs can be provided at a lower level of care The 
Plan denied your request. The Plan says the enrollee will benefit significantly from IRF care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of the enrollees nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does 
support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-
disciplinary rehabilitation program. There is not a reasonable expectation that the enrollee will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for dental services provided on March 8, 
2022. 
 
You asked the Plan to waive the coinsurance for the dental services. The Plan denied your request. The Plan 
says the correct coinsurance amount was applied. 
 
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 50% 
coinsurance for out-of-network non-Medicare covered preventive and comprehensive dental services.  
 
You have been asked to pay $168 for the dental services. The dental services fall within the Dental Services 
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 dental services provided on 
March 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for arthrocentesis and dexamethasone injection provided on 
March 18, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for arthrocentesis and dexamethasone injection. You say that you are appealing the 
claim payment denial. The Plan denied your request. The Plan says the services were provided out-of-network 
and were not approved in advanced. 
 
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 arthrocentesis and dexamethasone injection 
provided on March 18, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a laboratory panel provided to the enrollee on December 12, 
2021. 
 You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says this should be reported with one code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT 81479. 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 a laboratory panel provided to the enrollee on December 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), bitewing x-rays 
(D0274), and prophylaxis (D1110) provided on February 8, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the dental services. You say that you have been a patient of this provider's since 
at least 2009 with no insurance issues. You also say that the provider sold his practice and failed to inform you 
of the change. The Plan denied your request. The Plan says the dental services were received from an out-of-
network provider and are not covered by your supplemental 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 record shows you received the requested dental services from an OON provider. Though the Plan offers a 
dental benefit in excess of Medicare coverage, the requested items or services are not covered under this 
benefit when received from an OON provider. Therefore, we decided that the Plan does not have to pay for the 
periodic oral evaluation (D0120), bitewing x-rays (D0274), and prophylaxis (D1110) provided on February 8, 
2022, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Reblozyl. 
 
You asked the Plan to pre-approve Reblozyl. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Reblozyl. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the Food and Drug Administration has not 
stated that the requested drug is indicated for the enrollee's condition. The Medicare approved drug compendia 
do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. The 
elements of the coverage criteria are not satisfied. The requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Reblozyl have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Reblozyl.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to reimburse you for the dental services received on March 30, 2022. We decided 
that the Plan does not have to reimburse you for .  
 
You asked the Plan to reimburse you for the dental services. You say that you should be reimbursed $303.66 
for the dental services you received. The Plan denied your request. The Plan says the claim is not eligible for 
reimbursement. The Plan says that there was no evidence provided to support that the claim was mailed before 
the run-out date of March 31, 2022, or any proof that the letter was lost by the post office. 
 
Medicare generally does not cover supplemental services. However, the Plan offers a supplemental benefit that 
exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this case.  
 
We decided that the Plan has to reimburse you for the dental services received on March 30, 2022.  
 
The Plan offers a benefit for supplemental services where the claim must be received by the run-out date, 
March 31, 2023. The record shows that the claim was received on April 2, 2022. Therefore, we decided that the 
Plan has to reimburse you for the dental services received on March 30, 2022.  
 
We also decided that the Plan does not have to reimburse you for the dental services received on October 
14, 2021. 
 
Though the Plan offers a supplemental benefit in excess of Medicare coverage, the claim was not received on 
or before the run-out date of March 31, 2022. The record shows that the claim was postmarked April 2, 2022.  
Therefore, we decided that the Plan does not have to reimburse you for the dental services received on October 
14, 2021. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation services provided on May 7, 2021. 
 
You asked the Plan to pay for the services provided. You say that the claim was billed correctly. The Plan 
denied your request. The Plan says the service was not billed as required. 
 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 99153 is a technical component only code. There is a more comprehensive code that 
describes the professional component of the service at issue.  Based on this information, we decided that 
Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan 
does not have to pay for the moderate sedation services provided on May 7, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a laboratory panel provided to the enrollee on January 6, 
2022. 
 You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the claim submitted was found to include multiple genes billed individually, using T1 codes, 
which were all part of a genomic sequencing panel. 
 
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, the testing at 
issue in this case should be reported with CPT 81479. 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 a laboratory panel provided to the enrollee on January 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional intraoral periapical x-ray (D0230) provided on 
April 4, 2022. 
 
You asked the Plan to pay for the additional intraoral periapical x-ray. You say that when you joined this plan 
you were told that the facility you were treated at was in-network. You also say that you would not have gone 
to this dental office if it were out-of-network. The Plan denied your request. The Plan says your benefit for the 
requested item or service has already 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service April 4, 2022. Therefore, 
we decided that the Plan does not have to pay for the additional intraoral periapical x-ray (D0230) provided on 
April 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) provided 
on March 2, 2022. 
 
You asked the Plan to pay for the comprehensive periodontal evaluation. You say that you assumed this service 
would be covered with no copay. The Plan denied your request. The Plan says this service is not a covered 
benefit 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 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 
comprehensive periodontal evaluation (D0180) provided on March 2, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the incomplete endodontic therapy (D3332) provided on March 30, 
2022. 
 
You asked the Plan to pay for the incomplete endodontic therapy. You say that you believe this service should 
be included under your benefits, and count toward your $1,000 benefit. The Plan denied your request. The Plan 
says that this service is not covered under your benefit plan. 
 
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.  
 
We looked at the file and Medicare rules. The record shows that you received an incomplete endodontic 
therapy (D3332), which the Plan denied as not being covered. The 2022 Evidence of Coverage states 
endodontic services including root canals are covered. The contract does not clearly state what type(s) of root 
canals are covered. The documentation does not show that your root canal benefit had been exhausted prior to 
this date of service. Based on this information, we decided that the Plan's rules for coverage of the incomplete 
endodontic therapy have been met. Therefore, we decided that the Plan has to pay for the incomplete 
endodontic therapy (D3332) provided on March 30, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service January 13, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that you have provided medical records to 
support the services billed. The Plan denied your request. The Plan says procedure code 99100 is considered 
bundled and not separately payable. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service January 13, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a breast augmentation with implant (19325). 
 
You asked the Plan to pre-approve a breast augmentation with implant. You say that the requested service is a 
medical necessity for you. The Plan denied your request. The Plan says rules for coverage have not been met 
because the requested service is cosmetic. 
 
The Plan follows Medicare rules. Medicare rules say that reconstructive surgery is performed on abnormal 
structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors or 
disease. The rules also say that cosmetic surgery and related services 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 a breast augmentation with implant. 
Our reviewer says that the requested service is not medically reasonable and necessary in this case. Our 
physician reviewer found that the requested procedure is not being performed to repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, disease or to 
improve function. 
 
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 breast augmentation with implant have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a breast augmentation with implant (19325).
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve extraction of roots with bone, tooth 11 (CPT code D7250). 
 
You asked the Plan to pre-approve the extraction. You say that the service is medically necessary. The Plan 
denied your request. The Plan says that the x-rays do not support the code requested. The Plan states a less 
severe extraction code would be considered. 
 
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 extraction 
when the services are medically necessary and reasonable. 
 
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 extraction. Our physician reviewer 
found the documentation provided meets the criteria for coverage for procedure D7250, cutting procedure for 
removal of a residual root tooth #11. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the extraction have been met. Therefore, we decided that the Plan has to pre-
approve extraction of roots with bone, tooth 11 (CPT code D7250).  
 
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 the core buildups, including any pins when required 
(D2950), endodontic therapy (D3310), gingival irrigations (D4921), and to pay more for the periodontal 
scalings and root planings (D4341) provided on April 22, 2022. 
 
  You asked the Plan to pay for the core buildups, endodontic therapy, gingival irrigations, or pay more for the 
scalings and planings. You say that you were not advised of the charges prior to these services being rendered. 
The Plan denied your request. The Plan says the core buildups, endodontic therapy, gingival irrigations are not 
covered expenses under your dental plan. The Plan also says that the copayment amounts you were charged for 
the scalings and planings are 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, core buildup, including any pins when 
required (D2950), endodontic therapy (D3310), and gingival irrigation (D4921) are not among those covered 
under this benefit. The contract clearly states that you are responsible for a $25 copayment for scalings and root 
planings rendered by an in-network provider. Therefore, we decided that the Plan does not have to pay for the 
core buildups, including any pins when required (D2950), endodontic therapy (D3310), gingival irrigations 
(D4921), and to pay more for the periodontal scalings and root planings (D4341) provided on April 22, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Deep Brain Stimulation (DBS) placement to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve DBS placement to be provided by an OON provider. You say that the 
services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able 
to provide these services. Therefore, coverage criteria have not been met. 
 
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 
Deep Brain Stimulation (DBS) placement to be provided by an out-of-network (OON) provider.