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

 
We decided that the Plan does not have to pay for code 93042 billed for date of service February 15, 2022. 
 
You asked the Plan to pay for code 93042. You say that you have provided medical records to support 
payment. The Plan denied your request. The Plan says payment for code 93042 is bundled into payment for 
code 99291.  
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 93042 
is a column II code to column I code 99291 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 code 93042 billed for date of service February 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an endosteal implant on tooth #3 (D6010) and sinus 
augmentation on tooth #3 (D7952) provided on July 25, 2022. 
 
You asked the Plan to pay for an implant and sinus augmentation. You say that the sinus augmentation should 
be paid in full using medical code 21210. The Plan denied your request. The Plan says an implant (D6010) and 
sinus augmentation (D7952) are not covered by your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 an 
endosteal implant on tooth #3 (D6010) and sinus augmentation on tooth #3 (D7952) provided on July 25, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery provided May 24, 2022, 
to May 25, 2022. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that you are on a fixed income. The 
Plan denied your request. The Plan says this cost sharing was charged 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 $298 
copayment for each Medicare-covered outpatient surgery.  
 
You have been asked to pay $596 for outpatient surgery. This item/service falls within the outpatient surgery 
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 outpatient surgery provided  
May 24, 2022, to May 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on June 9, 2022, by an OON 
provider. 
 
You asked the Plan to pay for laboratory services. The Plan denied your request. The Plan says the out-of-
network services were not authorized. 
 
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 laboratory services provided on June 9, 2022, by 
an OON provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance oxygen and oxygen supplies (A0436) 
provided on May 19, 2022.  
You asked the Plan to pay for the ambulance oxygen and oxygen supplies. You say that the services should be 
paid. The Plan denied your request. The Plan says the claim processed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that ambulance supplies are considered part of the 
general ambulance service and payment for them is included in the payment rate for the transport. Therefore, 
we decided that the Plan does not have to pay for the ambulance oxygen and oxygen supplies (A0436) 
provided on May 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0453 billed for date of service December 2, 
2021. 
 
You asked the Plan to pay for procedure code G0453. You say that these services were medically necessary 
and should be paid. The Plan denied your request. The Plan says payment for code G0453 is bundled into 
payment for code 95887. 
 
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 G0453 
is a column II code to column I code 95887. 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 G0453 billed for date of service December 2, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental bone grafts (code D7953) you received on June 9, 
2022. 
 
You asked the Plan to pay for the dental bone grafts (code D7953). You say that you did not know that these 
services were not covered. The Plan denied your request. The Plan says dental bone grafts are not covered 
under your dental 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 the dental bone 
grafts (code D7953) you received on June 9, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says criteria for admission to the Acute Inpatient Rehabilitation setting have not been met. 
Your ongoing skilled therapy and nursing needs can be provided at a lower level of 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 your medical problems are stable and there are no complex nursing or rehabilitation 
needs. There is no documented need for intensive rehabilitation services and medically necessary care can be provided in a different 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and retreatment 
of previous root canal therapy (D3347) provided on June 14, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the dental services. 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 out-of-network 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 out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for the comprehensive oral evaluation (D0150) and retreatment of previous root canal therapy (D3347) 
provided on June 14, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive periodontal evaluation (D0180) provided 
on May 20, 2022. 
 
You asked the Plan to pay for an evaluation. You say that you disagree with the denial of dental services. The 
Plan denied your request. The Plan says a comprehensive periodontal evaluation (D0180) is not covered by 
your routine dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
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 
comprehensive periodontal evaluation (D0180) provided on May 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral - complete series of radiographic images 
(D0210) provided on May 9, 2022. 
 
You asked the Plan to pay for the dental images. You say that you were not told how much the images would 
cost. The Plan denied your request. The Plan says the intraoral - complete series of radiographic images 
(D0210) are not covered under your supplemental dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
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 - complete series of radiographic images (D0210) provided on May 9, 2022.  
 
Your complaint about the quality of service you received from the provider 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 intraoral-periapical first radiographic image (D0220), 
intraoral-periapical each additional radiographic image (D0230), periodic oral evaluation (D0120), unspecified 
diagnostic procedure, by report (D0999), bitewing x-rays-two radiographic images (D0272), and the dental 
cleaning (D1110) provided on May 9, 2022. 
 
You asked the Plan to pay for the dental 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 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 that you received the dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, supplemental dental services must be received from a 
participating provider in order to be covered by the Plan. Therefore, we decided that the Plan does not have to 
pay for the intraoral-periapical first radiographic image (D0220), intraoral-periapical each additional 
radiographic image (D0230), periodic oral evaluation (D0120), unspecified diagnostic procedure, by report 
(D0999), bitewing x-rays-two radiographic images (D0272), and the dental cleaning (D1110) provided on  
May 9, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the dental services provided on April 28, 2022, and May 6, 2022.
  
You asked the Plan to pay for the dental services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that your annual dental allowance has been exhausted. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not provide documentation showing your dental allowance has 
been exhausted. Therefore, we decided that the Plan has to pay for the dental services provided on April 28, 
2022, and May 6, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the screening mammography provided on April 21, 2022, by 
an OON provider. 
 
You asked the Plan to pay for screening mammography. You say that you request immediate payment of this 
claim with the benefits quoted at the time of service. The Plan denied your request. The Plan says the out-of-
network services were not authorized. 
 
 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 the screening mammography provided on April 
21, 2022, by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay from April 14, 
2022, to April 21, 2022. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you should not be liable 
for copayments at two separate hospitals. The Plan denied your request. The Plan says this cost sharing was 
charged 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 $335 
copayment per day for days 1 to 6 of a Medicare-covered inpatient hospital stay.  
 You have been asked to pay $2010 for an inpatient hospital stay. This item/service falls within the inpatient 
hospital care benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayment for an inpatient hospital stay 
from April 14, 2022, to April 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing (81162, 81297, 81294, 81300). 
 
You asked the Plan to pre-approve genetic testing. You say that you have prostate cancer with Gleason score of 
8. You were ordered for genetic testing that can help diagnose the cancer and guide treatment. The Plan denied 
your request. The Plan says the request is not medically necessary because you do not have an advanced, 
metastatic, or recurrent cancer. There is no indication the physician is considering chemotherapy. In addition, 
the lab test is not FDA approved nor TA certified. 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 genetic testing. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the records do not show that you have a family history of ovarian, breast, pancreatic, or prostate 
cancer in close blood relatives. The medical records do not support that you met the guidelines for this test: 
Having personal history of prostate cancer in combination with family history of ovarian, breast, pancreatic, or 
prostate cancer. 
 
We looked at this physician's review, the file, and Medicare rules. 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 pre-approve genetic testing (81162, 81297, 81294, 81300).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the inpatient services provided on June 
7th, 2022, to June 10th, 2022. 
 
You asked the Plan to reduce the copayment for inpatient hospital care. You say that you should pay $325 
copayment and the Plan would pay the rest The Plan denied your request. The Plan says this cost sharing was 
charged 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 $325 
copayment per day for days 1 to 5 for inpatient hospital care. This inpatient hospital stay lasted 3 days, 
resulting in a copayment amount of $975 ($325 per day for 3 days = $975). 
 
You have been asked to pay $325 copayment per day for days 1 to 5 for inpatient hospital care. This 
item/service falls within the inpatient hospital 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 reduce the 
copayment for the inpatient services provided on June 7th, 2022, to June 10th, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the limited oral evaluation-problem focused 
(D0140) provided on March 24, 2021. 
 
You asked the Plan to issue reimbursement 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 at issue is not payable 
as it was rendered by a dental provider who has opted out of the Medicare program. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
 The service at issue in this appeal was provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to issue 
reimbursement for the limited oral evaluation-problem focused (D0140) provided on March 24, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on December 20, 2021, billed 
with codes 0031U, 0032U, 0033U, 81225, 81226, 81227, 81230, 81231, 81232, 81291, 81306, 81335 and 
81355. 
 
You asked the Plan to pay for the genetic testing billed. You say that these services were necessary and are 
supported in the records provided. The Plan denied your request. The Plan says this claim was not billed in 
accordance with Medicare rules. 
 The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) 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 code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
December 20, 2021, billed with codes 0031U, 0032U, 0033U, 81225, 81226, 81227, 81230, 81231, 81232, 
81291, 81306, 81335 and 81355.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for resin-based composite two surfaces, posterior on April 23, 
2022. 
 
You asked the Plan to pay for the dental services. You say that that when you found out additional dental work 
was needed and it exceeded your dental coverage, you contacted the plan and purchased additional coverage. 
The Plan denied your request. The Plan says you are allowed two procedure codes from this group per calendar 
year at 50% in-network. 
 
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. Therefore, 
we decided that the Plan does not have to pay for resin-based composite two surfaces, posterior on April 23, 
2022.