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

 
We decided that the Plan does not have to pay for the hip x-ray (73502) and postoperative follow up visit 
(99024) provided on April 14, 2021. 
 
You asked the Plan to pay for the outpatient services. You say that the services rendered were not related to the 
enrollee's hospice care or benefits. 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 hip x-ray (73502) and postoperative follow up visit 
(99024) provided on April 14, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the angiography services provided on November 23, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the codes are 
not supported in the documentation. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 75716 is angiography, extremity, bilateral, radiological 
supervision and interpretation. The CPT Code Manual definition of code 75774 is angiography, selective, each 
additional vessel studied after basic examination, radiological supervision and interpretation (List separately in 
addition to code for primary procedure). 
 
We looked at the file and the rules. Open and percutaneous interventional vascular procedures include 
operative angiograms which shall not be separately reported as diagnostic angiograms. 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 angiography services provided on November 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a shoulder orthosis (L3670), provided on December 21, 
2021. 
 
You asked the Plan to pay for a shoulder orthosis. You say that the item should be covered. The Plan denied 
your request. The Plan says the member had already received this item. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that B. Melons had a shoulder orthosis (L3670) at the time a shoulder orthosis was received. a 
shoulder orthosis (L3670) serves the same purpose as a shoulder orthosis. Therefore, we decided that the Plan 
does not have to pay for a shoulder orthosis (L3670), provided on December 21, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the COVID-19 test (87635) provided on October 30, 2021. 
 
You asked the Plan to pay for the COVID-19 test. You say that you were in Ireland and were not able to enter 
the United States until the test was negative. The Plan denied your request. The Plan says it was determined 
that you had received a COVID-19 test while traveling. The Plan also says that a COVID-19 test for travel 
purposes is not considered medically necessary, and the test was not ordered by a physician. 
 
The Plan must follow Medicare rules. Medicare rules say that routine services required by third parties such as 
business establishments are not covered by Medicare.  
 
We looked at the file and Medicare rules. This testing was required by an airline for the purposes of routine 
travel. Based on this information, we decided that Medicare rules for coverage of screening testing have not 
been met. Therefore, we decided that the Plan does not have to pay for the COVID-19 test (87635) provided on 
October 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown (D2740) provided on January 11, 2022 
 
You asked the Plan to pay for the crown. You say that your dental coverage for 2022 was changed without your 
knowledge, and you did not authorize the changes to your policy. The Plan denied your request. The Plan says 
this service is not a covered expense under your dental plan. The Plan also says that you were sent an Annual 
Notice of Change (ANOC) that was mailed out to you on September 17, 2021 advising you of changes to your 
upcoming 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 crown 
(D2740) provided on January 11, 2022
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene panel provided on October 4, 2021. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says one code must 
be submitted for the 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. 
 
The file shows that a lung cancer gene panel was provided. The claim billed the gene panel with multiple 
codes. If a single procedure is performed, only one code with one unit of service may be reported for the 
procedure. 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 gene panel provided on October 4, 2021.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay for the problem focused limited oral evaluation (D0140). We decided that 
the Plan does not have to pay for the incision and drainage of abscess (D7510).  
 
You asked the Plan to pay for the problem focused limited oral evaluation (D0140) and incision and drainage 
of abscess (D7510). You say that the abscess was medically necessary, and the oral evaluation had to be 
completed before you could receive the root canal. The Plan says that the incision and drainage of abscess is 
not a covered service. The Plan also says that the frequency limitation has been met for the problem focused 
limited oral evaluation. 
 
We decided that the Plan has to pay for the problem focused limited oral evaluation (D0140).  
 
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 record shows that you received a problem focused limited oral evaluation 
(D0140) on January 12, 2022, which the Plan denied for exceeding the frequency limitation. The contract says 
that you are allowed one exam every six months. The Plan did not provide any documentation showing the last 
time you received an oral exam. Therefore, we decided that the Plan has to pay for the problem focused limited 
oral evaluation (D0140).  
 
We also decided that the Plan does not have to pay for the incision and drainage of abscess (D7510). 
 
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, incision and drainage of abscess 
(D7510) is not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pay for the incision and drainage of abscess (D7510). 
 
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 the services provided from August 31, 2021, to September 
23, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the services 
were not billed as required by 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. 
 
The file shows that CPT code 99072 was billed for services provided on August 31, 2021. We find that CPT 
code 99072 has a status indicator of B on the Physician Fee Schedule. This means that CPT code 99072 is not 
separately payable.  
 
The file shows that CPT code 97110 was billed with G0238 on September 23, 2021. We have confirmed that 
code 97110 is a column II code to column I code G0238. 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 services provided from August 31, 2021, to 
September 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on July 9, 2021, billed with 
codes 81206, 81235, and 81321. 
 
You asked the Plan to pay for the genetic testing as billed. You say that this is a medically necessary procedure. 
The Plan denied your request. The Plan says this is not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that 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 code.   
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the genetic testing as billed have not been met. Therefore, we decided that the Plan does not have 
to pay for the genetic testing provided on July 9, 2021, billed with codes 81206, 81235, and 81321.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an interim complete maxillary denture (D5810) provided by 
a participating provider on August 12, 2021. 
 
You asked the Plan to pay for an interim complete maxillary denture. You say that you would like the Plan to 
pay for this. The Plan denied your request. The Plan says this claim has been correctly processed and denied. 
 
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 interim 
complete maxillary denture (D5810) provided by a participating provider on August 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Shingrix vaccine received on October 7, 2021. 
 
You asked the Plan to pay for the Shingrix vaccine. You say that the service should be covered. The Plan 
denied your request. The Plan says this is not a covered service. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Shingrix 
vaccine. The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the Shingrix 
vaccine. Therefore, we decided that the Plan does not have to pay for the Shingrix vaccine received on October 
7, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the anesthesia services provided on March 13, 2020. 
 
You asked the Plan to pay for the anesthesia services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that they were unable to make a determination 
within the allotted time frame. 
 
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 has not provided sufficient evidence based on Medicare criteria for 
their denial of payment for these services. Therefore, we decided that the Plan has to pay for the anesthesia 
services provided on March 13, 2020.  
 
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 drug testing services provided on July 13, 2021. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the billed code 
cannot be verified. 
 
 The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. The claim in this case was billed with the laboratory POS code. The 
records do not support that the sample was taken in a laboratory setting. Based on this information, we decided 
that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan 
does not have to pay for the drug testing services provided on July 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pulp vitality tests (D0460) provided December 14, 2021, 
and local anesthesia in conjunction with operative or surgical procedures (D9215) provided December 15, 
2021. 
 
You asked the Plan to pay for the pulp vitality tests and local anesthesia. You say that these services are the 
standard of care and should be covered. The Plan denied your request. The Plan says these services are 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 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 pulp vitality tests (D0460) provided December 14, 2021, and local anesthesia in conjunction with operative or 
surgical procedures (D9215) provided December 15, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the GeneSight testing services provided on December 1, 
2021. 
 
You asked the Plan to pay for the testing services. You say that the test informs clinicians about which 
medications may require dose adjustments. The Plan denied your request. The Plan says the testing is not 
covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. The provided pharmacogenetic testing was reportedly ordered to 
make decisions about the patient's medications. Medications should be provided based on the presence of a 
diagnosis and should be adjusted based on a patient's response to the medication. It is not necessary to do 
genetic testing to provide or adjust medications. Based on this information, we decided that Medicare rules for 
coverage of the testing services have not been met. Therefore, we decided that the Plan does not have to pay for 
the GeneSight testing services provided on December 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete maxillary denture (D5110) provided on January 
6, 2022. 
 
You asked the Plan to pay for the complete maxillary denture. You say that you would like help paying for a 
portion of this denture. 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 
complete maxillary denture (D5110) provided on January 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional payment for the extractions, erupted tooth 
requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if 
indicated (D7210) provided November 5, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to provide additional payment for the extractions. You say that you would like the 
extractions covered. The Plan denied your request. The Plan says these services have been reprocessed and 
correctly paid according to your OON 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 Plan covers the 
extractions with 55% coinsurance. You may be billed by the out-of-network provider for any amount greater than the payment made by the Plan to the provider.   
 
We looked at the file and Medicare rules. You have been asked to pay 55% of the allowed amount for the tooth 
extractions. Additionally, you are responsible for the difference between the Plans allowed amount and the 
total cost billed by the OON provider. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. Therefore, we decided that the Plan does not have to provide additional payment 
for the extractions, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation 
of mucoperiosteal flap if indicated (D7210) provided November 5, 2021, by an out-of-network (OON) 
provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the walker (E0143), provided on November 24, 2021. 
 
You asked the Plan to pay for the walker. You say that the item should be covered. The Plan denied your 
request. The Plan says you purchased this item through a supplier that is not enrolled in Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the walker (E0143), provided on 
November 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the health club membership provided September 18, 2021. 
 
You asked the Plan to pay for the health club membership. You say that you would like reimbursement for 
your gym membership. The Plan denied your request. The Plan says you did not register with Silver Sneakers, 
nor did you go to a participating Silver Sneakers location. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers a fitness 
benefit through Silver Sneakers at participating locations. 
 
The Plans rules for coverage of gym benefits have not been met because the requested membership is not a 
participating Silver Sneakers location. Therefore, we decided that the Plan does not have to pay for the health 
club membership provided September 18, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cardiovascular risk assessment testing (81407, 81414, 81405, 
81411, 81238, 81413, 81161) provided October 13, 2021. 
 
You asked the Plan to pay for the cardiovascular risk assessment testing. You say that this testing was 
medically necessary. The Plan denied your request. The Plan says this service is non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that only the following codes should be billed for 
Cardiovascular Disease Screening: CPT code 80061 (Lipid panel) which includes CPT codes: 82465 
(Cholesterol, serum or whole blood, total), 83718 (Lipoprotein, direct measurement; high density cholesterol) 
and/or, 84478 (Triglycerides). 
 
We looked at the file and Medicare rules. This cardiovascular risk assessment testing is non-covered. Based on 
this information, we decided that Medicare rules for coverage of the cardiovascular risk assessment testing 
have not been met.  
 
  
Therefore, we decided that the Plan does not have to pay for cardiovascular risk assessment testing (81407, 
81414, 81405, 81411, 81238, 81413, 81161) provided October 13, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the COVID-19 test (87426) provided on December 21, 2021. 
 
You asked the Plan to pay for the COVID-19 test. You say that this test was travel related and was a 
requirement to take a return flight back to the United States. The Plan denied your request. The Plan says this 
service is not a benefit under your plan. 
 
The Plan must follow Medicare rules. Medicare rules say that routine services required by third parties such as 
business establishments are not covered by Medicare.  
 
We looked at the file and Medicare rules. This testing was required by an airline for the purposes of routine 
travel. Based on this information, we decided that Medicare rules for coverage of screening testing have not 
been met. Therefore, we decided that the Plan does not have to pay for the COVID-19 test (87426) provided on 
December 21, 2021.