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

 
We decided that the Plan does not have to pay for genetic testing (81542, 88381) provided October 12, 2021. 
 
You asked the Plan to pay for the genetic testing. You say that this service was medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
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 pay for the genetic testing. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the record shows that the enrollee has Gleason 7 Prostate cancer. The provided records do not 
support that the genetic testing was medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does 
not have to pay for genetic testing (81542, 88381) provided October 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the requested transit option with an approved 
wheelchair. 
 
You asked the Plan to pre-approve the transit option. You say that the requested mobility device should be 
approved. The Plan denied your request. The Plan says all requested items have been approved, aside from the 
transit option. This feature includes items for transporting the equipment. This is not considered medical in 
nature. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve the requested transit option with an approved wheelchair.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on October 4, 2021, billed with 
codes 81206, 81162, 81301, and 81311. 
 
You asked the Plan to pay for the genetic testing as billed. You say that this was medically necessary testing. 
The Plan denied your request. The Plan says a panel such as this must be billed with one code. Therefore, only 
6 of the 10 billed codes can be paid. 
 
The Plan must follow Medicare rules. Medicare 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 panel is NGS testing that was not billed with a single panel 
code. 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 
October 4, 2021, billed with codes 81206, 81162, 81301, and 81311.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete series of radiographic images (D0210) provided 
by a participating provider on February 8, 2022. 
 
You asked the Plan to pay for a complete series of radiographic images. You say that you only had your teeth 
cleaned. The Plan denied your request. The Plan says the benefit limit for D0210 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 a complete 
series of radiographic images once every five years. 
 
We looked at the file and Medicare rules. Evidence was provided to show that D0210 was provided on January 
22, 2019. Based on this information, we decided that the Plan's rules for coverage of a complete series of 
radiographic images have not been met. Therefore, we decided that the Plan does not have to pay for a 
complete series of radiographic images (D0210) provided by a participating provider on February 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) provided on January 6, 
2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the periodic oral evaluation. You say that you would like this claim to be 
reconsidered for coverage. The Plan denied your request. The Plan says services performed by an OON 
provider are not covered because your healthcare plan does not have 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, you are responsible for 100% of the 
cost for dental services rendered by an OON provider. Therefore, we decided that the Plan does not have to pay 
for the periodic oral evaluation (D0120) provided on January 6, 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 the three periodontal scalings and root planings (D4341 x3) 
and debridement and osseous contouring (D6102) provided on October 5, 2021, and October 12, 2021. 
 
You asked the Plan to pay for the scalings and planings and debridement and osseous contouring. You say that 
you were not aware that the treating provider opted out of Medicare. You also say that the treating provider 
was out-of-network, and you believe you should be reimbursed 50% for these charges. The Plan denied your 
request. The Plan says you received these services from a provider who chose not to receive Medicare funds. 
The Plan also says that the treating provider is on the Medicare opt out list, and you did not contact the plan 
prior to receiving these services. 
 
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 three 
periodontal scalings and root planings (D4341 x3) and debridement and osseous contouring (D6102) provided 
on October 5, 2021, and October 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implant placement (D6010). 
 
You asked the Plan to pre-approve the dental services. You say that you would like this service to be covered 
so you can keep your partial. You say that the tooth you need to be replaced is the one that holds your partial in 
place. You also say that the only other option is to pull all your other teeth and get dentures. The Plan denied 
your request. The Plan says implant placement is not listed as a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested implant placement is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
implant placement (D6010).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the mandibular denture (D5140), the alveoloplasty with 
extractions (D7311), nitrous oxide (D9230), and deep sedation (D9222, D9223 x2) to be provided by a network 
provider. 
 
You asked the Plan to pre-approve the mandibular denture (D5140), the alveoplasty with extractions (D7311), 
the nitrous oxide (D9230), and the deep sedation (D9222, D9223 x 2). You say that the services are medically 
necessary. The Plan denied your request. The Plan says the requested services exceed the amount available at 
this time for your quarterly 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 Plan also has a maximum benefit 
of $250 allowance for covered comprehensive dental services every quarter. The requested services are not 
covered because the Plan applied the remaining $447 of the first and second quarter allowance of $500 which 
exhausted your benefit.  Therefore, we decided that the Plan does not have to pre-approve the mandibular denture (D5140), the alveoloplasty with extractions (D7311), nitrous oxide (D9230), and deep sedation (D9222, D9223 x2) to be 
provided by a network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete maxillary denture (D5110) and complete 
mandibular denture (D5120) provided on August 12, 2021. 
 
You asked the Plan to pay for the complete dentures. You say that the provider told you they contacted the Plan 
and were advised that you had coverage for 50% of the denture replacement. You also say that you feel you 
should not have to pay more for the dentures. The Plan denied your request. The Plan says these services are 
not covered. The Plan also says that when the provider's office contacted the Plan, they requested the eligibility 
for you and coverage for dentures was not discussed. 
 
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. The only type of denture related service that is covered under your 
plan is adjustments and repairs of prosthetics, like denture repairs. Therefore, we decided that the Plan does not 
have to pay for the complete maxillary denture (D5110) and complete mandibular denture (D5120) provided on 
August 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve four surgical placements of implant bodies: endosteal 
implants (D6010 x4). 
 
You asked the Plan to pre-approve the endosteal implants. The Plan denied your request. The Plan says the 
implant benefit has a limit to two in a calendar year. The Plan also says that the enrollee's history plus this 
request have gone over this limit. 
 
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, surgical placement of implant body: 
endosteal implant (D6010) is limited to two per 1 calendar year. The record shows that the enrollee received 
two endosteal implants (D6010 x2) on January 27, 2022 and the enrollee's surgical placement of implant body: 
endosteal implant (D6010) benefit has been exhausted. Therefore, we decided that the Plan does not have to 
pre-approve four surgical placements of implant bodies: endosteal implants (D6010 x4).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an upper partial denture (D5213). 
 
You asked the Plan to pre-approve the dental item. You say that your denture broke. You also say that it is 
currently being held together with adhesive. The Plan denied your request. The Plan says dentures are covered 
once per 5 calendar years. The Plan also says that the frequency limit has been reached. 
 
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 partial upper denture is covered 
once per 5 calendar years, the frequency limit has been exceeded. The record shows that the Plan paid for an 
upper partial denture that you received on April 26, 2021. Therefore, we decided that the Plan does not have to 
pre-approve an upper partial denture (D5213).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve abutment supported crowns (D6063) and implant 
supported crowns (D6065) for teeth #9 and #10. 
 
You asked the Plan to pre-approve implant/abutment supported crowns. You say that these services are 
necessary and should be covered. The Plan denied your request. The Plan says these services are not covered 
by 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 pre-approve 
abutment supported crowns (D6063) and implant supported crowns (D6065) for teeth #9 and #10.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 81161, 81286, 81410, 
81411, 81413, 81414, and 81479) provided on July 23, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not covered as billed. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The review of the appeal request for cardiac risk assessment genetic screening testing rendered on DOS 
07/23/2021 and billed with CPT codes 81161-XS x1 unit, 81286-XS x1 unit, 81410-XS x1 unit, 81411- 
XS x1 unit, 81413-XS x1 unit, 81414-XS x1 unit and 81479-GY x1 unit has been completed. The result 
is that the initial denial has been upheld per Medicare guidelines: The documentation submitted on appeal 
indicates the cardiovascular genetic screening panel was initiated by the laboratory and not by the member's treating physician nor following a consultation or evaluation by the member's treating physician. The member 
reports she was contacted by a lab via email and the kit was sent to her home. States her doctor 
did not order the testing. Per a person at the doctor's office the lab requisition was faxed to them, already 
filled out, asking for a signature and diagnosis codes. States the order was not initiated by their provider. 
Therefore, the denial of the cardiovascular screening/risk assessment panel is administratively upheld for 
not meeting Medicare coverage criteria. LCD and other Medicare policy guidance apply to both contracted and 
non-contracted providers and cannot be overridden by plan directed care. Therefore, we decided that the Plan 
does not have to pay for the laboratory services (CPT code(s): 81161, 81286, 81410, 81411, 81413, 81414, and 
81479) provided on July 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on February 28, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that it was medical necessary to provide the 
service to the enrollee and the specimen was sent to your lab to process. The Plan denied your request. The 
Plan says the rendering provider is an OON provider and there was no referral from an in-network provider or 
an approved authorization. Also, the service rendered was not urgent or emergent. 
 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 laboratory services provided on February 28, 
2022, by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 13 additional home health aide hours per week. 
 
You asked the Plan to pre-approve 13 additional home health hours per week. You say that the services are 
medically necessary. The Plan denied your request. The Plan says additional hours are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.   
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 13 additional home health hours per 
week. Our reviewer says that the requested 13 additional home health aide hours are not medically necessary. 
Our physician reviewer found the enrollee is medically stable without any recent hospitalizations or medical 
complications. The reviewer found that the approved weekly hours of home health aide services allow for 
appropriate support and care. The reviewer also found that the documentation does not support that the 
additional hours are needed to provide adequate support for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 13 additional home health hours per week have not been met. Therefore, we 
decided that the Plan does not have to pre-approve 13 additional home health aide hours per week.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for domiciliary services provided on October 21, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for domiciliary services. You say that that it isn't your responsibility to obtain prior 
authorization. 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 domiciliary services provided on October 21, 2021 
by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pharmacogenetic testing (CPT code(s): 81230, 81240, 
81241, 81291, 81408, and 81335) provided on May 31, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the laboratory services have not been met. Medicare denies 
coverage when a laboratory assays two or more genes in a patient in parallel. Those two or more genes will be 
considered part of the same panel. A panel constitutes a single procedural service, so one CPT code must be 
submitted for the panel. Therefore, we decided that the Plan does not have to pay for pharmacogenetic testing 
(CPT code(s): 81230, 81240, 81241, 81291, 81408, and 81335) provided on May 31, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on November 15, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that the assisted living facility is 
responsible to obtain prior authorization for all of their patients, which should also cover for the medical 
treatments provided by this provider. The Plan denied your request. The Plan says this provider is out-of-
network with the Plan, and authorization was not obtained prior to the services being rendered. 
 
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 a domiciliary or rest home visit provided on 
November 15, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye refraction you had on February 9, 2022. 
 
You asked the Plan to pay for the refraction. The Plan denied your request. The Plan says this is not a covered 
benefit. 
 Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when provided during a routine eye exam. 
 
We looked at the file and the Plan's rules. The records show that the refraction was provided during a medical 
eye exam, not a routine exam. Based on this information, we decided that the Plan's rules for coverage of the 
refraction have not been met. Therefore, we decided that the Plan does not have to pay for the eye refraction 
you had on February 9, 2022.