Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a lower partial denture (D5214) provided on April 12, 2022. 
 
You asked the Plan to pay for a lower partial denture. You say that you want the Plan to pay part of these 
charges. The Plan denied your request. The Plan says you had teeth numbers 28-30 extracted prior to January 
01, 2022. You had tooth number 31 extracted on February 10, 2022. Because the denture provided covers 
multiple teeth and only indicates one procedure code, partial payment cannot be provided. 
 
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 file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage 
of a lower partial denture have not been met. Therefore, we decided that the Plan does not have to pay for a 
lower partial denture (D5214) provided on April 12, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pelvic angiography (75736) billed for date of service 
March 10, 2022. 
 You asked the Plan to pay for a pelvic angiography. You say that you have provided medical records to support 
the service billed. The Plan denied your request. The Plan says the service at issue is included in another billed 
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. 
 
In this case, we have confirmed that code 75736 is a column II code to column I code 37243; however, 75736 
was billed with a modifier.  
 
We asked our coder 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 a pelvic angiography. Our reviewer says that the CPT code at 
issue does not meet criteria for payment. Our reviewer found that the available documentation does not support 
that CPT code 75736 was distinct from code 37243. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a pelvic angiography have not been met. Therefore, we decided that the Plan 
does not have to pay for a pelvic angiography (75736) billed for date of service March 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided by a participating 
provider on April 4, 2022, to April 21, 2022. 
 
You asked the Plan to pay for a limited oral evaluation. You say that you would like the Plan to pay for this. 
The Plan denied your request. The Plan says D0140 is not a covered 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 a limited 
oral evaluation (D0140) provided by a participating provider on April 4, 2022, to April 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 7, 2022, billed with 
codes 81317, 81407, 81408, 81432, 81295, and 81298. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as billed. 
 
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. In addition, we have confirmed that codes 81295 and 91298 are column II codes to column I code 
81432 with a modifier indicator of 0. The column II codes are therefore not payable. 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 March 7, 2022, billed with codes 
81317, 81407, 81408, 81432, 81295, and 81298.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99053 billed for date of service January 13, 
2022. 
 
You asked the Plan to pay for procedure code 99053. You say that this claim was denied incorrectly. The Plan 
denied your request. The Plan says procedure code 99053 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 99053 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99053 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99053 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99053 billed for date of service January 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on May 
26, 2022. 
 
You asked the Plan to pay for the dental services. You say that the service should have been covered. 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 October 15, 2020. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) 
provided on May 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on 
March 24, 2022. 
 
You asked the Plan to pay for the comprehensive oral evaluation. You say that you were not advised that your 
insurance would not cover this service. You also say that you cannot pay for this service. The Plan denied your 
request. The Plan says your benefit for the requested 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 service was exhausted on date of service August 23, 2021. Therefore, we 
decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on March 
24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a surgical placement of implant (D6010) provided on April 
25, 2022. 
 
You asked the Plan to pay for a surgical placement of implant. You say that you were told services would be 
covered. The Plan denied your request. The Plan says the service at issue is not a covered 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 a surgical 
placement of implant (D6010) provided on April 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the reline complete mandibular denture (indirect) 
(D5751) provided April 21, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you were told the services would be 
covered. The Plan denied your request. The Plan says you are responsible for any charged amount above the 
Plans cost-sharing amount when your services are received from an out-of-network provider. The Plan also 
says that they have reviewed call logs and found that you were not provided incorrect information about 
network status or coverage. 
 
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. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for the reline complete mandibular denture 
(indirect) (D5751) provided April 21, 2022.  
 Your complaint about potentially being provided misinformation from a plan representative 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on April 26, 2021. 
 
You asked the Plan to pay for the lab services. You say that this is supported in the records. The Plan denied 
your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for 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. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on April 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiation treatment delivery (77401) and echo guidance 
radiotherapy (G6001). 
 
You asked the Plan to pre-approve radiation treatment delivery and echo guidance radiotherapy. You say that 
the requested service is medically necessary. The Plan denied your request. The Plan says the request does not 
meet the Medicare or health plan coverage criteria. 
 
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 radiation treatment delivery and echo 
guidance radiotherapy. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found certainly using ultrasound on a daily basis 
is not unreasonable, but to bill for daily simple simulations and/or IGRT for a technology for which need has 
not been established by published data or supported by consensus guidelines (many of which recommend 
against treatment with these devices in general citations below), my decision is unfavorable as billing for daily 
simulations or IGRT would not be furnished in accordance with accepted standards of medical practice. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radiation treatment delivery and echo guidance radiotherapy have not been met. 
Therefore, we decided that the Plan does not have to pre-approve radiation treatment delivery (77401) and echo 
guidance radiotherapy (G6001).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the Medicare part b drugs (A4649, J2469, 
96413, 96417) provided on March 17, 2022. 
 
You asked the Plan to waive the copayment for the Medicare part b drugs. You say that the services should be 
covered as you disagree with the charges. 
 The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services provided. 
 
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 20% 
coinsurance for Medicare Part B prescription drugs.  
 
 
  You have been asked to pay a 20% coinsurance for Medicare part b drugs (allowed is 279.70 x 20% = $55.95). 
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 the Medicare part b drugs (A4649, J2469, 96413, 96417) 
provided on March 17, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a rest home visit provided on May 11, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the rest home visit. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they were non-
emergent and prior authorization was not obtained. 
 
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 rest home visit provided on May 11, 2022 by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a myocardial perfusion imaging, 
tomographic (SPECT) test and regadenoson injection (J2785, 78452) provided on June 3, 2022. 
 
You asked the Plan to waive the copayment for the myocardial perfusion imaging, tomographic (SPECT) test 
and regadenoson injection. You say that the services should be covered as you disagree with the charges and 
were not made aware of them beforehand. The Plan denied your request. The Plan says the cost-sharing applied 
correctly based on the services provided. 
 
 
  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 enrollees must pay 
a 20% coinsurance for Medicare Part B prescription drugs and a $250 copayment for Outpatient diagnostic 
tests and therapeutic services and supplies. 
 
You have been asked to pay a 20% coinsurance for the regadenoson injection (allowed is $257.57 x 20% = 
$$51.51) and a $250 copayment for the myocardial perfusion imaging, tomographic (SPECT) test. This means 
that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for a myocardial perfusion imaging, tomographic (SPECT) test and 
regadenoson injection (J2785, 78452) provided on June 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on March 15, 2022 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they were 
non-emergent and prior authorization was not obtained. 
 
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 March 15, 2022 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 64490 and 64491 billed for date of service 
February 14, 2022. 
 You asked the Plan to pay for procedure codes 64490 and 64491. You say that the records support that the 
billed services were performed. The Plan denied your request. The Plan says the number of units billed exceeds 
the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT codes 64490 and 64491 is 1. The MAI value for this code is 2. You billed 2 
units of each of these codes, exceeding the MUE. Based on this information, we decided that Medicare rules 
for coverage of procedure codes 64490 and 64491 have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure codes 64490 and 64491 billed for date of service February 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pain management services provided on April 8, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the pain management services. You say that the services provided to the enrollee 
were medically necessary and should be paid following Medicare guidelines. 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 pain management services provided on April 
8, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the GeneSight Psychotropic Assay provided on April 13, 
2022. 
 
You asked the Plan to pay for the GeneSight Psychotropic Assay. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the enrollee did not meet criteria for the testing provided. 
 
The Plan must follow Medicare rules. Medicare rules say that GeneSight is only covered when the enrollee's 
medical records clearly reflects that the clinician has made an initial personalized decision for the enrollee 
based on the enrollee's diagnosis, the enrollee's other medical conditions, other medications the enrollee is 
taking, professional judgement, clinical science and basic science pertinent to the drug (e.g. mechanism of 
action, side effects), the enrollee's past medical history and when pertinent family history and the enrollee's 
preferences and values. 
 
 
 We looked at the file and Medicare rules. Review of the file shows that no medical records were provided to 
support the services rendered. The documentation does not support that the pharmacogenomic testing rendered 
was necessary for the enrollees decision-making process regarding safely administering or dosing the drug. 
Based on this information, we decided that Medicare rules for coverage of the GeneSight Psychotropic Assay 
have not been met. Therefore, we decided that the Plan does not have to pay for the GeneSight Psychotropic 
Assay provided on April 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the telephone evaluation and management service coded 
99441 provided on 
 
You asked the Plan to pay for the telephone evaluation and management service. You say that you disagree 
with the Plan's denial. The Plan denied your request. The Plan says the services billed are not supported by 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 99441 is telephone evaluation and management service 
by a physician or other qualified health care professional who may report evaluation and management services 
provided to an established patient, parent, or guardian not originating from a related E/M service provided 
within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest 
available appointment; 5-10 minutes of medical discussion. 
 
We find that CPT code 99441 is not supported in the medical record. Specifically, the documentation shows 
that the provider billed and was paid for an evaluation and management (E/M) service code, 99213 on March 
24, 2022. This is within the seven days allowed per the Telephone E/M services and thus is included in the 
previously billed E/M code. This means this code is not separately payable. Based on this information, we 
decided that Medicare rules for coverage of the telephone evaluation and management service have not been 
met. Therefore, we decided that the Plan does not have to pay for the telephone evaluation and management 
service coded 99441 provided on