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

 
We decided that the Plan does not have to pay for the genetic testing provided on October 17, 2021, billed with 
codes 81206, 81235, 81292, 81301, and 81321. 
 
You asked the Plan to pay for the genetic testing. You say that the testing is medically necessary and should be 
paid. The Plan denied your request. The Plan says this was billed with multiple codes but only one should be 
billed. Therefore, only 7 of the 12 line items are 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 testing is 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 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
October 17, 2021, billed with codes 81206, 81235, 81292, 81301, and 81321.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Skilled Nursing facility services.

You asked the Plan to pre-approve Skilled Nursing facility services. You say that I need the rehab. I have been walking with a walker, with someone in attendance while in the hospital, so I haven't been able to walk by myself or walk with a walker by myself without someone in attendance. The Plan denied your request. The Plan says the record shows that Classified as Confidential you do not meet Medicare guidelines for services in a skilled nursing facility (SNF).

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Skilled Nursing facility services. Our reviewer says that given the clinical conditions of this case, the appeal request for coverage is denied and the denial is upheld as not medically necessary. Our physician reviewer found Based on the documentation provided, it is my opinion that the enrollee does not qualify for SNF coverage. The enrollee does not have documented skilled nursing needs.  The enrollee does not have documented skilled therapy needs.  The enrollee is consistently ambulating more than 100 feet. Daily skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs, as a practical matter, can be provided at a lower level of care (ex. home, AL, LTC).

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Skilled Nursing facility services have not been met. Therefore, we decided that the Plan does not have to pre-approve Skilled Nursing facility services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an extraction (D7210) provided by opted-out dentist on 
December 8, 2021. 
 
You asked the Plan to pay for an extraction. You say that you were told the provider was in-network. The Plan 
denied your request. The Plan says this provider has opted out of Medicare and is not eligible for payment. 
 
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 services at issue in this appeal were 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 pay for an 
extraction (D7210) provided by opted-out dentist on December 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for at-home COVID-19 tests you purchased from November 18, 
2021, to January 6, 2021. 
 
You asked the Plan to pay for the at-home COVID-19 tests. You say that you were given incorrect information 
and were advised these were covered. The Plan denied your request. The Plan says at-home COVID-19 tests 
were not covered on the dates you purchased them. 
 
The Plan must follow Medicare rules. Medicare rules say that effective April 4, 2022, Medicare will cover up 
to 8 over-the-counter test kits per month through the end of the COVID-19 Public Health Emergency.  You 
purchased these tests months before this new benefit went into effect.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the at-home COVID-19 tests have not been met. Therefore, we decided that the Plan does not have 
to pay for at-home COVID-19 tests you purchased from November 18, 2021, to January 6, 2021.  
 
Your complaint about getting incorrect information from the Plan 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (81206, 81292) provided on October 19, 2021. 
 
You asked the Plan to pay for genetic testing. You say that this was medically necessary. The Plan denied your 
request. The Plan says this was not billed correctly. 
 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 rules also say that the submission of claims 
using individual gene CPT codes, when either 5-50 or more than 50 gene panels are ordered, is considered 
incorrect coding. 
 
We find that CPT codes 81206 and 81292 are not supported in the medical record. Specifically, these codes 
were used to report components of a panel, which is considered incorrect coding. 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 pay for genetic testing (81206, 81292) provided on October 19, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this is a medically necessary 
treatment. The Plan denied your request. The Plan says this is experimental at this time. 
 
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 the Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Intracept procedure is experimental, more research is needed to show safety and 
efficacy. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional payment for the retreatment of previous root canal 
therapy - molar (D3348) provided January 12, 2022. 
 
You asked the Plan to provide additional payment for the retreatment of previous root canal therapy. You say 
that this treatment was necessary. The Plan denied your request. The Plan says you have exhausted your dental 
benefit and no further payment is due. 
 
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 
retreatment of previous root canal therapy up to the annual maximum of $1,000. 
 
We looked at the file and Medicare rules. The Plan provided documentation showing that you had $636 
remaining in your annual maximum when the service was processed. This amount was applied to your claim. 
Therefore, we decided that the Plan does not have to provide additional payment for the retreatment of previous 
root canal therapy - molar (D3348) provided January 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene panel testing provided on July 29, 2021. 
 
You asked the Plan to pay for the testing services. You say that you submitted a corrected claim by adding 
place of service 12. 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 the enrollee received a full hereditary cancer gene panel. We find that the panel was billed 
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 of the testing 
services have not been met. Therefore, we decided that the Plan does not have to pay for the gene panel testing 
provided on July 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cone beam imaging (D0364) provided on February 10, 2022. 
 
You asked the Plan to pay for imaging. You say that you disagree with the denial for cone beam imaging. The 
Plan denied your request. The Plan says that cone beam imaging (D0364) is not covered by your Plan's 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 cone 
beam imaging (D0364) provided on February 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150) and an 
extraction (D7210) to be performed by an oral surgeon. 
 
You asked the Plan to pre-approve a comprehensive oral evaluation and an extraction to be performed by an 
oral surgeon. You say that the requested services are medically necessary. The Plan denied your request. The 
Plan says the services at issue are not covered unless they are performed by a participating general dentist. 
Dental services performed by an oral surgeon are not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of a comprehensive oral evaluation and an extraction to be performed by an oral surgeon have not 
been met. Specifically, the services at issue are not covered unless they are performed by a participating 
general dentist. Therefore, we decided that the Plan does not have to pre-approve a comprehensive oral 
evaluation (D0150) and an extraction (D7210) to be performed by an oral surgeon.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), prophylaxis 
(D1110), and a panoramic x-ray (D0330) provided on December 6, 2021, and a resin-based composite on two 
surfaces (D2331 x 2) and a resin-based composite on one surface (D2330 x 3) provided on January 31, 2022. 
 
You asked the Plan to pay for an evaluation, prophylaxis, x-ray, and resin composites. You say that you were 
told the provider was in-network. You also say you are on a fixed income and cannot afford to pay for dental 
services. The Plan denied your request. The Plan says that dental services are only covered when received by a 
participating provider. 
 
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 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 among those covered under this 
benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have to 
pay for a comprehensive oral evaluation (D0150), prophylaxis (D1110), and a panoramic x-ray (D0330) 
provided on December 6, 2021, and a resin-based composite on two surfaces (D2331 x 2) and a resin-based 
composite on one surface (D2330 x 3) provided on January 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for extractions (D7140, D7210), dentures (D5130, D5140), and 
prosthesis (D5899) provided on October 4, 2021. 
 
You asked the Plan to pay for extractions, dentures, and prosthesis. You say that you are on a tight budget and 
would have a hard time paying for these dental services. The Plan denied your request. The Plan says that 
extractions (D7140, D7210), dentures (D5130, D5140), and prosthesis (D5899) are not covered by your 
preventive 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 
extractions (D7140, D7210), dentures (D5130, D5140), and prosthesis (D5899) provided on October 4, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services (81206, 81292) provided on 
March 16, 2021. 
 
You asked the Plan to pay for the genetic testing services. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says this claim has not been billed as 
required by Medicare billing 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. 
 
 We looked at the file and Medicare rules. In this case, the services provided should have been billed as a single 
procedural service. Based on this information, we decided that Medicare rules for coverage of the genetic 
testing services have not been met. Therefore, we decided that the Plan does not have to pay for the genetic 
testing services (81206, 81292) provided on March 16, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 81238, 81225, 81335, 81230, 
81241, 81291, and 81240 provided on May 27, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services billed are 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 CPT code. 
 
 We find that CPT codes 81238, 81225, 81335, 81230, 81241, 81291, and 81240 are not supported in the 
medical record. Specifically, when a laboratory assays two or more genes in an enrollee in parallel, those two 
or more genes will be considered part of the same panel. A panel constitutes a single procedural service, so one 
code must be submitted for the panel. Review of the file does not support that only one code was billed for the 
panel provided. Based on this information, we decided that Medicare rules for coverage of the laboratory 
services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services 
coded 81238, 81225, 81335, 81230, 81241, 81291, and 81240 provided on May 27, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on September 30, 2021, billed 
with codes 81238, 81226, 81335, 81230, 
81241, 81291, and 81240. 
 
You asked the Plan to pay for the genetic testing. You say that this is medically necessary testing. The Plan 
denied your request. The Plan says this was 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 (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 testing is 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 have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
September 30, 2021, billed with codes 81238, 81226, 81335, 81230, 
81241, 81291, and 81240.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dexcom G6 continuous glucose monitor (CGM) system 
(K0554) and supply allowance (K0553). 
 
You asked the Plan to pre-approve the CGM system and supplies. You say that your fingers are raw due to the 
current testing method and you want to get a handle on your diabetes. The Plan denied your request. The Plan 
says the enrollee is not using insulin and does not meet the coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of the CGM system and supplies have not been met. 
Therefore, we decided that the Plan does not have to pre-approve Dexcom G6 continuous glucose monitor 
(CGM) system (K0554) and supply allowance (K0553).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established 
patient (D0150) and intraoral - complete series of radiographic images (D0210) provided December 28, 2020. 
 
You asked the Plan to pay for the comprehensive oral exam and complete series of x-rays. You say that you 
would like this covered. The Plan denied your request. The Plan says you have exceeded the frequency limit 
for this service. 
 
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. The Plan covers the 
comprehensive oral exam and complete series of x-rays once every three plan years. 
 
We looked at the file and Medicare rules. The Plan provided documentation showing that a comprehensive oral 
exam and complete series of x-rays were previously covered on December 17, 2020. Based on this information, 
we decided that the Plan's frequency limit for coverage of the comprehensive oral exam and complete series of 
x-rays has been exceeded. Therefore, we decided that the Plan does not have to pay for the comprehensive oral 
evaluation - new or established patient (D0150) and intraoral - complete series of radiographic images (D0210) 
provided December 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bitewings (D0272), periodic oral evaluation (D0120), and 
prophylaxis (D1110), provided by an out-of-network provider on March 2, 2022. 
 
You asked the Plan to pay for bitewings, periodic oral evaluation, and prophylaxis. You say that this should be 
covered 100%. The Plan denied your request. The Plan says the correct charges have been applied. 
 
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 bitewings, 
periodic oral evaluation, and prophylaxis when the services are medically necessary and reasonable.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of bitewings, periodic oral evaluation, and prophylaxis have not been met. Therefore, we decided that 
the Plan does not have to pay for bitewings (D0272), periodic oral evaluation (D0120), and prophylaxis 
(D1110), provided by an out-of-network provider on March 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral radiographic image (D0220) provided by a 
participating provider on February 15, 2022. 
 
You asked the Plan to pay for an intraoral radiographic image. You say that bitewings are included. The Plan 
denied your request. The Plan says the rendered dental service is not covered. 
 
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 
intraoral radiographic image (D0220) provided by a participating provider on February 15, 2022.