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

 
We decided that the Plan does not have to pay for procedure code 93042 billed for date of service April 10, 
2022. 
  You asked the Plan to pay for procedure code 93042. You say that a provider who prepares a separately 
identifiable interpretation which contributes to the diagnosis and treatment of the enrollee is entitled to 
payment. You say that this interpretation was improperly denied. The Plan denied your request. The Plan says 
payment for code 93042 is bundled into payment for code 36556. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 93042 
is a column II code to column I code 36556. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 93042 billed for date of service April 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for complete series of radiographic images (D0210), the 
panoramic radiographic images (D0330), 2D photographic images (D0350), hygiene instructions (D1330), and 
application of fluoride (D1206) provided on July 18, 2022. 
  You asked the Plan to pay for the dental services. You say that the amount for the denied services is too high 
and you would like the Plan to pay for the procedures. The Plan denied your request. The Plan says the denial 
of payment for these services is correct, because complete series of radiographic images, the panoramic 
radiographic images, 2D photographic images, hygiene instructions, and application of fluoride are not covered 
by the 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 complete 
series of radiographic images (D0210), the panoramic radiographic images (D0330), 2D photographic images 
(D0350), hygiene instructions (D1330), and application of fluoride (D1206) provided on July 18, 2022.  
 
Your complaint about experience with the provider is not a valid appeal for medical coverage. This part of your 
complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision 
about these types of complaints.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the IRF services you 
are requesting do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer 
found that this enrollee does not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a 
need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation 
services. Our physician reviewer also found that there is not a reasonable expectation that this enrollee will be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee currently meets LTACH 
admission criteria. The Plan denied your request. The Plan says the denial of authorization for LTACH care is 
correct. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to be more stable and should only require short-term additional 
acute care services that can be safely provided at the current facility until stable for discharge to a lower level 
of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Sertraline HCL (J8499). 
 
You asked the Plan to pre-approve Sertraline HCL. You say that the enrollee has been on this medication since 
2018, and it works well for them. The Plan denied your request. The Plan says this drug is not covered for the 
enrollee's condition by their Medicare Part B plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Sertraline HCL (J8499).  
 
Benefits for Sertraline HCL may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120) and the removal of plaque 
(D1110) provided on July 21, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were never told that this provider was out-
of-network and are now stuck with a bill for date of service July 1, 2022. The Plan denied your request. The 
Plan says the dental services were received from an out-of-network provider and are not covered by your 
supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a periodic oral evaluation (D0120) and the removal of plaque (D1110) provided on July 21, 2022.  
 Your complaint about potentially not being informed by the Plan or by the provider that the provider is out-of-
network is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be 
answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an extraction (D7210) provided on June 28, 2022. 
 
You asked the Plan to pay for the dental services. You say that you needed this extraction. 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 April 26, 2022. 
Therefore, we decided that the Plan does not have to pay for an extraction (D7210) provided on June 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the manual therapy (97014) provided on June 30, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not covered under your 
contractual policy or by Medicare. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the manual therapy (97014) provided on June 30, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 23, 2022, billed with 
codes 0031U, 0032U, 81225, 81226, 81227, 81230, 81231, 81240, 81241, 81291, 81328, 81355, and 81401. 
 
You asked the Plan to pay for the genetic testing billed. You say that the testing was medically necessary. The 
Plan denied your request. The Plan says panel testing should be billed using one Current Procedural 
Terminology (CPT) code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code.  
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
May 23, 2022, billed with codes 0031U, 0032U, 81225, 81226, 81227, 81230, 81231, 81240, 81241, 81291, 
81328, 81355, and 81401.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental services. 
 
You asked the Plan to pre-approve the dental services. You say that you would like to request reconsideration 
of the denied authorization. The Plan denied your request. The Plan says the dental services requested are not 
medically necessary. 
 
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 the 
dental services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on June 10, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for office visit. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says as a member of our plan, the enrollee must use network providers. If the enrollee 
receives unauthorized care from a an out-of-network provider, we may deny coverage and the enrollee will be 
responsible for the entire cost. 
 
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 office visit provided on June 10, 2022, by an out-
of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental crowns, core-buildup services, and denture clasps 
(D2740, D5660, D2950) 
 
You asked the Plan to pre-approve the dental 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 do 
not fall within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
dental crowns, core-buildup services, and denture clasps (D2740, D5660, D2950)
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lift chair you purchased on March 12, 2022. 
 
You asked the Plan to pay for the lift chair. You say that the reason why you chose this company was because 
you called the Plan and they gave you a list of companies to us, but every time you called their number, it was 
either disconnected or the company didn't have the chair you needed. The Plan denied your request. The Plan 
says it has no phone records showing that you called in asking for a list of vendors from whom to purchase this 
chair.  This provider is not a Medicare-certified provider, so this chair is not covered. 
 
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. The provider at issue is not enrolled in the Medicare program. Therefore, 
we decided that the Plan does not have to pay for the lift chair you purchased on March 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral complete series of radiographic images (D0210) 
provided on April 27, 2022. 
 
You asked the Plan to pay for the dental services. You say that you only wanted a bitewing done because there 
is no yearly charge for it. 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 March 24, 2021. 
Therefore, we decided that the Plan does not have to pay for the intraoral complete series of radiographic 
images (D0210) provided on April 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the removal of residual tooth roots (D7250) for tooth #20, 
#21, #31 provided on May 20, 2022. 
 
You asked the Plan to pay for the dental services. You say that the coding for the dental service was wrong, and 
it was a simple extraction which would be covered by the Plan. The Plan denied your request. The Plan says 
the denial of payment for these services is correct, because the removal of residual tooth roots is not covered by 
the 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 
removal of residual tooth roots (D7250) for tooth #20, #21, #31 provided on May 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a medical eye examination (92014) 
provided on April 15, 2022. 
 
You asked the Plan to waive the deductible for a medical eye examination (92014). You say that the charge for 
the eye examination should have been covered as zero cost as an annual Medicare routine eye examination. 
The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $500 deductible for all items and services except those specifically 
excluded by the Plan contract. Your contract with the Plan also clearly says that until you have paid the 
deductible amount, you must pay the full cost for most of your covered services. Your contract with the Plan 
also clearly says that the deductible applies to a medical eye examination (92014).  
 
 
  The item or service you asked the Plan to waive the deductible for falls within the vision services benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 
deductible which applies to vision services. This cost sharing is a contractual obligation that had not been met 
at the time a medical eye examination (92014) was received on April 15, 2022. Therefore, we decided that the 
Plan does not have to waive the deductible for a medical eye examination (92014) provided on April 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visits and outpatient services provided on June 17, 
2022, June 23, 2022, and July 8, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visits and outpatient services. You say that you were unable to get a 
backdated referral and you would like the treatment to be paid for. The Plan denied your request. The Plan says 
the rendering providers are all OON providers and there was no referral from the enrollee's primary care 
provider or an approved authorization for the services that were 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 the office visits and outpatient services provided 
on June 17, 2022, June 23, 2022, and July 8, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system (E2300), an expandable 
controller (E2377), expandable controller harness (E2313), and electronic connection (E2311) to control power 
tilt, recline and power elevating leg rests through the joystick. 
 
You asked the Plan to pre-approve a power seat elevation system (E2300), expandable controller (E2377), 
expandable controller harness (E2313), and electronic connection (E2311) to control power tilt, recline and 
power elevating leg rests through the joystick. You say that the requested power seat elevation system (E2300), 
expandable controller (E2377), expandable controller harness (E2313), and electronic connection (E2311) to 
control power tilt, recline and power elevating leg rests through the joystick are medically necessary. The Plan 
denied your request. The Plan says the requested power seat elevation system (E2300), expandable controller 
(E2377), expandable controller harness (E2313), and electronic connection (E2311) to control power tilt, 
recline and power elevating leg rests through the joystick are not medically necessary. 
 
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 a power seat elevation system (E2300), 
expandable controller (E2377), expandable controller harness (E2313), and electronic connection (E2311) to 
control power tilt, recline and power elevating leg rests through the joystick. Our reviewer says that the 
requested expandable controller (E2377), expandable controller harness (E2313), and electronic connection 
(E2311) to control power tilt, recline and power elevating leg rests through the joystick are not medically 
necessary. Our physician reviewer found the documentation shows that the enrollee has sufficient upper body 
and hand strength to manage standard switches for power drives. Medicare specifically excludes coverage of 
power seat elevation systems coded as E2300. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a power seat elevation system (E2300), expandable controller (E2377), 
expandable controller harness (E2313), and electronic connection (E2311) to control power tilt, recline and 
power elevating leg rests through the joystick have not been met.  Therefore, we decided that the Plan does not 
have to pre-approve a power seat elevation system (E2300), an expandable controller (E2377), expandable 
controller harness (E2313), and electronic connection (E2311) to control power tilt, recline and power 
elevating leg rests through the joystick.