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

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete 
series of intraoral x-rays (D0210) provided on March 17, 2022. 
 
You asked the Plan to pay for the comprehensive oral evaluation and complete series of intraoral x-rays. You 
say that you did not realize that the full year had not passed by six days. You also say that your previous dentist 
is no longer practicing, and you hurriedly scheduled an appointment with a new dentist. The Plan denied your 
request. The Plan says these services exceed the frequency limitations in your benefit plan. 
 
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, comprehensive oral evaluation 
(D0150) and complete series of intraoral x-rays (D0210) are each limited to one procedure every three plan 
years. The record shows that you received a comprehensive oral evaluation (D0150) and complete series of 
intraoral x-rays (D0210) on February 7, 2020 and your comprehensive oral evaluation (D0150) and complete 
series of intraoral x-rays (D0210) benefits have been exhausted. Therefore, we decided that the Plan does 
not have to pay for the comprehensive oral evaluation (D0150) and complete series of intraoral x-rays 
(D0210) provided on March 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional payment for the crowns - porcelain fused to high 
noble metal (D2750) and unspecified preventive procedure, by report (D1999) provided February 4, 2022. 
 
You asked the Plan to provide additional payment for the crowns and unspecified preventative procedure. You 
say that you told the dentist you could not afford to pay out of pocket. The Plan denied your request. The Plan 
says you have exhausted your dental allowance for 2022. The Plan also says the unspecified preventative 
procedure is not 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. The Plan covers the crowns up 
to a $2,000 annual maximum.  
 
We looked at the file and Medicare rules. The Plan provided documentation showing that at the time of your 
services you had $1,877 remaining in your dental maximum. This amount was applied to your crowns. You 
have been asked to pay the remaining amount above the annual maximum. Additionally, the unspecified preventative procedure is not a covered service under your benefits. Therefore, we decided that the Plan does 
not have to provide additional payment for the crowns - porcelain fused to high noble metal (D2750) and 
unspecified preventive procedure, by report (D1999) provided February 4, 2022.  
 
Your complaint about potentially being provided misinformation about coverage 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 of tooth #30 (D7210) and alveoloplasty 
(D7311) provided on March 15, 2022. 
 
You asked the Plan to pay for an extraction and alveoloplasty. You say that your dentist told you some of the 
services would be covered. The Plan denied your request. The Plan says an extraction (D7210) and 
alveoloplasty (D7311) are not covered by your 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 an 
extraction of tooth #30 (D7210) and alveoloplasty (D7311) provided on March 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical extraction (D7210) provided on February 16, 2021. 
 
You asked the Plan to pay for the surgical extraction. You say that it is not your fault that this claim was not 
submitted correctly. You also say that if the claim had been submitted properly, it should be covered in full. 
The Plan denied your request. The Plan says this claim was submitted over the 12 month claim filing 
limitation. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the surgical extraction was not filed until March 21, 2022. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the surgical extraction (D7210) provided on February 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an occlusal guard-hard appliance, full arch on April 4, 2022. 
 
You asked the Plan to pay for an occlusal guard-hard appliance, full arch. You say that you would like to 
request reconsideration for payment. The Plan denied your request. The Plan says the requested service is not 
covered by the member's benefit 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 an 
occlusal guard-hard appliance, full arch on April 4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive PGx testing provided on June 26, 2022. 
 
You asked the Plan to pay for the comprehensive PGx testing. You say that you would like this claim 
reprocessed based on medical necessity. The Plan denied your request. The Plan says payment cannot be made 
because the enrollee's provider did not order the testing in question. 
 
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 comprehensive PGx testing. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the review indicates that the enrollee is a 75-year-old-male with a history 
of Parkinson's disease, diabetes mellitus, hypertension, and hypercholesterolemia. There was no specific 
clinical rationale for the Comprehensive PGx testing. The review has determined that the items/services at 
issue in this case were not medically reasonable or 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 comprehensive PGx testing have not been met. Therefore, we decided that 
the Plan does not have to pay for the comprehensive PGx testing provided on June 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiac genetic testing panel provided on September 24, 
2021. 
 
You asked the Plan to pay for the cardiac genetic testing panel. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says there is no evidence that 
the provider ordered the genetic testing. 
 
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 cardiac genetic testing panel. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found at issue is whether the requested genetic testing is medically appropriate 
and necessary. The test is described as a genetic based cardiovascular risk factor screening test in which multiple genes are assessed using genomic DNA extracted from patient sampling. It assesses the presence of 
pathogenic or likely pathogenic variants in genes known to be associated with increased cardiac risk. It is not a 
diagnostic test. There is no evidence to support its role in this patient clinical management. In summary, the 
requested testing is not considered reasonable or 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 cardiac genetic testing panel have not been met. Therefore, we decided that 
the Plan does not have to pay for the cardiac genetic testing panel provided on September 24, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (64561) provided October 20, 2021. 
 
You asked the Plan to pay for the surgical services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the number of units billed exceed the allowed amount. 
 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 3.  
 
In this case, the MUE for CPT code 64561 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the 
surgical services have not been met. Therefore, we decided that the Plan does not have to pay for surgical 
services (64561) provided October 20, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT 
code 22869). 
 
You asked the Plan to pre-approve the service. You say that this treatment is considered safe and effective, as 
supported by its clinical benefits to patients, continued medical professional adoption, and strong clinical 
evidence with numerous peer reviewed studies. The Plan denied your request. The Plan says experimental and 
investigational procedures are not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We 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 service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Vertilfex device is experimental. More research is needed. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Vertiflex superion device placement surgery (CPT code 22869).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical and esophagogastroduodenoscopy services provided 
to the enrollee on December 10, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the denied codes remain not supported. 
 
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 the denied codes is: 
 
CPT 43236: 
 
Esophagogastroduodenoscopy, flexible, transoral; with directed submucosal injection(s), any substance 
 
CPT 43999: 
 
Unlisted procedure, stomach  
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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that in this case, the record indicates 
that the enrollee underwent an overstitch for enlarged gastrojejunostomy anastomotic opening. The provided 
operation does not describe submucosal injection of a substance and therefore the elements of CPT code 43236 
is not satisfied.  The CPT code 43999 is not proper of revision of anastomosis. The elements of the coverage 
criteria are not satisfied. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for surgical and esophagogastroduodenoscopy services provided to the enrollee on December 10, 
2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the transplant related lodging, meals and transportation, per diem 
(S9975) unlisted special service, procedure or report (99199) provided October 2, 2021 to November 19, 2021. 
 
You asked the Plan to pay for transplant related lodging fees. You say that you ask for reconsideration of these 
charges as they are valid cost items of accommodations that was required by the hospital to hold during your 
treatment. The Plan denied your request. The Plan says that the denied items on the claim denied correctly. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. the Plan has not substantiated their reason to continue to deny the claim. The 
Plan contract says that the Plan will cover the costs of lodging and transportation. There is nothing in the 
documents that indicates that these charges are unreasonable or unrelated to the transplant lodging fees. There 
is also nothing in the EOC that specifies only certain areas of transplant lodging and transportation fees are 
covered. Therefore, we decided that the Plan has to pay for the transplant related lodging, meals and 
transportation, per diem (S9975) unlisted special service, procedure or report (99199) provided October 2, 2021 
to November 19, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6549. 
 
You asked the Plan to pre-approve the compression stockings. You say that you are requesting a 
reconsideration of the Plan's denial. The Plan denied your request. The Plan says this item is not a covered 
benefit under your contractual policy or by Medicare. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
 
 Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6549.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positioning wheelchair back cushion and skin 
protection wheelchair seat cushion. 
 
You asked the Plan to pre-approve a positioning wheelchair back cushion and skin protection wheelchair seat 
cushion. You say that you would like the plan to reconsider their denial. The Plan denied your request. The 
Plan says you do not meet criteria for the requested items. 
 
The Plan must follow Medicare rules. Medicare rules say that certain wheelchair accessories are only covered 
for certain indications.  
 
We looked at the file and Medicare rules. Review of the file shows that the requested special skin protection 
cushion exceeds your needs. You have an approved power wheelchair with a sling/solid seat/back. You do not 
have a current pressure ulcer history or any past history of a pressure ulcer on the area of contact with the 
seating surface. You do not have absent or impaired sensation in the area of contact with the seating surface. 
You are able to carry out a functional weight shift independently. Based on this information, we decided that 
Medicare rules for coverage of a positioning wheelchair back cushion and skin protection wheelchair seat 
cushion have not been met. Therefore, we decided that the Plan does not have to pre-approve a positioning 
wheelchair back cushion and skin protection wheelchair seat cushion.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrocardiogram (ECG) with interpretation and report 
(93000) provided on August 17, 2021. 
 
You asked the Plan to pay for the ECG with interpretation and report. You say that this service was billed 
appropriately. The Plan denied your request. The Plan says a National Correct Coding Initiatives (NCCI) Procedure to Procedure (PTP) edit exists between 93015 and 93000. This PTP edit has a modifier indicator of 
1, meaning modifiers associated with NCCI are allowed. However, an appropriate modifier was not billed with 
this PTP code edit. This service was not billed appropriately by Medicare coding regulations. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 93000 
is a column II code to column I code 93015. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the electrocardiogram (ECG) with interpretation and report 
(93000) provided on August 17, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for drug testing provided on June 7, 2017. 
 
You asked the Plan to pay for the drug testing. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says that the documentation submitted does not 
support the service billed. 
 
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 G0482 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs 
and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to 
gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, 
eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other 
universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and 
variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control 
material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all 
sources, includes specimen validity testing, per day; 15-21 drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0482 is supported in the medical record. Specifically, the lab report clearly shows that 
15-21 drug classes were tested in this case. Please note, we counted the classes based on the separately billable 
tests from the CPT Handbook. Also, the record indicates that this provider was directed by the Plan to not 
obtain records. With this direction, it is inappropriate for the Plan to deny these services based on the physician 
signature. Based on this information, we decided that Medicare rules for coverage of the drug testing have been 
met. Therefore, we decided that the Plan has to pay for drug testing provided on June 7, 2017.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.