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 December 21, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered 
benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that the MolDX Team has determined that testing for 
the FANCC is not a Medicare benefit and is a statutorily excluded service. In addition to single gene testing, 
MolDX will also deny panels of tests that include the FANCC gene.  
 
We looked at the file and Medicare rules. Per LCA A53628, the requested FANCC genetic testing is not a 
covered benefit. Based on this information, we decided that Medicare rules for coverage of the testing have not 
been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
December 21, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on September 30, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.  
 
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results 
and was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on September 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prefabricated post and core in addition to crown (D2954) 
provided September 30, 2021. 
 
You asked the Plan to pay for the prefabricated post and core. You say that you should be reimbursed for this 
service. The Plan denied your request. The Plan says this service is not covered under your 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 the 
prefabricated post and core in addition to crown (D2954) provided September 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a prophylaxis, periodic oral evaluation and bitewing x-rays 
(D0120, D0274, D1110) provided on March 9, 2022. 
 
You asked the Plan to pay for the prophylaxis, periodic oral evaluation and bitewing x-rays. You say that the 
services should be covered as you disagree with the charges. The Plan denied your request. The Plan says the 
coinsurance applied correctly as the covered services were performed out-of-network. 
 
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 Plan is only obligated to pay 50% 
of the allowed amount for these services when received from an out-of-network provider. You are responsible 
for any amount greater than the payment made by the Plan to the provider. Therefore, we decided that the Plan 
does not have to pay for a prophylaxis, periodic oral evaluation and bitewing x-rays (D0120, D0274, D1110) 
provided on March 9, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that this level of service will be beneficial for 
the enrollee. The Plan denied your request. The Plan says that the enrollee's records do not show that the 
enrollee is likely to get better with LTACH care. 
 
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. The patient 
appears to be somewhat unstable and requires short-term additional acute care services that can safely be 
administered at the current facility for the time being. The patient does not require services at the LTACH that 
are not already available at the current facility. Our physician reviewer found that the enrollee's condition does 
not meet Medicare criteria for LTACH services. 
 
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 for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cone beam imaging (D0383). 
 
You asked the Plan to pre-approve the imaging. You say that the treatment is necessary for the patient's oral 
health and wellbeing. The Plan denied your request. The Plan says that cone beam imaging (D0383) is not 
covered by the Plan's 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 cone 
beam imaging (D0383).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220) provided on 
March 16, 2021. 
 
You asked the Plan to pay for the first intraoral periapical x-ray. You say that you would like to appeal this 
service. The Plan denied your request. The Plan says this service is not a covered expense under your dental 
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 first 
intraoral periapical x-ray (D0220) provided on March 16, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic procedure, 1 or more areas, each 15 minutes; 
therapeutic exercises to develop strength and endurance, range of motion and flexibility (97110), manual 
therapy techniques (eg, mobilization/ manipulation, manual lymphatic drainage, manual traction), 1 or more 
regions, each 15 minutes (97140), and electrical stimulation (unattended), to one or more areas for indication(s) 
other than wound care, as part of a therapy plan of care (G0283) provided on April 2, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the OON physical therapy services and electrical stimulation. You say that you 
are a participating provider with Medicare. The Plan denied your request. The Plan says these services are not 
covered because they were provided OON without prior authorization. The Plan also says that the referring 
provider is OON as well.  
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 therapeutic procedure, 1 or more areas, each 
15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility (97110), 
manual therapy techniques (eg, mobilization/ manipulation, manual lymphatic drainage, manual traction), 1 or 
more regions, each 15 minutes (97140), and electrical stimulation (unattended), to one or more areas for 
indication(s) other than wound care, as part of a therapy plan of care (G0283) provided on April 2, 2022, by an 
out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete maxillary denture (D5110) provided on 
December 16, 2021. 
 
You asked the Plan to pay for the complete maxillary denture. You say that you could not eat and went OON 
because you got an appointment sooner. The Plan denied your request. The Plan says this service is not a 
covered benefit under your dental plan. The Plan also says that you were not active with the optional dental 
rider on this date of service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
complete maxillary denture (D5110) provided on December 16, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the hearing aid, digital, binaural, behind the ear (V5261) and 
dispensing fee, binaural (V5160) provided November 2, 2021. 
 
You asked the Plan to pay for the hearing aid and dispensing fee. You say that these services should be paid. 
The Plan denied your request. The Plan says that the documentation submitted did not include an itemized 
shipping/billing invoice to indicate the specific supplies, or proof of delivery for the billed date of service. 
 
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. In this case there is no citation in the EOC or Medicare rules stating that proof of 
delivery is necessary for reimbursement of hearing aids. Additionally, the case file includes a signed and dated 
bill and a shipping receipt which confirms that the hearing aids were purchased. Thus, we find that there is no 
documentation provided substantiating the Plans denial. Therefore, we decided that the Plan has to pay for the 
hearing aid, digital, binaural, behind the ear (V5261) and dispensing fee, binaural (V5160) provided November 
2, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unspecified preventive procedure (code D1999) provided 
on August 16, 2021, to August 25, 2021. 
 
You asked the Plan to pay for the unspecified preventive procedure. You say that you visited an in-network 
provider, and that it was the responsibility of the provider to guide you in the case of a service not being 
covered by the Plan. The Plan denied your request. The Plan says these specific dental services are not covered 
under your supplemental 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, 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 
unspecified preventive procedure (code D1999) provided on August 16, 2021, to August 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the wheelchair component or accessory, not otherwise 
specified, transit bracket (K0108). 
 
You asked the Plan to pre-approve the transit bracket. You say that you are requesting reconsideration of the 
denial for the manual wheelchair and accessories. The Plan denied your request. The Plan says this item is for 
use for transportation outside of the home and is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the transit bracket have not been met. Therefore, we decided that the Plan does not have to pre-
approve the wheelchair component or accessory, not otherwise specified, transit bracket (K0108).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infectious agent detection by nucleic acid services coded 
87801 provided on August 25, 2021. 
 
You asked the Plan to pay for the infectious agent detection by nucleic acid 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 a 
covered benefit. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The infectious agent detection by nucleic acid services at issue in this appeal were requested solely for 
screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that 
the Plan does not have to pay for the infectious agent detection by nucleic acid services coded 87801 provided 
on August 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (17004, 99213) provided on March 1, 
2022, by a provider who has opted out of the Medicare program. 
 
You asked the Plan to pay for physician services. You say that you have been treated by the provider at issue 
for over 50 years. The Plan denied your request. The Plan says rules for payment have not been met because 
the provider at issue has opted out of Medicare. 
 
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 physician 
services (17004, 99213) provided on March 1, 2022, by a provider who has opted out of the Medicare program.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mandibular partial denture (D5214) provided on January 
25, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the mandibular partial denture. You say that your dentist's office contacted the 
Plan prior to completing this were and was advised that you had OON benefits. The Plan denied your request. 
The Plan says services performed by an OON provider are not covered because your healthcare plan does not 
have OON benefits. The Plan says that the provider contacted the Plan during the 2021 benefit year and was 
advised of your benefits for the 2021 plan year. The Plan also says that there were no calls for benefits or 
provider eligibility prior to this January 25, 2022 date of service, and the benefits that you had in 2021 are no 
longer available for the 2022 plan year. 
 
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, you are responsible for 100% of the 
cost for dental services rendered by an OON provider. Therefore, we decided that the Plan does not have to pay 
for the mandibular partial denture (D5214) provided on January 25, 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 genetic testing provided on February 16, 2021, billed 
with codes 81120, 81121, 81210, 81235, 81245, 81270, 81272, 81275, 81276, 81310, 81311, 81315, and 
81351. 
 
You asked the Plan to pay for the genetic testing. You say that this is medically necessary testing that should be 
paid. The Plan denied your request. The Plan says this is a panel and should be billed with one single code. 
Therefore, only two of the line items are approved for payment.  
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 
codes 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 
February 16, 2021, billed with codes 81120, 81121, 81210, 81235, 81245, 81270, 81272, 81275, 81276, 81310, 
81311, 81315, and 81351.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and periodontal 
maintenance (D4910) provided on March 4, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the periodic oral evaluation and periodontal maintenance. You say that the 
treating provider is not in the Plan's network, but you believe the Plan should still pay a percentage for these 
procedures. The Plan denied your request. The Plan says services performed by an OON provider are not 
covered because your healthcare plan does not have OON benefits. The Plan also says that you did not contact 
the Plan prior to the date of service to verify benefits and provider eligibility. 
 
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, you are responsible for 100% of the 
cost for dental services rendered by an OON provider.  
 
Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and 
periodontal maintenance (D4910) provided on March 4, 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 addition, endoskeletal system, below knee (BK), 
alignable system (CPT code L5910). 
 
You asked the Plan to pre-approve the item. You say that the item is medically necessary. The Plan denied your 
request. The Plan says the preparatory prosthesis is a non-alignable system, therefore, the medical necessity for 
the requested alignable system (L5910) is not met. 
 
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 item. Our physician reviewer found 
according to Medicare additional features or components to a prosthesis may be necessary depending on the 
beneficiarys potential functional abilities. Potential functional ability is based on the reasonable expectations 
of the prosthetist, and treating practitioner, considering multiple factors. These factors include the beneficiarys 
past history, current condition including the status of the residual limb and the nature of the other medical 
problems and the beneficiarys desire to ambulate. It is standard that after a below-the-knee amputation heals a 
preparatory prefabricated prosthesis is provided to help achieve limb maturation and total contact and to avoid 
multiple socket changes. Medicare allows for replacement of a prosthesis or prosthetic component if there is a 
change in the physiological condition of the beneficiary, there is irreparable wear of the device or a part of the 
device or if the condition of the device, or part of the device, requires repairs and the cost of such repairs would 
be more than 60% of the cost of a replacement device, or the part being replaced. In this case, the requested 
component cannot be used with the approved preparatory prosthesis therefore it is not 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 item have not been met. Therefore, we decided that the Plan does not have 
to pre-approve addition, endoskeletal system, below knee (BK), alignable system (CPT code L5910).