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

 
We decided that the Plan does not have to pay for the laboratory services (81321, 81206, 81210, 81235, 81272, 
81275, 81276, 81292, 81301, and 81311) provided on October 26, 2021. 
 
You asked the Plan to pay for codes 81321, 81206, 81210, 81235, 81272, 81275, 81276, 81292, 81301, and 
81311. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your 
request. The Plan says the services are not covered as 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. 
 
We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT code 81479. Therefore, we decided that the Plan does not have 
to pay for the laboratory services (81321, 81206, 81210, 81235, 81272, 81275, 81276, 81292, 81301, and 
81311) provided on October 26, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81206 and 81292) provided on July 2, 2021. 
 
You asked the Plan to pay for codes 81206 and 81292. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as 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. 
 
We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT code 81479. Therefore, we decided that the Plan does not have 
to pay for the laboratory services (81206 and 81292) provided on July 2, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for sedation services billed with code 99152 for date of service 
June 25, 2021. 
 
You asked the Plan to pay for procedure code 99152. You say that this service was necessary and was billed 
appropriately. The Plan denied your request. The Plan says this service is not supported as 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 99152 is moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older. 
 
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 procedure code 99152. Our reviewer says that the records do 
not support the service reported. Our reviewer found that the provided documentation includes a procedure 
report for vascular services and monitored sedation; however, documentation does not support the presence of 
an independent trained observer to assist in the monitoring of the patient's level of consciousness and 
physiological status per CPT code description. In this case, CPT 99152 cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99152 have not been met. Therefore, we decided that the Plan 
does not have to pay for sedation services billed with code 99152 for date of service June 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for other drugs and/or medicaments (code D9630) provided on 
July 17, 2020. We also decided that the Plan does not have to pay more for the immediate denture - maxillary 
(code D5130), since the annual maximum dental benefit of $1,000 has been reached.  
 
  You asked the Plan to pay for the denture and other drugs and/or medicaments. You say that you would like 
these services covered. The Plan denied your request. The Plan says the immediate denture denied due to the 
annual maximum being met after the claim reprocessed. The Plan also says the drugs and/or medicaments are 
not covered by the supplemental benefit.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, other drugs and/or medicaments are 
not among those covered under this benefit. The Plan also offers a $1,000 annual dental benefit maximum. The 
record shows that you met the annual maximum benefit on July 17, 2020, and your annual maximum benefit 
has been exhausted. Therefore, we decided that the Plan does not have to pay more for the immediate denture - 
maxillary (code D5130) and pay for other drugs and/or medicaments (code D9630) provided on July 17, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 81225, 81230, 81238, 
81240, 81241, 81291, 81479) provided on March 22, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not covered as billed. 
 The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the laboratory services have not been met. The provider performed 
a 61 gene phamacogenomic panel. The laboratory billed multiple individual CPT codes with the same date of 
service. Procedures shall be reported with the most comprehensive CPT code that describes the services 
performed. Providers/suppliers must not unbundle the services described by a HCPCS/CPT code. If one 
laboratory procedure evaluates multiple genes using a next generation sequencing 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 CPT code. Therefore, we 
decided that the Plan does not have to pay for the laboratory services (CPT code(s): 81225, 81230, 81238, 
81240, 81241, 81291, 81479) provided on March 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140), intraoral x-rays (D0220), 
and endodontic therapy (D3320) provided on March 2, 2022. 
 
You asked the Plan to pay for the dental services. You say that these services were denied because your benefit 
has been exhausted but you say you have only had this insurance since January 2022. The Plan denied your 
request. The Plan says your annual maximum benefit has been exhausted. 
 
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 after the annual maximum has been exhausted. The record shows your 
annual maximum benefit has been met. Therefore, we decided that the Plan does not have to pay for a limited 
oral evaluation (D0140), intraoral x-rays (D0220), and endodontic therapy (D3320) provided on March 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services (81206 and 81292) provided on 
November 1, 2021. 
 You asked the Plan to pay for the genetic testing services. You say that this claim should be 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 and 81292) provided on November 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray and extraction provided on February 15, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were told cleanings, x-rays, and extractions 
were included in your plan. The Plan denied your request. The Plan says the claim processed correctly. 
 
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 file shows that you received a dental extraction. Although the Plan offers a dental benefit in excess of 
Medicare coverage, extractions are not among those covered under this benefit. You also received 2 intraoral x-
rays. The Plan paid for 1 x-ray. Per your contract, 1 intraoral x-ray is covered per calendar year. We found no 
exception which would require the Plan to pay for the additional x-ray. Therefore, we decided that the Plan 
does not have to pay for the x-ray and extraction provided on February 15, 2022.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for injection services provided to the enrollee on January 16, 2022.
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 service was billed incorrectly.
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 73090: Radiologic examination; forearm, 2 views CPT 73110: Radiologic examination, wrist; complete, minimum of 3 views
An anatomical modifier would be required in this case. The record does not show that it was appended to the claim. 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 injection services provided to the enrollee on January 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81404 and 81479) provided on April 
28, 2021. 
 
You asked the Plan to pay for codes 81404 and 81479. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 
The file does not contain documentation of an established relationship between the enrollee and the ordering 
provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this 
testing have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services 
(81404 and 81479) provided on April 28, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hereditary cardiovascular screening panel provided on 
February 22, 2021. 
 You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says there is no 
evidence to support the ordering provider was treating the enrollee. 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that CPT code 81479 is not supported in the medical record. It appears that the testing may have been 
ordered by an unsolicited outreach telephone call to the enrollee. The records show that the enrollees treating 
physician did not order the testing for a specific diagnosis or treatment plan. Based on this information, we 
decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have 
to pay for the hereditary cardiovascular screening panel provided on February 22, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the COVID-19 vaccine rendered on April 5, 2021, and May 5, 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 that the vaccine is covered by Original Medicare. 
 
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 states that they do not cover the COVID-19 vaccine; however, the 
COVID-19 resources from the Plan state that they cover the vaccine at 100 percent from an in- or out-of-
network provider. The Plan has not provided any documentation to support that the services are not covered. 
Therefore, we decided that the Plan has to pay for the COVID-19 vaccine rendered on April 5, 2021, and May 
5, 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 an extraction (D7140) provided on March 8, 2021, and an 
unspecified adjunctive procedure (D9999), maxillary complete denture (D5110), and a resin-based composite 
filling (D2331) provided on July 6, 2021. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says that both providers have opted out of Medicare and the services 
are 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 (D7140) provided on March 8, 2021, and an unspecified adjunctive procedure (D9999), maxillary 
complete denture (D5110), and a resin-based composite filling (D2331) provided on July 6, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 81120, 81121, 81206, 81210, 
81292, 81295, 81298, 81317 and 81301 provided on June 8, 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 are not payable as 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. 
 We find that CPT codes 81120, 81121, 81206, 81210, 81292, 81295, 81298, 81317 and 81301 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 code, so one code must be submitted for the panel. Review of the file does not support that only one 
code was submitted 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 81120, 81121, 81206, 81210, 81292, 81295, 81298, 81317 and 81301 
provided on June 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral evaluation (D0150), cleaning (D1110), and fluoride 
varnish (D1206) provided on July 23, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the bill that you received. The 
Plan denied your request. The Plan says the claim denied correctly.  
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 dental services from an out-of-network provider. Though the Plan offers a 
dental benefit in excess of Medicare coverage, the dental services are not covered under this benefit when 
received from an out-of-network provider. Additionally, there were in-network providers available. Therefore, 
we decided that the Plan does not have to pay for the oral evaluation (D0150), cleaning (D1110), and fluoride 
varnish (D1206) provided on July 23, 2021, 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 take home drug (D9630) and localized delivery of 
antimicrobial agents (D4381) provided from February 1, 2022, to February 23, 2022. 
 
You asked the Plan to pay for the take home drug and localized delivery of antimicrobial agents. You say that 
you were advised the provider was in network. You also say that you verified this information when you went 
for your appointment. The Plan denied your request. The Plan says the dental services are not listed as 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 dental services are not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the take home drug 
(D9630) and localized delivery of antimicrobial agents (D4381) provided from February 1, 2022, to February 
23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on June 28, 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 June 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed on July 28, 2021. 
  You asked the Plan to pay for procedure code 99100. You say that the attached medical records support the 
medical necessity, and the claim should be reprocessed for payment accordingly. The Plan denied your request. 
The Plan says procedure code 01638 and 64415 were overturned. The Plan also says procedure code 99100 
remains denied as bundled services are not eligible for separate payment. 
 
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 code 99100 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99100 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 99100 billed on July 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the extraction, erupted tooth or exposed root (elevation 
and/or forceps removal) (D7140) and panoramic radiographic image (D0330) provided February 22, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay more for the dental services. You say that you did not know the provider was OON 
and cannot afford the cost. The Plan denied your request. The Plan says you are responsible for any charged 
amount above the Plans cost-sharing amount when your services are received from an out-of-network 
provider. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to pay more for the extraction, erupted tooth or exposed root 
(elevation and/or forceps removal) (D7140) and panoramic radiographic image (D0330) provided February 22, 
2022, by an out-of-network (OON) provider.