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

 
We decided that the Plan does not have to waive the cost share for a crown (D2740) provided on March 29, 
2022. 
 
You asked the Plan to waive the cost share for a crown. You say that you told the dentist not to do any 
procedures that would cost you anything out-of-pocket. The Plan denied your request. The Plan says your 
annual dental allowance has been exhausted. 
 The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that this benefit includes 
coverage up to $4,500 for covered preventive and comprehensive dental services. The contract also says that 
you are responsible for any amount over the allowance amount. 
 
The record shows your annual dental allowance has been exhausted. You have been asked to pay the remaining 
balance of $52 for a crown. A crown falls within the Dental Benefits benefit category. This means that you 
have been asked to pay the correct amount based on your contract with the Plan. 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 waive the cost share for a crown (D2740) provided on March 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 1, 2021, billed with 
codes 81225, 81230, 81238, 81240, 81241, 81291 and 81335. 
 
You asked the Plan to pay for the genetic testing billed. You say that these services were necessary and are 
supported in the medical record. The Plan denied your request. The Plan says these services were not billed in 
accordance with Medicare rules. 
 
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 
June 1, 2021, billed with codes 81225, 81230, 81238, 81240, 81241, 81291 and 81335.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 83789 billed for date of service April 11, 
2022. 
 You asked the Plan to pay for procedure code 83789. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 83789 is bundled into payment for code G0481. 
 
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 83789 
is a column II code to column I code G0481. This claim has not been billed with an appropriate modifier to 
bypass the edit. The -59 modifier is not supported as a separate and distinct procedural service. 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 83789 billed for date of service April 11, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76700 billed for date of service May 11, 
2022. 
 
You asked the Plan to pay for procedure code 76700. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76700 is bundled into payment for 
code 93976. 
 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 76700 
is a column II code to column I code 93976. 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 76700 billed for date of service May 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 14, 2022, billed with 
codes 81227, 81230, 81231, 81232, 81291, 81306, 81328, 81355, 81335, 0031U, 0032U and 0033U. 
 
You asked the Plan to pay for the genetic testing billed. You say that these services were reported correctly and 
are supported in the medical record. The Plan denied your request. The Plan says these services were not billed 
in accordance with Medicare rules. 
 
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 April 14, 2022, billed with codes 81227, 81230, 81231, 81232, 81291, 81306, 81328, 81355, 81335, 0031U, 
0032U and 0033U.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 83789-59 provided on March 
30, 2022. 
 
You asked the Plan to pay for the laboratory services as billed. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says the documentation does 
not support payment for this service as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services as billed have not been met. Specifically, we find that the testing described 
by the billed code is considered specimen validity testing which is not separately payable. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 83789-59 provided on March 30, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the bone marrow concentrate (CPT code 38220). 
 
You asked the Plan to pre-approve the bone marrow concentrate. You say that the services are necessary. The 
Plan denied your request. The Plan says the clinical value and effectiveness of the application of bone marrow 
concentrate in the setting of a transforaminal lumbar interbody fusion has not been demonstrated in the peer-
reviewed literature. 
 
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 bone marrow concentrate. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found bone marrow aspirate remains experimental in spinal surgery. 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 bone marrow concentrate have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the bone marrow concentrate (CPT code 38220).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the root canal (D3320) and limited oral exam (D0140) 
provided June 1, 2022. 
 
You asked the Plan to pay more for the dental services. You say that this provider was your only option. 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 for the root canal. This cost sharing is a contractual obligation you agreed to pay when you enrolled in 
the Plan. Additionally, the Plan provided documentation showing that a limited oral exam was previously 
covered on April 15, 2022. Therefore, we decided that the Plan does not have to pay more for the root canal 
(D3320) and limited oral exam (D0140) provided June 1, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve forty additional physical therapy visits. 
 
You asked the Plan to pre-approve the additional visits. You say that you are in pain and need therapy. The 
Plan denied your request. The Plan says the plan approved 16 visits, and the remaining 40 are not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 additional visits. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that you have already received 18 sessions of physical therapy as of 
8/24/22, and the 16 additional sessions that were approved should be sufficient to make continued progress. If 
additional physical therapy is required, another re-revaluation should be provided to justify the need for 
continued physical therapy. Therefore, the 40 visits of additional therapy cannot be considered 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 additional visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve forty additional physical therapy visits.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on March 11, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services are supported in the medical records. 
The Plan denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on March 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental bone grafts and implants. 
 
You asked the Plan to pre-approve bone grafts and implants. You say that these procedures are medically 
necessary. The Plan denied your request. The Plan says these dental services are not covered by Medicare or 
the Plan. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement 
of the enrollees teeth or the structures directly supporting the enrollees teeth. These are dental services that 
are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve 
dental bone grafts and implants.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service May 18, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service May 18, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service May 20, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service May 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the removal of residual tooth roots on tooth #8 (D7250) 
provided on April 7, 2022. 
 
You asked the Plan to pay for tooth root removal. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says the removal of residual tooth roots (D7250) is not covered by 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 pay for the 
removal of residual tooth roots on tooth #8 (D7250) provided on April 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the at-home COVID-19 tests purchased on December 20, 
2021, and December 26, 2021. 
 You asked the Plan to pay for the at-home COVID-19 tests. You say that you did not exercise this benefit in 
February of 2022 because you had already purchased test kits and did not need more. The Plan denied your 
request. The Plan says these tests were not a covered benefit at the time you purchased them. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and at-home 
COVID-19 test kits are an OTC item. The contract clearly states that coverage for these tests through the Plan 
began on February 1, 2022. These tests were purchased before February 1, 2022, and are not covered. The 
Plan's call log with you also states you were advised that the tests are not eligible for reimbursement. 
Therefore, we decided that the Plan does not have to pay for the at-home COVID-19 tests purchased on 
December 20, 2021, and December 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for complete mandibular dentures (D5120) provided on April 
11, 2022. 
 
You asked the Plan to pay for dentures. You say that you were told you had $1,000 towards dentures. The Plan 
denied your request. The Plan says your annual dental benefit has been met. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that this benefit includes 
coverage up to $1,000 for covered dental services. The record shows your annual dental benefit has been met. You have been asked to pay $53 for a complete 
mandibular denture. Dentures fall within the Dental Services benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. 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 for complete mandibular dentures (D5120) provided on April 11, 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.

You asked the Plan to pre-approve the LTACH services. You say that the LTACH is medically necessary. The
Plan denied your request. The Plan says the LTACH is not medically necessary and continued acute hospital
stay was offered until the enrollee can discharge to a lower level of care such as a skilled nursing facility
(SNF).

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 was admitted with severe sepsis in the setting of Covid-19 infection. The
record indicates that the enrollee is improving but still requires acute care services before transitioning to a
lower level of care. The medical record does not indicate that the enrollee requires services that she is not
currently receiving but that would be available at the LTACH facility.

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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable folding power chair (A9270). 
 
You asked the Plan to pre-approve a portable folding power chair. You say that your balance is unsteady, your 
legs become uncontrollably weak with no warning, and you have fallen down several times in and out of the 
house. You use a cane or a walker to walk in and out of the house and still have fallen due to sudden and 
unexplained weakness. You are requesting that the Plan reconsider this denial due to these circumstances. The 
Plan denied your request. The Plan says the requested chair is not covered under your Plan. The Plan also says 
the safety of this power chair is not known. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
While a portable folding power chair may be appropriate in this case, neither the Plan nor Medicare offers 
coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a portable folding 
power chair (A9270).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on March 28, 2022. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on March 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre 2 continuous glucose monitor (CGM) 
and supplies (K0553, K0554). 
 
You asked the Plan to pre-approve a FreeStyle Libre 2 CGM and supplies. You say that you were using a 
regular meter, but it hurts when you pinch your fingers. The Plan denied your request. The Plan says 
documentation submitted did not include a valid physician order. 
 
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 record does not contain a valid physician order. The record 
shows that the Plan made several attempts to obtain the information that was necessary from your provider 
without success. Based on this information, we decided that Medicare rules for coverage of a FreeStyle Libre 2 
CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
FreeStyle Libre 2 continuous glucose monitor (CGM) and supplies (K0553, K0554).