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

 
We decided that the Plan does not have to pay for the core buildup (D2950) and waive the coinsurance for the 
resin-based composite (D2392) provided on September 2, 2021. 
 
You asked the Plan to pay for the core buildup and waive the coinsurance for the resin-based composite. You 
say that you would like reconsideration because your tooth still hurts and the dentist will not do any more. The 
Plan denied your request. The Plan says you do not have a benefit for core buildup. 
 
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 core buildup is not 
among those covered under this benefit. Additionally, you are responsible for 50% coinsurance for the resin-based composite. This coinsurance has been applied correctly. Therefore, we decided that the Plan does not 
have to pay for the core buildup (D2950) and waive the coinsurance for the resin-based composite (D2392) 
provided on September 2, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (87631) provided January 3, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that the service was medically necessary. The Plan 
denied your request. The Plan says this testing is non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that Multiplex PCR respiratory viral panels of 6 or 
more pathogens are non-covered. 
 
We looked at the file and Medicare rules. The record shows testing for more than 5 pathogens. 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 genetic testing (87631) provided January 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an Office Visit provided on November 18, 2021 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for an Office Visit. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider is out-of-network and it was determined 
these services were not urgent or emergent. 
 
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 an Office Visit provided on November 18, 2021 
by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (87150) provided on January 10, 2021. 
 
You asked the Plan to pay for laboratory services. You say that this was medically necessary. The Plan denied 
your request. The Plan says this was not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that 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 laboratory 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 laboratory services (87150) provided on January 10, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance imaging (MRI) of the 
lumbar spine provided on December 26, 2021. 
 
You asked the Plan to waive the copayment for an MRI. You say that you want the copayment for the MRI to 
be waived. The Plan denied your request. The Plan says you have been charged the correct cost sharing 
amount. 
 
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 you must pay a $325 
copayment for diagnostic radiology services, including MRIs.  
 
You have been asked to pay a $325 copayment for an MRI. An MRI falls within the Outpatient Diagnostic 
Tests and Therapeutic Services and Supplies 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 copayment 
for a magnetic resonance imaging (MRI) of the lumbar spine provided on December 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for dental services received on September 14, 2021. 
 
You asked the Plan to waive the coinsurance for the services. You say that you do not agree with the cost-share 
and that no additional payment was made. The Plan denied your request. The Plan says the claim was 
processed appropriately. 
 
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 you must pay 50% 
coinsurance for endodontics.  
 
You have been asked to pay 50% coinsurance for the services. the services falls within the endodontics 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 coinsurance for dental services received on September 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental cleaning (D1110) provided by a dentist other than 
your assigned dental provider. 
 
You asked the Plan to pay for the cleaning. You say that you have been with this dental office for over 40 years 
and did not know that you needed to see a specific provider for coverage. The Plan denied your request. The 
Plan says the services in this case were received from a provider other than your assigned dentist. Services 
must be received from your assigned provider within the Plan's dental network in order to be covered. 
 
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. The Plan requires that dental 
services be performed by the assigned network dentist in order to be covered. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, items or services received from a 
dentist other than the assigned network dentist are not covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental cleaning (D1110) provided by a dentist other than your assigned dental provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital discharge day management (99239) provided on 
May 25, 2021. 
 
You asked the Plan to pay for hospital discharge day management (99239). You say that the enrollee was 
already a patient in the hospital when the service was rendered. You say that this claim is for an inpatient 
physician and the medical records should be reviewed. The Plan denied your request. The Plan says the 
medical records submitted don't support a hospital discharge day management of more than 30 minutes was 
performed. 
 
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 99239 is hospital discharge day management; more than 
30 minutes. 
 
We find that CPT code 99239 is not supported in the medical record. Specifically, the medical records do not 
document more than 30 minutes were spent on discharge management services as required by the code billed. 
Based on this information, we decided that Medicare rules for coverage of hospital discharge day management 
(99239) have not been met. Therefore, we decided that the Plan does not have to pay for hospital discharge day 
management (99239) provided on May 25, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on September 10, 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 are not covered.
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 test at issue in this appeal, a cardiovascular risk assessment panel, was 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 laboratory services rendered on September 10, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive drug testing of 22 or more drug classes 
provided on September 21, 2021, billed with code G0483. 
 
You asked the Plan to pay for the drug testing as billed. You say that this was medically necessary testing and 
was billed correctly. The Plan denied your request. The Plan says the lab report does not support testing for 22 
or more drug classes. 
 
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 G0483 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; 22 or 
more drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, only 16 drug classes (as 
defined by separately reportable tests per the CPT codebook) were documented as being tested in this case. 
Based on this information, we decided that Medicare rules for coverage of the drug testing as billed have not 
been met. Therefore, we decided that the Plan does not have to pay for the definitive drug testing of 22 or more 
drug classes provided on September 21, 2021, billed with code G0483.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Latuda. 
 
You asked the Plan to pre-approve Latuda. You say that the enrollee has had a good response to this 
medication. The Plan denied your request. The Plan says coverage of this medication is the responsibility of the 
enrollee's prescription drug 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 Latuda.  
 
 
 Benefits for Latuda 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 cone beam CT capture (D0367) provided by an out-of-
network provider on December 13, 2021. 
 
You asked the Plan to pay for cone beam CT capture. You say that you were told that this would be covered. 
The Plan denied your request. The Plan says D0367 is not a covered dental 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, 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 cone 
beam CT capture (D0367) provided by an out-of-network provider on December 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on April 13, 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 April 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cardiac risk assessment genetic screening testing coded as 
81404 and 81479 provided July 1, 2021. 
 
You asked the Plan to pay for cardiac risk assessment genetic screening testing. You say that the medical 
records provided support the necessity of the services in dispute. The Plan denied your request. The Plan says 
the diagnosis does not substantiate 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Medicare rules say that 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. 
 
In this case, we find that CPT code 81404, 81479 is not supported in the medical record. Specifically, per 
outreach to the ordering providers office the doctor did not write an order for this enrollee to undergo 
cardiovascular testing. The doctors office also stated that the enrollee was seen in the office on 6/26/2021, prior 
to cardiovascular testing, for follow up of diabetes and excessive thirst, no notes suggesting cardiovascular 
genetic testing. The Plan also spoke to a staff member at the lab who stated that all cardiovascular genetic 
testing are provided to member's home via mail and returned to the lab via mail. Therefore, POS 81 is also not 
applicable. Based on this information, we decided that Medicare rules for coverage of cardiac risk assessment 
genetic screening testing have not been met. Therefore, we decided that the Plan does not have to pay for 
cardiac risk assessment genetic screening testing coded as 81404 and 81479 provided July 1, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve retainer crowns (D6740 x 2), and pontics (D6245 x 2). 
 
You asked the Plan to pre-approve a fixed bridge. You say that you have had similar services done in the last 5 
years. You say that you feel this should be covered. You also say that you signed up for the plan because you 
would be covered for 50% up to the $3,000 allowance. The Plan denied your request. The Plan says that the 
frequency limit has been reached. 
 
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. Specifically, the requested bridge is a routine dental procedure. The file does not 
include any indicate that the Plan has previously paid for a fixed bridge, or crowns for teeth # 3, 4, 5 and 6 
within the last 5 years. Therefore, we decided that the Plan has to pre-approve retainer crowns (D6740 x 2), and 
pontics (D6245 x 2).  
 
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 a crown (D2740) for teeth #7 and #10 provided by a 
participating provider on January 14, 2022. 
 
You asked the Plan to pay for a crown. You say that this is essential to retaining the two middle front teeth. The 
Plan denied your request. The Plan says these crowns 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. The Plan covers a crown when 
the services are medically necessary and reasonable.  
 
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 a crown. Our reviewer says that a crown for 
teeth #7 and #10 is not medically necessary. Our physician reviewer found there does not appear to be any 
damage or fracture to the tooth structure on #7 with #10 showing some decay and/or lost restoration.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of a crown have not been met. Therefore, we decided that the Plan does not have 
to pay for a crown (D2740) for teeth #7 and #10 provided by a participating provider on January 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the technical component (TC) of the surgical pathology 
services provided on August 10, 2021, billed with code 88305. 
 
You asked the Plan to pay for the TC of code 88305. You say that this was billed correctly and should be paid. 
The Plan denied your request. The Plan says the global payment for code 88305 was denied as the services 
were rendered to a hospital patient. 
 
The Plan must follow Medicare rules. Medicare rules say that the TC of physician pathology services are not 
payable when provided for samples taken from a hospital patient.  
 
We looked at the file and Medicare rules. The documentation supports that this sample was taken during an 
outpatient hospital encounter. As such, 88305 can only be paid as the professional component, with modifier 
26. Based on this information, we decided that Medicare rules for coverage of the TC of code 88305 have not 
been met. Therefore, we decided that the Plan does not have to pay for the technical component (TC) of the surgical 
pathology services provided on August 10, 2021, billed with code 88305.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scalings and root planings (D4341) for the 
upper right, upper left, and lower left quadrants. 
 
You asked the Plan to pre-approve the scalings and planings. The Plan denied your request. The Plan says this 
service is limited to 1 time every 3 calendar years. The Plan also says that you already had this service done on 
the upper right, upper left, and lower left quadrants during that time. 
 
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, periodontal scaling and root planing 
(D4341 and D4342) is limited to 1 per 3 calendar years per quadrant. The record shows that you received 
periodontal scalings and root planings (D4341) for the upper right, upper left, and lower left quadrants on 
September 22, 2021 and your periodontal scalings and root planings (D4341) benefits for the upper right, upper 
left, and lower left quadrants have been exhausted. Therefore, we decided that the Plan does not have to pre-
approve periodontal scalings and root planings (D4341) for the upper right, upper left, and lower left quadrants.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-emergency transportation and air travel (A0140), 
non-emergency transportation; taxi (A0100), and non-emergency transportation; patient attendant/escort 
(T2001). 
 
You asked the Plan to pre-approve the non-emergency transportation services. You say that you do not live on 
the main island. You say that air fare is $800 round trip. You say that you require medical services from the 
Main Island. You also say that this disease is life threatening and requires immediate attention. The Plan denied 
your request. The Plan says that routine, non-emergency transportation is not covered. 
 The Plan must follow Medicare rules. Medicare does not cover transport in a vehicle that is not an ambulance. 
The Plan follows the same rule.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Medicare rules for coverage of the non-emergency transportation services have not been met. 
Therefore, we decided that the Plan does not have to pre-approve non-emergency transportation and air travel 
(A0140), non-emergency transportation; taxi (A0100), and non-emergency transportation; patient 
attendant/escort (T2001).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on September 7, 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 are not covered.
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 test at issue in this appeal, a cardiovascular risk assessment panel, was 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 laboratory services rendered on September 7, 2021.