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

 
We decided that the Plan has to pay for the drug testing (80307 and G0483) provided on February 28, 2019. 
 
You asked the Plan to pay for the drug testing. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says that the documentation does not support the 
services 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 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 supported in the medical record. Specifically, the lab report clearly shows that 
22+ drug classes were tested in this case. Please note, we counted the classes based on the separately billable 
tests from the CPT Handbook. Additionally, the Plan has not forwarded any evidence to support why CPT code 
80307 is not eligible for payment. It is the burden of the Health Plan to substantiate their denial with evidence. 
In this case, the Plan's denial has not been substantiated so we must find in your favor. Also, the record 
indicates that this provider was directed by the Plan to not obtain records. With this direction, it is inappropriate 
for the Plan to deny these services based on the physician signature. Based on this information, we decided that 
Medicare rules for coverage of the drug testing have been met. Therefore, we decided that the Plan has to pay 
for the drug testing (80307 and G0483) provided on February 28, 2019.  
 
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 comprehensive oral evaluation (D0150) provided on 
March 16, 2022. 
 
You asked the Plan to pay for the dental service. You say that you feel this should be covered. You say that you 
had a new dentist and needed an exam. You also say that exams should be covered twice a year or once every 6 
months. The Plan denied your request. The Plan says the claim was processed correctly in accordance with 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage and a comprehensive oral evaluation is 
covered once every 36 months, the frequency limit has been exceeded. The record shows that the Plan paid for 
a comprehensive oral evaluation that you received on July 16, 2020.  
 
Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) 
provided on March 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 81206 and 81292 provided on 
May 14, 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 81206 and 81292 are not supported in the medical record. Specifically, when a 
laboratory assays two or more genes in a patient in parallel. Those two or more genes will be considered part of 
the same panel. A panel constitutes a single procedural service, so one code must be submitted for the panel. 
Review of the file does not support that only one code was billed for the services rendered. 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 81206 and 81292 
provided on May 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture for tooth #12 (D5225). 
 
You asked the Plan to pre-approve a partial denture. You say that your granddaughter's dog ate your partial 
denture. The Plan denied your request. The Plan says this service is covered by the Plan's denture benefits; 
however, your benefit for one maxillary partial denture (D5225) 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. The Plan covers one maxillary 
partial denture (D5225) every five plan years. 
 
We looked at this case file, the Plan's rules, and Medicare rules. The record shows the Plan paid for a maxillary 
partial denture provided on February 28, 2022; therefore, the benefit for a maxillary partial denture has been 
exhausted. Therefore, we decided that the Plan does not have to pre-approve a maxillary partial denture for 
tooth #12 (D5225).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found there is no documented need for intensive inpatient rehabilitation services. Medically necessary care can be provided in a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Ultrasound on February 11, 2022. 
 
You asked the Plan to waive the copayment for Ultrasound. You say that you are requesting to pay 20% of 
$109.86 since it requires annual follow up. The Plan denied your request. The Plan says the cost-sharing you 
are being charged is correct. 
 
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 $115 
copayment for Medicare-covered radiological diagnostic services, not including x-rays performed in a 
physicians office or at a free-standing facility (such as a radiology center or medical clinic). Covered services 
include but are not limited to: Other outpatient diagnostic tests - Radiological diagnostic services, not including 
x-rays. The provider billed in the amount of $1,560. The total cost is $377.36, and the Plan paid $267.50. 
Therefore, resulting in the total cost-sharing amount of $109.86, which is less than the copayment amount. 
 
 
 You have been asked to pay the allowed amounts of $109.86, which is less than the $115 copayment for 
Ultrasound. Ultrasound 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 Ultrasound on February 11, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diagnostic digital breast tomosynthesis (77062) provided 
on January 14, 2022. 
 
You asked the Plan to pay for the diagnostic digital breast tomosynthesis. You say that you would like this 
claim reprocessed and approved for payment. The Plan denied your request. The Plan says this code is assigned 
a status indicator that is not valid for Medicare purposes. 
 
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 77062 has a Status Indicator of I on the Physician Fee Schedule. This means that CPT code 77062 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for 
coverage of the diagnostic digital breast tomosynthesis have not been met. Therefore, we decided that the Plan 
does not have to pay for the diagnostic digital breast tomosynthesis (77062) provided on January 14, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vertiflex Superion Interspinous device. 
 
You asked the Plan to pre-approve Vertiflex Superion Interspinous device. You say that you would like the 
plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not 
medically necessary. 
 
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 Vertiflex Superion Interspinous device. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the enrollee has a diagnosis of back pain with lumbar spinal stenosis 
and neurogenic claudication. The Vertiflex spacer is experimental. 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 Vertiflex Superion Interspinous device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Vertiflex Superion Interspinous device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedures codes 95908, 95885 and 95999 provided on 
November 3, 2021. 
 
You asked the Plan to pay for procedures codes 95908, 95885 and 95999. You say that the charges are 
appropriate for the level of acuity and intensity of the medical services provided. You say that the claim has 
been properly coded, and you are willing to accept reimbursement at 100% of the billed charges. The Plan 
denied your request. The Plan says procedures codes 95908, 95885 and 95999 are not supported by the medical 
records submitted. 
 
  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 95908 is nerve conduction studies; 3-4 studies. The CPT 
Code Manual definition of code 95885 is needle electromyography, each extremity, with related paraspinal 
areas, when performed, done with nerve conduction, amplitude and latency/velocity study; limited (List 
separately in addition to code for primary procedure. The CPT Code Manual definition of code 95999 is 
unlisted neurological or neuromuscular diagnostic procedure. 
 
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 procedures codes 95908, 95885 and 95999. Our reviewer 
says that the documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer 
found the procedure report does not include documentation to support nerve conduction studies. Since nerve 
conduction studies cannot be verified, CPT code 95885 cannot be verified. In addition, the procedure report 
does not include documentation of unlisted procedures. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedures codes 95908, 95885 and 95999 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedures codes 95908, 95885 and 95999 provided on 
November 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee orthosis provided on January 6, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the knee orthosis. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained before 
these services were obtained. 
 
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 knee orthosis provided on January 6, 2022 by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99213) and X-ray of the hip (73502) 
provided on January 26, 2022, by a provider who has opted-out of Medicare. 
 
You asked the Plan to pay for the office visit and X-ray of the hip. You say that you would like this claim paid 
by the Plan as it was medically necessary care. The Plan denied your request. The Plan says no payment can be 
made to a provider who 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 the office 
visit (99213) and X-ray of the hip (73502) provided on January 26, 2022, by a provider who has opted-out of 
Medicare.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided by a 
participating provider on March 30, 2022. 
 
You asked the Plan to pay for the dental services. You say that you do not understand why this is not being 
paid. The Plan denied your request. The Plan says your benefit for the requested item or service has already 
been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service July 28, 2020. Therefore, 
we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided by a 
participating provider on March 30, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found there is not a reasonable expectation that this patient will be able to fully participate 
in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an evaluation (D0150) and extraction (D7210) to be 
performed by an oral surgeon. 
 
You asked the Plan to pre-approve the dental services. You say that the medication you are on affects your 
teeth. You also say that your oncologist recommended you for the extraction. The Plan denied your request. 
The Plan says dental services performed by an oral surgeon are not 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested dental services to be 
performed by an oral surgeon are not among those covered under this benefit. 
 
Therefore, we decided that the Plan does not have to pre-approve an evaluation (D0150) and extraction 
(D7210) to be performed by an oral surgeon.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an opt-out provider on 
November 4, 2021. 
 
You asked the Plan to pay for dental services. You say that you had an implant that needed to be removed by 
an oral surgeon. The Plan denied your request. The Plan says this provider 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 until January 1, 2023. Therefore, we decided that the Plan does not have 
to pay for dental services provided by an opt-out provider on November 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lumbar spine fusion with StabiLink Device. 
 
You asked the Plan to pre-approve a lumbar spine fusion with StabiLink Device. You say that you are 
requesting a lumbar fusion with StabiLink Device as conservative and interventional treatments have failed to 
relieve pain. You say that The Plan denied your request. The Plan says the service is not a covered benefit until 
its efficacy for the enrollee's condition has been established. 
 
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 a lumbar spine fusion with StabiLink 
Device. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the StabiLink fusion system is experimental. In addition, 
the imaging studies do not show evidence of spinal instability, fracture, or lesion. 
 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a lumbar spine fusion with StabiLink Device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a lumbar spine fusion with StabiLink Device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pulp vitality tests (D0460) provided February 9, 2022. 
 
You asked the Plan to pay for the pulp vitality tests. You say that this service was necessary to determine 
whether a costlier procedure was needed. 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 pulp 
vitality tests (D0460) provided February 9, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT) of the heart with calcium 
scoring (75571). 
 
You asked the Plan to pre-approve the cardiac CT with calcium scoring. You say that the services are 
medically necessary. The Plan denied your request. The Plan says this is not a covered service. 
 
The Plan must follow Medicare rules. Medicare rules say that quantitative calcium scoring is not a covered 
service and will be denied as not medically necessary. 
 
We looked at the file and Medicare rules. The requested service is not covered under Medicare rules. Based on 
this information, we decided that Medicare rules for coverage of the cardiac CT with calcium scoring have not 
been met. Therefore, we decided that the Plan does not have to pre-approve computed tomography (CT) of the 
heart with calcium scoring (75571).