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

 
We decided that the Plan does not have to pay an additional amount for the diagnostic services provided on 
November 10, 2021. 
 
You asked the Plan to pay an additional amount for the diagnostic services provided on November 10, 2021. 
You say that the provider is billing you again stating that you still owe money. The Plan denied your request. 
The Plan says the claims processed correctly. 
 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 $50 
copayment for Outpatient Diagnostic Tests and Therapeutic Services and Supplies.  
 
You have been asked to pay a $50 copayment for the diagnostic services provided on November 10, 2021. The 
diagnostic services provided on November 10, 2021, fall within the Outpatient Diagnostic Tests and 
Therapeutic Services and Supplies benefit category under Specialists Office. 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 an additional amount for the diagnostic services provided on November 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve oral evaluation with periodontist. 
 
You asked the Plan to pre-approve oral evaluation. You say that you were referred to a Periodontist because of 
bone and gum issues. The Plan denied your request. The Plan says your dental services are only covered when 
provided by a general dentist. 
 
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. Services must be performed 
by a participating general dentist. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested oral evaluation with 
periodontist is not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pre-approve oral evaluation with periodontist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a periodic oral evaluation (D0120) and prophylaxis 
(D1110). 
 
You asked the Plan to pre-approve the dental services. You say that there is a lack of participating dentists in 
your area. The Plan denied your request. The Plan says dental services from an out-of-network provider are not 
covered by your supplemental 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. 
 
You are requesting dental services from an out-of-network provider. Though the Plan offers a dental benefit in 
excess of Medicare coverage, the requested items or services are not covered under this benefit when received 
from an out-of-network provider. Therefore, we decided that the Plan does not have to pre-approve a periodic 
oral evaluation (D0120) and prophylaxis (D1110).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve four gingival irrigations (D4921 x4). 
 
You asked the Plan to pre-approve the gingival irrigations. The Plan denied your request. The Plan says this 
service is not covered under your benefit plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve four 
gingival irrigations (D4921 x4).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve retainer crowns on tooth #11 and 13 (D6750) and a 
pontic on tooth #12 (D6240). 
 
You asked the Plan to pre-approve retainer crowns and a pontic. You say that these services are medically 
necessary. The Plan denied your request. The Plan says there cannot be any missing posterior teeth in the arch. 
 
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 retainer 
crowns and a pontic 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 pre-approve retainer crowns and a pontic. Our 
reviewer says that the coverage criteria has not been met. Our physician reviewer found that a replacement 
fixed bridge replacing tooth #12 does not meet the criteria for coverage due to a poor prognosis resulting from 
poor bone support of abutment teeth #11 and 13. 
 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 retainer crowns and a pontic have not been met. Therefore, we decided that the 
Plan does not have to pre-approve retainer crowns on tooth #11 and 13 (D6750) and a pontic on tooth #12 
(D6240).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extractions (D7210 x 2, D7140 x 2), and unspecified oral 
surgery procedure (D7999) provided on September 24, 2021. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered. The Plan denied 
your request. The Plan says the extractions and oral surgery procedure are not listed as covered services. 
 
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 extractions and oral surgery 
procedure are not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pay for the extractions (D7210 x 2, D7140 x 2), and unspecified oral surgery procedure (D7999) provided on 
September 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mandibular partial denture - flexible base (D5226). 
 
You asked the Plan to pre-approve the partial denture. You say that the enrollee only has four permanent teeth 
remaining on the lower side resulting in the enrollee being unable to chew properly. The Plan denied your 
request. The Plan says certain preventative and comprehensive dental services are covered but dentures are not 
included. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
mandibular partial denture - flexible base (D5226).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an occlusal adjustment (D9952). 
 
You asked the Plan to pre-approve an occlusal adjustment. You say that this service is medically necessary. 
The Plan denied your request. The Plan says an occlusal adjustment (D9952) is not covered by your routine 
dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an 
occlusal adjustment (D9952).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a dental implant (D6010) provided on March 30, 2022. 
 
You asked the Plan to pay for an implant. You say that you disagree with the denial of dental services. The 
Plan denied your request. The Plan says dental implants (D6010) are 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 a dental 
implant (D6010) provided on March 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve abutment supported cast metal crowns (D6063) and 
implant supported porcelain/ceramic crowns (D6065). 
 
You asked the Plan to pre-approve the abutment supported cast metal crowns and implant supported 
porcelain/ceramic crowns. You say that the provider denied the repair because they want to know if the Plan 
will cover the services first. The Plan denied your request. The Plan says these services are not covered under 
your benefit plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
abutment supported cast metal crowns (D6063) and implant supported porcelain/ceramic crowns (D6065).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care rendered on February 16, 2022. 
 
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 separately payable. 
 
The Plan must follow Medicare rules. The rules say that Current Procedural Terminology (CPT) modifier -25 
should only be used on claims for evaluation and management (E/M) services, and only when these services 
are provided by the same physician (or same qualified nonphysician practitioner) to the same patient on the 
same day as another procedure or other service. 
 
We looked at the file and Medicare rules. The file shows that billed procedure code 99305 was not a separate 
procedural service for the date of service at issue. Based on this information, we decided that Medicare rules 
for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for 
the nursing facility care rendered on February 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injections provided on April 20, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for injections. You say that you would like to request reconsideration of the denied 
claim. The Plan denied your request. The Plan says the provider is out-of-network, and it was determined these 
services can be received in-network. 
 
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 injections provided on April 20, 2022, by an out-
of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), panoramic x-ray 
(D0330), and additional periapical x-rays (D0230 x 2) provided on April 25, 2022. 
 
You asked the Plan to pay for the dental services. You say that you moved out of state and needed new x-rays. 
The Plan denied your request. The Plan says your benefit for the requested items or services 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 a comprehensive oral evaluation and panoramic x-ray was exhausted on date of service 
January 15, 2021. The record also shows your benefit for a periapical x-ray was exhausted on date of service 
April 25, 2022. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation 
(D0150), panoramic x-ray (D0330), and additional periapical x-rays (D0230 x 2) provided on April 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne CDx (F1CDx) test (0037U) provided 
February 2, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the provision of F1CDx to the enrollee 
meets the requirements of the NCD and has been determined by CMS to be reasonable and necessary for the 
management of the enrollee's advanced cancer. The Plan denied your request. The Plan says does not meet 
Medicare NCD/LCD criteria. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. The next generation sequence testing (NGS) testing panel performed 
included testing for the FANCC gene. Testing for this gene is not a Medicare benefit and is statutorily excluded 
service. In addition to single gene testing, panels that include the FANCC gene are statutorily excluded service. 
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 FoundationOne CDx (F1CDx) test 
(0037U) provided February 2, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a nerve stimulator implant (63650). 
 
You asked the Plan to pre-approve the nerve stimulator implant. You say that the stimulator is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that the implantation of a stimulator is covered only when 
being used only as a late resort (if not a last resort) for chronic intractable pain; and other treatment modalities 
(pharmacological, surgical, physical, psychological therapies) have been tried and did not prove satisfactory, or 
are judged to be unsuitable or contraindicated for the given patient. 
 
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 nerve stimulator implant. Our 
reviewer says that the requested implant is not medically necessary. Our physician reviewer found the record 
shows a failed trial of nerve stimulator use in the past. The record also shows a recent surgical consult. 
 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 nerve stimulator implant have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a nerve stimulator implant (63650).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the imaging services rendered on February 19, 2022. 
 
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 must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 93971 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of these 
services have not been met. Therefore, we decided that the Plan does not have to pay for the imaging services 
rendered on February 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 3, 2022, 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 of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network, and it was 
determined these services can be received in-network. 
 
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 March 3, 2022, by an 
out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay on November 15, 
2021, to November 22, 2021. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that would the enrollee be 
receiving this bill if she had not passed away. These charges are uncalled for. The Plan denied your request. 
The Plan says the cost sharing the enrollee is 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $225 copayment per day (Days 1-6 only) for each Medicare-covered in-network inpatient hospital 
care stay. Includes inpatient acute, inpatient rehabilitation, long-term care hospitals, and other types of inpatient 
hospital services. Inpatient hospital care starts the day you are formally admitted to the hospital with a doctors 
order. The day before you are discharged is your last inpatient day. $225 x 6 = $1,350. Therefore, results in the 
total cost sharing amount of $1,350.  
 The enrollee has been asked to pay a $225 copayment per day for inpatient hospital stay. Inpatient hospital stay 
falls within the Inpatient hospital care benefit category. This means that the enrollee has been asked to pay the 
correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee 
agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for inpatient hospital stay on November 15, 2021, to November 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a targeted genomic sequence analysis panel of 51 or more 
genes (81455) provided on December 18, 2021. 
 
You asked the Plan to pay for the targeted genomic sequence analysis panel. You say that this panel was 
medically necessary. The Plan denied your request. The Plan says this testing is not medically necessary and is 
not likely to impact therapeutic decision-making in the clinical management of this enrollee and therefore is 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 pay for the targeted genomic sequence analysis 
panel. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found not all of the genes tested in the panel are reasonable and necessary for the enrollee's condition. Therefore, this panel was not reasonable and 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 targeted genomic sequence analysis panel have not been met. Therefore, we 
decided that the Plan does not have to pay for a targeted genomic sequence analysis panel of 51 or more genes 
(81455) provided on December 18, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the targeted genomic sequence analysis, solid organ neoplasm, DNA 
analysis of 324 genes, interrogation for sequence variants, gene copy number amplifications, gene 
rearrangements, microsatellite instability and tumor mutational burden (0037U) provided October 4, 2021. 
 
You asked the Plan to pay for the FoundationOne CDx (F1CDx) test. You say that this test is a medically 
necessary covered benefit. The Plan denied your request. The Plan says that the next generation sequence 
testing (NGS) testing panel performed included testing for FANCC genes. Testing for these genes 
is not a Medicare benefit and is statutorily excluded service. 
 
The Plan must follow Medicare rules. Medicare rules say that the FoundationOne CDx test is covered when it 
is FDA approved for the enrollees diagnosis. 
 
We looked at the file and Medicare rules. In this case the documentation shows that the F1CDx test was 
performed for the enrollees diagnosis of non-small cell lung cancer. Non-small cell lung cancer is a covered 
indication for F1CDx. Based on this information, we decided that Medicare rules for coverage of the 
FoundationOne CDx test have been met. Therefore, we decided that the Plan has to pay for the targeted 
genomic sequence analysis, solid organ neoplasm, DNA analysis of 324 genes, interrogation for sequence 
variants, gene copy number amplifications, gene rearrangements, microsatellite instability and tumor 
mutational burden (0037U) provided October 4, 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.