Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on April 14, 2022. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says services 
from non-participating providers are not covered unless preauthorized. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for physician's services provided on April 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a root canal on March 3, 2022. 
 
You asked the Plan to pay for a root canal. You say that you would like to request reconsideration of the denied 
claim. The Plan denied your request. The Plan says the service is not a covered 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 a root 
canal on March 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the sedation services coded 99152 and 99153 provided on 
January 10, 2022. 
 
You asked the Plan to pay for the sedation services. You say that you would like this claim reprocessed and 
approved for payment based on the submitted records. The Plan denied your request. The Plan says the 
documentation does not support payment for the services as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99152 is moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older. The CPT Code Manual definition of code 99153 is moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; each additional 15 minutes intraservice time (List separately in addition to code for primary service). 
 
We find that CPT code 99152 and 99153 is not supported in the medical record. Specifically, these two codes 
require the presence of an independent trained observer. The medical records do not indicate the presence of an 
independent trained observer in this case. Based on this information, we decided that Medicare rules for 
coverage of the sedation services have not been met. Therefore, we decided that the Plan does not have to pay 
for the sedation services coded 99152 and 99153 provided on January 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cone beam computed tomography (CT) capture with 
interpretation (D0367) provided on February 28, 2022. 
 
You asked the Plan to pay for the dental service. You say that you do not understand what services are not 
covered. The Plan denied your request. The Plan says the cone beam CT is not listed as a covered service. 
 
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 cone beam CT is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the cone beam 
computed tomography (CT) capture with interpretation (D0367) provided on February 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for four radiographic bitewing images (D0274) and adult 
prophylaxis (D1110) provided on March 9, 2022. 
 
You asked the Plan to pay for four radiographic bitewing images (D0274) and adult prophylaxis (D1110). You 
say that you did not have any books that had the name of the providers that were in the network. You also say 
that you did not know this provider was not in the network. The Plan denied your request. The Plan says the 
service is a covered benefit, but the member is disputing the amount assessed by the health plan as out of 
network liability. The Plan also says that out of network member liability was applied correctly per the 
member's plan 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. The Plan contract says that 
this benefit includes services obtained out of network. The Plan contract also says that for services obtained 
out-of-network the plan only pays up to a certain amount.  The Plan contract also says that if you choose to 
see an out-of-network dentist you might be billed by that provider for any amount greater than what the 
Plan says, even for services listed as $0 copayment. 
 
We looked at the file, the Plan's rules, and Medicare's rules. The record shows that the Plan paid up to their 
allowed amount, and the enrollee is responsible for any amount beyond that. Therefore, we decided that the 
Plan does not have to pay for four radiographic bitewing images (D0274) and adult prophylaxis (D1110) 
provided on March 9, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve OptiMesh infuse and intraoperative discography (CPT 
code(s): 62290 and 22853). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says medical studies have not proven this service/ item is helpful for the treatment of your 
health problem. 
 
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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found both OptiMesh infuse, and intraoperative discography remain experimental in cases of spinal 
surgery. More research is needed. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve OptiMesh infuse and intraoperative discography (CPT code(s): 62290 and 22853).
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for core build up on tooth #3 (D2950) and a crown on tooth #3 (D2740) 
provided on April 15, 2022. 
 
You asked the Plan to pay for core build up and a crown. You say that you were unaware of the cost, and you 
do not feel you should have to pay the difference in the allowed amounts for a crown. The Plan denied your 
request. The Plan says that you have been charged the correct cost sharing amount of the least costly treatment 
method. The Plan also says that you have exceeded the benefit period program maximum amount. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not provide medical records to show if the least costly treatment for 
a crown on tooth #3 would produce a satisfactory result. There is also no evidence showing you met your 
annual maximum amount. Therefore, we decided that the Plan has to pay for core build up on tooth #3 (D2950) 
and a crown on tooth #3 (D2740) provided on April 15, 2022.  
 
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 dental services on March 9, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. 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 combined allowance of $1,000 was exhausted on date of service March 9, 2022. Therefore, we 
decided that the Plan does not have to pay for dental services on March 9, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient hospital services for the enrollee. 
 
You asked the Plan to pre-approve inpatient hospital services. You say that these services are medically 
necessary. The Plan denied your request. The Plan says that there is no documentation provided to support the 
expectation the enrollee will require a greater than 2 midnight stay. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 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 inpatient hospital services. Our 
reviewer says that inpatient hospital services are not medically reasonable and necessary. The health plan has 
approved a total knee arthroplasty. The procedure is not on the inpatient only list. The preoperative clearance 
and comorbid conditions suggest that the procedure could be performed on an ambulatory/observation basis. 
There is no documentation provided to support the expectation the enrollee will require a greater than 2 
midnight stay. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of 
inpatient hospital services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient hospital services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve inpatient hospital services for the enrollee.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on SNF criteria. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our physician reviewer 
found the enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a 
SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) and an incisional biopsy of 
oral tissue (D7286), provided by an out-of-network provider on December 2, 2021. 
 
You asked the Plan to pay for a limited oral evaluation and an incisional biopsy of oral tissue. You say that 
these services were medically necessary. The Plan denied your request. The Plan says these services have been 
correctly denied. 
 
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. 
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of a limited oral evaluation and an incisional biopsy of oral tissue have not been met due to these 
services being purely dental in nature. Therefore, we decided that the Plan does not have to pay for a limited 
oral evaluation (D0140) and an incisional biopsy of oral tissue (D7286), provided by an out-of-network 
provider on December 2, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for bitewings (D0274) provided on April 18, 2022. 
 
You asked the Plan to pay for the bitewings. You say that the dental benefit in your coverage shows that 
bitewings and full x-rays are separate services. The Plan denied your request. The Plan says that a full mouth x-
ray was approved on July 28, 2021; therefore, exhausting the dental benefit of the bitewings for the date of 
service. 
 
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 1 set of dental 
bitewing x-rays every year. 
 
We looked at this the file, the Plans rules, and Medicare rules. The Plans EOC clearly states that 1 set of 
dental bitewing x-rays every year is covered and 1 full mouth/panoramic x-ray every 3 years is covered; 
therefore, making the full mouth x-ray on July 28, 2021, not counting towards the bitewing benefit. Based on 
this information, we decided that the Plan's rules for coverage of the bitewings have been met. Therefore, we 
decided that the Plan has to pay for bitewings (D0274) provided on April 18, 2022.  
 
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: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a PERS (CPT code A9280). 
 
You asked the Plan to pre-approve a PERS. You say that you need this to be covered because you have 
multiple heart problems. You state that you live alone and run the risk of having an accident. The Plan denied 
your request. The Plan says the requested service is not covered by Medicare or the health plan. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of a PERS have not been met. The rules say a PERS are not covered 
because emergency communications systems do not serve a diagnostic or therapeutic purpose. Therefore, we 
decided that the Plan does not have to pre-approve a PERS (CPT code A9280).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a 3D photo image (D0351) provided on July 20, 2021. 
 You asked the Plan to pay for a photo image. You say that you disagree with the denial of dental services. The 
Plan denied your request. The Plan says a 3D photo image (D0351) 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 a 3D 
photo image (D0351) provided on July 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on October 28, 2021 billed with 
codes 81321, 81206, 81210, 81235, 81272, 81275, 81276, 81292, 81301, and 81311. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as billed. 
 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 
October 28, 2021 billed with codes 81321, 81206, 81210, 81235, 81272, 81275, 81276, 81292, 81301, and 81311.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 8, 2022, billed with 
codes 81226, 81227, 81230, 81231, 81232, 81240, 81241, 81291, 81306, 81328, 81355, 81335 XS, 81401, 
0031U, 0032U, and 0033U. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like this claim reprocessed 
based on the medical records. The Plan denied your request. The Plan says this claim has not been billed as 
required by Medicare billing regulations. 
 
 
 
 The Plan must follow Medicare rules. 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 
February 8, 2022, billed with codes 81226, 81227, 81230, 81231, 81232, 81240, 81241, 81291, 81306, 81328, 
81355, 81335 XS, 81401, 0031U, 0032U, and 0033U.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a HHA for eight (8) hours a day, seven (7) days a week. 
 
You asked the Plan to pre-approve the home health aide services. You say that you need the services and would 
like five (5) hours a day since it was not approved for 8 hours a day 7 days a week. You state that you cannot 
get on the bed and cannot walk. The Plan denied your request. The Plan says you do not qualify for home 
health aide 8 hours a day, 7 days a week as it is considered custodial care. The Plan states they have approved a 
HHA services for 3 hours a day, 7 days a week, as it is considered medically necessary for your condition. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or 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 home health aide services. Our 
physician reviewer found you are medically stable without any recent hospitalizations or medical 
complications. The approved weekly hours of HHA services allow for appropriate support and care. The 
documentation does not support that the additional hours are needed to provide adequate support for you. 
 
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 home health aide services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a HHA for eight (8) hours a day, seven (7) days a week.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit on February 8, 2022.

You asked the Plan to waive the copayment for an office visit. You say that you would like to appeal the cost share. The Plan denied your request. The Plan says the copayment applied 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 $40 copayment for each covered visit or consultation in an outpatient location with a specialist for an office visit. 

You have been asked to pay a $40 copayment for each covered visit or consultation in an outpatient location with a specialist for an office visit. An office visit falls within the Physician/Practitioner services, including doctor's office visits 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 an office visit on February 8, 2022.