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

 
We decided that the Plan does not have to waive the copayments for the magnetic resonance imaging (MRI) of 
the lumbar spine (72148) and the magnetic resonance imaging (MRI) of the brain (including brain stem); 
without contrast material, followed by contrast material(s) and further sequences (70553) provided on  
March 21, 2022. 
 
You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayments have been applied correctly to 
the services provided. 
 
 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 $100 
copayment for diagnostic radiology services (computed tomography (CT), magnetic resonance imaging (MRI), 
and positron emission tomography (PET scan) etc. 
 
You have been asked to pay $200 ($100 copayment x 2) for the diagnostic radiology services provided. 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 copayments for the magnetic resonance imaging (MRI) of the lumbar spine 
(72148) and the magnetic resonance imaging (MRI) of the brain (including brain stem); without contrast 
material, followed by contrast material(s) and further sequences (70553) provided on March 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DetermaRx 14-Gene Lung Cancer Assay testing (81479) 
provided October 27, 2021. 
 
You asked the Plan to pay for the pathology services. You say that testing was ordered for the enrollee after the 
ordering physician made a professional determination of medical necessity. The Plan denied your request. The 
Plan says the required DEX Z-code was not provided. 
 
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 81479 is unlisted molecular pathology 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 the pathology services. Our reviewer says that the medical 
documentation does not fully support the use of the unlisted code 81479. Our reviewer found in accordance 
with the current procedure guidelines, when reporting a procedure with an unlisted code, submit a cover letter 
explaining the reason for choosing the unlisted code instead of a defined, active code. Include one or more 
similar codes and compare your service to those codes to justify the claim amount you are billing. Also include the relevant documentation to strengthen the claim and to avoid a possible denial. Payers will consider claims 
with unlisted procedure codes on a case by case basis, and they will determine payment based on the 
documentation you provide. The medical documentation does not justify the use of the unlisted nor did it give 
any comparison codes at all. Due to the failure of that guideline the unlisted procedure is not supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the pathology services have not been met. Therefore, we decided that the Plan 
does not have to pay for the DetermaRx 14-Gene Lung Cancer Assay testing (81479) provided October 27, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on December 17, 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 appeal the denial of the claim. The 
Plan denied your request. The Plan says the provider is out-of-network and authorization is required prior to an 
out-of-network visit. 
 
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 December 17, 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 provided on October 26, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says based on the information received, this service was 
not provided by you for your patient. You are not entitled to reimbursement for claims for non-patients or for 
services you did not render. 
 
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 laboratory services provided on October 26, 2021, 
by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for debridement services provided on January 4, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the debridement services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says no prior authorization was 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 did not pre-approve the 
debridement services. We found no exception that would require the Plan to pay for the debridement services. 
The records provided for review do not show that the debridement services at issue were urgent or emergent. Therefore, we decided that the Plan does not have to pay for debridement services provided on January 4, 2022, 
by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided from February 5, 2020, to 
February 10, 2020, as billed with Diagnosis Related Group (DRG) 406. 
 
You asked the Plan to pay for inpatient care billed with DRG 406. You say that these services were medically 
necessary and are supported in the record. The Plan denied your request. The Plan says DRG 406 is not appropriate as the diagnosis of porphyria cutanea tarda (E80.1) is not supported in the medical record. The Plan 
argues that DRG 407 is more appropriate in this case. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes. 
 
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 inpatient care billed with DRG 406. Our 
reviewer says that the diagnosis of porphyria cutanea tarda (E80.1) is not supported in the medical record for 
this inpatient admission. Our physician reviewer found that the enrollee was admitted with Malignant 
Neoplasm of Liver Hepatocellular. The enrollee underwent liver resection and liver lesion ablation. The 
History and Physical that was completed in the office setting stated there was porphyria cutanea tarda and the 
enrollee has not needed phlebotomies. The anesthesiologist had a historical problem list; however, this only 
mentioned the problem list was reviewed. The anesthesiologist did not mention the significance of the 
porphyria cutanea tarda diagnosis for this stay. The physician did not document on the progress notes or 
discharge summary the porphyria cutanea tarda diagnosis. Without such documentation, the porphyria 
cutaneous tarda would not be considered a relevant diagnosis on this admit. This also indicates the diagnosis 
was not reviewed or evaluated and did not extend the length of stay. The review has determined that the 
medical records did not support the billing of porphyria cutanea tarda (E80.1). 
 
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 care billed with DRG 406 have not been met. Therefore, we decided 
that the Plan does not have to pay for inpatient hospital care provided from February 5, 2020, to February 10, 
2020, as billed with Diagnosis Related Group (DRG) 406.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for maxillary complete dentures (D5110) and mandibular 
complete dentures (D5120) provided on March 21, 2022. 
 
You asked the Plan to pay for the dentures. You say that you disagree with the denial of dental services. The 
Plan denied your request. The Plan says maxillary complete dentures (D5110) and mandibular complete 
dentures (D5120) are excluded from coverage. 
 
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 when services replace one (1) or more teeth missing prior to the 
enrollee's eligibility under the Plan contract. The medical record shows all remaining teeth were extracted on 
date of service October 13, 2021. Therefore, we decided that the Plan does not have to pay for maxillary 
complete dentures (D5110) and mandibular complete dentures (D5120) provided on March 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a prefabricated post on tooth #6 (D2954) and a porcelain 
crown on tooth #6 (D2740) provided on December 29, 2021. 
 
You asked the Plan to pay for the dental services. You say that most of your dental work was completed in 
2022 and you thought you had some allowance left over. The Plan denied your request. The Plan says you have 
been charged the correct cost sharing amount and your annual allowance has been exhausted. 
 The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $2,000 
combined allowance for supplemental preventive and comprehensive dental services every year. The contract 
also says that the enrollee is responsible for any amount over and above the allowance amount. 
 
The record shows you have exhausted your annual $2,000 allowance for dental services. Therefore, you are 
responsible for the remaining amount over and above the allowance amount. Prefabricated posts and crowns 
fall within the Dental Services benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to pay for a prefabricated post on tooth 
#6 (D2954) and a porcelain crown on tooth #6 (D2740) provided on December 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete upper denture (D5110) and the complete lower 
denture (D5120) provided on March 23, 2022. 
 
You asked the Plan to pay for the dental items. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the dental items were received from an out-of-
network provider and 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 Plans coverage rules apply in this case. 
 
The record shows you received the dental items from an out-of-network provider. Though the Plan offers a 
dental benefit in excess of Medicare coverage, the items provided are not covered under this benefit when 
received from an out-of-network provider. Therefore, we decided that the Plan does not have to pay for the 
complete upper denture (D5110) and the complete lower denture (D5120) provided on March 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene panel testing provided on June 4, 2021. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says there is no 
evidence to support the referring provider was treating the enrollee. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 We looked at the file and Medicare rules. The case file shows that the enrollees treating physician did not 
order the testing at issue for a specific medical problem or treatment plan. Based on this information, we 
decided that the Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not 
have to pay for the gene panel testing provided on June 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided on January 21, 2022, by an 
out-of-network provider. 
 
You asked the Plan to pay for chiropractic services. You say that the provider and referring providers are 
participating providers with Medicare. The Plan denied your request. The Plan says the enrollee went to an out-
of-network provider and services were not approved in advance. 
 
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 chiropractic services provided on January 21, 
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 canal preparation and fitting of preformed dowel or post 
(D3950). 
 
You asked the Plan to pay for canal preparation. You say that you must complete all parts of the root canal. 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 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 pay for canal 
preparation and fitting of preformed dowel or post (D3950).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on July 1, 2021 billed with codes 
81206, 81292, and 81301. 
 
You asked the Plan to pay for the genetic testing billed. 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. 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 
July 1, 2021 billed with codes 81206, 81292, and 81301.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical extraction (D7210) provided on March 10, 2022. 
 
You asked the Plan to pay for the extraction. You say that this dental cost has caused you great financial 
hardship. The Plan denied your request. The Plan says this service is not a covered expense under your dental 
plan. The Plan also says that you did not contact the Plan prior to the date of service to verify 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 
surgical extraction (D7210) provided on March 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation, removal of 
impacted tooth, and anesthesia services provided on February 10, 2022, and February 22, 2022, by a Medicare 
opt out provider. 
 
You asked the Plan to pay for the problem focused limited oral evaluation, removal of impacted tooth, and 
anesthesia services. You say that you were not advised prior to receiving these services that the treating 
provider did not accept Medicare. The Plan denied your request. The Plan says the treating provider opted out 
of Medicare. 
 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 
covered when they are rendered by a provider who has opted out of Medicare. Therefore, we decided that the 
Plan does not have to pay for the problem focused limited oral evaluation, removal of impacted tooth, and 
anesthesia services provided on February 10, 2022, and February 22, 2022, by a Medicare opt out provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transport provided on December 
22, 2021. 
 
You asked the Plan to waive the copayment for ambulance transport. You say that this should be covered since 
its not your fault the first hospital didn't have a neurosurgeon for you, and you had to be transferred. 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 $265 
copayment per date of services regardless of the number of trips.  
 
You have been asked to pay $265 copayment for ambulance transport. Ambulance transport falls within the 
Ambulance Services benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for ambulance transport 
provided on December 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture treatment (97810) rendered by the out-of-
network (OON) provider on January 19, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not payable as it was rendered 
by an out-of-network provider. 
 
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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the acupuncture treatment (97810) rendered by the out-of-network (OON) provider on 
January 19, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the paramedic intercept services (A0432) provided on March 
11, 2022. 
 
You asked the Plan to pay for the paramedic intercept services. The Plan denied your request. The Plan says 
this service is not covered. 
 
The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by 
an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. 
Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area as 
defined above. It is noted that the only State in which these criteria are met is New York. 
 The paramedic intercept services at issue in this appeal were not furnished in an area that is considered rural 
according to the Medicare definition. Therefore, we decided that the Plan does not have to pay for the 
paramedic intercept services (A0432) provided on March 11, 2022.