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

 
We decided that the Plan does not have to pay for the genetic testing provided on December 30, 2021 billed 
with codes 81401 and 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that this should be paid for. The Plan denied 
your request. The Plan says Medicare denies coverage when a laboratory assays two or more genes in a patient 
in parallel. 
 
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 
December 30, 2021 billed with codes 81401 and 81479.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for consultation provided on July 8, 2022. 
 
You asked the Plan to pay for consultation. You say that you drove all the way to the providers office just for 
them to tell you the service is not covered under your Plan. The Plan denied your request. The Plan says this 
service is not covered under your 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 consultation is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
consultation provided on July 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral exam (D0150) provided June 7, 
2022. 
 
You asked the Plan to pay for the dental services. You say that the second exam was necessary. 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 January 27, 2022. 
Therefore, we decided that the Plan does not have to pay for the comprehensive oral exam (D0150) provided 
June 7, 2022.  
 
Your complaint about being dissatisfied with your dental benefits is not a valid appeal for medical coverage. 
This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to 
make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair with multiple power 
options (K0861), expandable controller (E2377), expandable controller harness (E2313), and electronic 
connection (E2311). 
 
You asked the Plan to pre-approve a group 3 power wheelchair with multiple power options (K0861), 
expandable controller (E2377), expandable controller harness (E2313), and electronic connection (E2311). You 
say that the requested group 3 power wheelchair with power tilt and upgraded electronics are medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested 
group 3 power wheelchair with power tilt and upgraded electronics. 
 
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 group 3 power wheelchair with 
multiple power options (K0861), expandable controller (E2377), expandable controller harness (E2313), and 
electronic connection (E2311). Our reviewer says that the enrollee does not meet criteria for the requested 
group 3 power wheelchair with power tilt and upgraded electronics. Our physician reviewer found the member 
has a neurologic disorder with functional deficits. Criteria for a power wheelchair are met, however the criteria 
for the requested power wheelchair with multiple power options and upgraded electronics are not met. The 
documentation does not indicate that the member has any pressure injuries or requires intermittent 
catheterization of the bladder that would necessitate power tilt or recline. The requested electrical accessories 
are not medically necessary as the member does have use of the upper extremity and could operate and control 
the power options using the switches that are included in the basic wheelchair. 
 
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 group 3 power wheelchair with multiple power options (K0861), expandable 
controller (E2377), expandable controller harness (E2313), and electronic connection (E2311) have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair with 
multiple power options (K0861), expandable controller (E2377), expandable controller harness (E2313), and 
electronic connection (E2311).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 75736-26-59 provided on March 24, 2022. 
 
You asked the Plan to pay for procedure code 75736-26-59. You say that the medical records support that CPT 
code 75736-26-59 was distinct from CPT code 37242. The Plan denied your request. The Plan says the medical 
records do not support that CPT code 75736-26-59 was distinct from CPT code 37242. 
 
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, we have confirmed that code 75736 is a column II code to column I code 37242; however, 75736 
was billed with a modifier.  
 
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 procedure code 75736-26-59. Our reviewer says that the 
medical records do not support that CPT code 75736-26-59 was distinct from CPT code 37242. Our reviewer 
found the documentation does not support post embolization angiography as a separate procedure from the 
primary embolization procedure (CPT 37242), which includes "all radiological supervision and interpretation".  
Therefore, CPT code 75736 with modifier 59 cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 75736-26-59 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 75736-26-59 provided on March 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator. 
 
You asked the Plan to pre-approve the oxygen equipment.. You say that the tanks you have are too heavy. The 
Plan denied your request. The Plan says duplicate equipment is not covered. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that the enrollee has portable oxygen concentrator. The requested portable oxygen concentrator 
serves the same purpose as the current equipment. Therefore, we decided that the Plan does not have to pre-
approve a portable oxygen concentrator.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee can remain at the current acute care hospital until such time no acute 
services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing 
long-term care needs. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a medical eye examination (92014), and extended eye 
examination (92202), and diagnostic imaging of retina (92134) provided on March 29, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the vision services. You say that you want the Plan to pay for the services. The 
Plan denied your request. The Plan says the services were provided by an out-of-network provider, and the 
services were not referred by a network provider or rendered in an in-network facility. The services were not 
urgent or emergent, nor were they 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 a medical eye examination (92014), and extended 
eye examination (92202), and diagnostic imaging of retina (92134) provided on March 29, 2022, by an out-of-
network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the prefabricated abutments (D6056) and implants 
(D5065) for tooth #3, #4, #5, #12, and #18. 
 
You asked the Plan to pre-approve the dental services. You say that you need these dental procedures done. 
The Plan denied your request. The Plan says the denial of authorization for this service is correct, because 
dental implants and all associated services are not covered by the 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 the 
prefabricated abutments (D6056) and implants (D5065) for tooth #3, #4, #5, #12, and #18.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150), intraoral - 
complete series of radiographic images (D0210), and overdenture  complete mandibular (D5865). 
 
You asked the Plan to pre-approve the dental services. The Plan denied your request. The Plan says the denial 
is correct, because these services are not covered by the Plans dental benefits or they are covered but the 
coverage benefit 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 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 August 9, 2022. 
Therefore, we decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150), 
and intraoral - complete series of radiographic images (D0210). The Plans dental benefits to do not include 
coverage for the overdenture  complete mandibular (D5865).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve complete denture - mandibular (5120). 
 
You asked the Plan to pre-approve dental services. You say that you are unable to eat solid food because your 
bottom denture is broken. The Plan denied your request. The Plan says this service is not covered under your 
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 complete denture - 
mandibular (5120) is not among those covered under this benefit. Therefore, we decided that the Plan does not 
have to pre-approve complete denture - mandibular (5120).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 15, 2022, and billed 
with codes 81227, 81230, 81231, 81232, 81291, 81306, 81328, 81355, 81335, 0031U, 0032U, 0033U, 81479, 
81407, and 81238. 
 
You asked the Plan to pay for genetic testing. You say that this testing should be covered. The Plan denied your 
request. The Plan says this was not billed correctly. 
 
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 genetic testing have not 
been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on February 
15, 2022, and billed with codes 81227, 81230, 81231, 81232, 81291, 81306, 81328, 81355, 81335, 0031U, 
0032U, 0033U, 81479, 81407, and 81238.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the removal of exostosis (D7471), the removal of 
mandibularis (D7473), and reduction of tuberosity (D7485). 
 
You asked the Plan to pre-approve the dental services. You say that you need these dental procedures done. 
The Plan denied your request. The Plan says the denial of authorization for these services is correct, because 
they are not covered by the 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 the 
removal of exostosis (D7471), the removal of mandibularis (D7473), and reduction of tuberosity (D7485).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve electronic connection between wheelchair controller and 
two or more power seating system motors (E2311) expandable controller (E2377) and harness (E2313) and seat 
elevator (E2300). 
 
You asked the Plan to pre-approve the upgraded electronics and seat elevator. You say that it is expected that 
the enrollee will have further decline in function without appropriate equipment to facilitate their 
independence. The Plan denied your request. The Plan says the upgraded electronics cannot be covered as it is 
not medically necessary to control the three approved power options through the joystick and the seat elevator 
does not serve a medical purpose. 
 
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 upgraded electronics and seat 
elevator. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found based on the medical records provided there is no 
documentation that the upgraded electronics at issue in this case meet all of Medicare's Local Coverage Article: 
Wheelchair Options/Accessories - Policy Article (A52504) criteria for medically reasonable and necessary for 
the patient. Provided records document that the enrollee has 5/5 bilateral upper extremity strength with grip 
rated as within functional limits and is independent with eating and is modified independent with grooming and 
upper body dressing thus indicating the enrollee has adequate upper extremity strength and function to operate 
the wheelchair's power options with their own switches. The requested power seat elevation feature is 
statutorily non-covered as it serves no primary medical purpose. 
 
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 upgraded electronics and seat elevator have not been met. Therefore, we 
decided that the Plan does not have to pre-approve electronic connection between wheelchair controller and 
two or more power seating system motors (E2311) expandable controller (E2377) and harness (E2313) and seat 
elevator (E2300).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone graft at time of implant placement (D6104) 
provided by a participating provider. 
 
You asked the Plan to pre-approve a bone graft at time of implant placement. You say that these services are 
medically necessary. The Plan denied your request. The Plan says the requested dental 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 pre-approve a 
bone graft at time of implant placement (D6104) provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two removable prosthodontic procedures (D5899 x2) and 
additional simple extraction (D7140) provided on October 15, 2021. 
 
You asked the Plan to pay for the removable prosthodontic procedures and simple extraction. You say that it is 
not fair to have insurance with a company and not receive all the services required. The Plan denied your 
request. The Plan says the removable prosthodontic procedures is not a covered expense under your dental 
plan. The Plan also says your extractions benefit has been satisfied and the frequency limitation has been 
exceeded.  
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 removable prosthodontic procedure 
(D5899) is not among those covered under this benefit. The contract says extractions are limited to three 
procedure codes per calendar year. The record shows that the Plan paid for one simple extraction (D7140), one 
surgical extraction (D7210), and one removal of residual tooth roots (D7250) provided on October 15, 2021, 
and your extractions benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for 
the two removable prosthodontic procedures (D5899 x2) and additional simple extraction (D7140) provided on 
October 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shoulder sling identified by code A4566. 
 
You asked the Plan to pre-approve a shoulder sling identified with code A4566. You say that you disagree with 
the Plan's denial. The Plan denied your request. The Plan says the requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code A4566 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code A4566 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code A4566 have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a shoulder sling identified by code A4566.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the wheel lock assembly (E2206) transit option 
(K0108). 
 
You asked the Plan to pre-approve the wheelchair accessories. You say that the records provided support the 
necessity of the requested service. The Plan denied your request. The Plan says the requested transit option is 
not covered under Medicare. E2206 is not available for separate payment and is included in the approved 
wheelchair. 
 
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 wheel lock assembly is included in the package for the 
wheelchair and is not to be considered for separate billing. The Transit option is for use outside of the home 
and is not a covered benefit for any wheelchair. Medicare does not cover items that are for outside use only.. 
Based on this information, we decided that Medicare rules for coverage of the wheelchair accessories have not 
been met. Therefore, we decided that the Plan does not have to pre-approve the wheel lock assembly (E2206) 
transit option (K0108).