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

 
We decided that the Plan does not have to pay for the duplex scan of extremity veins provided on October 03, 
2022. 
 
You asked the Plan to pay for the duplex scan of extremity veins. You say that the services were ordered 
immediately and there was no time for authorization. The Plan denied your request. The Plan says that 
unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the duplex scan of 
extremity veins provided on October 03, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bitewing x-ray (D0274) provided on October 3, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. 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 March 28, 2022. 
Therefore, we decided that the Plan does not have to pay for a bitewing x-ray (D0274) provided on October 3, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an unspecified removable prosthodontic procedure (D5899) 
provided on August 26, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with these charges. The Plan 
denied your request. The Plan says the dental services 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 requested 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 pay for an unspecified removable prosthodontic procedure (D5899) provided on August 26, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on May 18, 
2022, to May 21, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you disagree with the 
copayment. The Plan denied your request. The Plan says this cost sharing was charged 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 $350 
copayment for inpatient hospital care.  
 
You have been asked to pay a $350 copayment for inpatient hospital care. The total amount you are being 
asked to pay $1,050 ($350 x 3days = $1,050). This item/service falls within the inpatient hospital care 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 inpatient hospital care provided on May 18, 
2022, to May 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a nursing facility visit provided on September 22, 2022. 
 
You asked the Plan to pay for a nursing facility visit. You say that we depend on the facility staff to verify 
eligibility and to obtain authorization. The Plan denied your request. The Plan says that unauthorized, out-of-
network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a nursing facility visit 
provided on September 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for endodontic therapy on tooth #24 (D3310) and core build up 
on tooth #24 and 25 (D2950) provided on September 22, 2022. 
 
You asked the Plan to pay for endodontic therapy and core build up. You say that the services were billed 
incorrectly. You also say that you should be reimbursed for the cleaning you received on this date of service. 
The Plan denied your request. The Plan says core build up (D2950) is not covered by your dental benefits. The 
Plan also says that your benefit for endodontic therapy 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. 
 
 The Plan confirmed that you did not receive a cleaning on September 22, 2022. Though the Plan offers a dental 
benefit in excess of Medicare coverage, core build up is not among those covered under this benefit. The record 
shows your benefit for endodontic therapy was exhausted on this appealed claim. Therefore, we decided that 
the Plan does not have to pay for endodontic therapy on tooth #24 (D3310) and core build up on tooth #24 and 
25 (D2950) provided on September 22, 2022.
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 (CPT code E2311), harness for upgrade to expandable controller 
(E2313) and expandable controller (E2377). 
 
You asked the Plan to pre-approve the DME. You say that the DME is medically necessary. The Plan denied 
your request. The Plan says the DME is not medically necessary. 
 
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 the DME have not been met. Upgraded electronics (electronic 
connector) cannot be covered per Medicare rules. They are necessary when there is a medical need to control 
power options though the joystick. The notes do not show a medical need to control the power options through 
the joystick. The power options can be controlled using their own switches. These switches can be made any 
size without asking for a separate request. They can be made from any material without asking for a separate 
request. All of this can be done without the need to use the joystick to control the power features. 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 (CPT code E2311), harness for upgrade to expandable controller 
(E2313) and expandable controller (E2377).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99153 billed for date of service April 19, 
2022.  

You asked the Plan to pay for procedure code 99153. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says this code is included in the facility payment and is not separately 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that this service was provided to the enrollee while an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 99153. This means 
there is both a professional and technical component for the CPT code(s). In this case, an appropriate modifier 
to indicate the professional component has not been billed with CPT code(s) 99153. Based on this information, 
we decided that Medicare rules for coverage of procedure code 99153 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 99153 billed for date of service April 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Fluid flow or fluid GF, 1 cc (CPT Q4206) provided on 
February 7, 2022. 
 
You asked the Plan to pay for Fluid flow or fluid GF, 1 cc (CPT Q4206). The Plan denied your request. The 
Plan says Fluid flow or fluid GF, 1 cc (CPT Q4206) is not medically necessary per the Medicare LCD coverage 
criteria. 
 
The Plan must follow Medicare rules.  
 
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 Fluid flow or fluid GF, 1 cc (CPT Q4206).   
Our reviewer says that Fluid flow or fluid GF, 1 cc (CPT Q4206) is not medically necessary. Our physician 
reviewer found that the medical documentation establishes that this enrollee is suffering with right foot painful 
scar tissue, tenosynovitis, neuralgia, neuritis, and unspecified osteoarthritis. Medicare guidelines advise that 
application of bioengineered skin substitutes is sometimes recommended under certain criteria for lower 
extremity chronic nonhealing wounds. The guidelines go on to say that bioengineered skin substitutes or 
cellular and tissue-based products have been developed in an attempt to circumvent problems inherent with 
autografts, allograft, and xenografts. These constitute biologic covers for refractory wounds with full thickness 
skin loss secondary to 3rd degree burns or other disease processes such as diabetic neuropathic ulcers and the 
skin loss of chronic venous stasis or venous hypertension. The medical documentation does not support that 
this enrollee is suffering with a nonhealing wound to their right foot. Therefore, it is my opinion that the Fluid 
Flow or Fluid GF, 1 mL CPT code Q4206 injected on February 7, 2022 was not medically reasonable or 
necessary per the LCD coverage criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Fluid flow or fluid GF, 1 cc (CPT Q4206) have not been met. Therefore, we 
decided that the Plan does not have to pay Fluid flow or fluid GF, 1 cc (CPT Q4206) provided  
on February 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ophthalmic diagnostic imaging (92134) provided on August 
26, 2022. 
 
You asked the Plan to pay for ophthalmic diagnostic imaging (92134). You say that you were unaware the 
provider was out-of-network with the vision care plan. The Plan denied your request. The Plan says based on 
Medicare guidelines, this service does not meet the requirements for approval. 
 
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. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of ophthalmic diagnostic imaging 
(92134) have been met. Specifically, the appeal is missing medical records. Therefore, we decided that the Plan 
does not have to pay for ophthalmic diagnostic imaging (92134) provided on August 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cone beam computed tomography (CT) scan, capture and 
interpretation with limited field of view-less than one whole jaw (D0364) and the therapeutic parenteral drugs, 
two or more administrations (D9612) provided on August 17, 2022 and September 13, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the items/services provided are 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the items/services provided are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for cone 
beam computed tomography (CT) scan, capture and interpretation with limited field of view-less than one 
whole jaw (D0364) and the therapeutic parenteral drugs, two or more administrations (D9612) provided on 
August 17, 2022 and September 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve wheelchair component or accessory, not otherwise 
specified, Jazzy Air 2 flag holder (K0108). 
 
You asked the Plan to pre-approve Jazzy Air 2 flag holder. You say that please reconsider the documentation 
provided for the wheelchair and accessories that are medically necessary to meet the enrollee's current needs. 
The Plan denied your request. The Plan says a Jazzy Air 2 flag holder is not primarily medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve wheelchair component or accessory, not otherwise 
specified, Jazzy Air 2 flag holder (K0108).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate (20939). 
 
You asked the Plan to pre-approve bone marrow aspirate. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested services are 
experimental/investigational. 
 
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 bone marrow aspirate. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that bone marrow aspirate is experimental when used as bone graft material in spinal 
surgery. More research is needed to demonstrate safety and effectiveness. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bone marrow aspirate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone marrow aspirate (20939).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for localized delivery of antimicrobial agents via a controlled 
release vehicle into diseased crevicular tissue, per tooth (D4381) x2 and gingival irrigation - per quadrant 
(D4921) x4 provided on July 18, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were told the provider was in-network, so 
you should not have to pay the billed amount. 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 Plan's coverage rules apply in this case. This benefit includes the 
requested localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular 
tissue, per tooth (D4381) but cannot be used on the same day as scaling and root planing (D4341 or D4342) 
and Gingival irrigation - per quadrant (D4921) is not covered under the Plan's dental benefits. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested D4381 was exhausted on date of service July 18, 2022. You had D4341 
and D4381, these two services cannot be provided on the same date. Therefore, we decided that the Plan does 
not have to pay for localized delivery of antimicrobial agents via a controlled release vehicle into diseased 
crevicular tissue, per tooth (D4381) x2 and gingival irrigation - per quadrant (D4921) x4 provided on July 18, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the topical application of fluoride varnish (D1206) provided 
on September 20, 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 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 service provided is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the topical 
application of fluoride varnish (D1206) provided on September 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wheelchair component or accessory, not otherwise 
specified, wheel bumper angle and adjustment footplate (K0108). 
 
You asked the Plan to pre-approve wheel bumper angle and adjustment footplate. You say that please 
reconsider all the documentation provided that supports the enrollee's need for the power wheelchair and all 
components requested. The Plan denied your request. The Plan says there is no separate billing for angle 
adjustable footplates with Group 1 or 2 power wheelchairs.  

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at this the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of wheel bumper angle and adjustment footplate have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a wheelchair component or accessory, not otherwise specified, wheel 
bumper angle and adjustment footplate (K0108).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system (E2300). 
 
You asked the Plan to pre-approve a power seat elevation system. You say that you are appealing to get the 
denial for a new wheelchair overturned. The Plan denied your request. The Plan says this item is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  We looked at this the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a power seat elevation system have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power seat elevation system (E2300).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 8, 2022, billed with 
codes 81201, 81292, 81295, 81298, 81314, 81317, 81334, 81351, and 81479. 
 
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 panel testing should be billed using one CPT code on the claim. 
 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 
June 8, 2022, billed with codes 81201, 81292, 81295, 81298, 81314, 81317, 81334, 81351, and 81479.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
August 17, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service August 17, 2022.