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

 
We decided that the Plan has to pay for the drug testing services provided on December 19, 2018. 
 
You asked the Plan to pay for the drug testing services. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says that these services have been up coded. 
 
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 G0482 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs 
and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to 
gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, 
eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other 
universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and 
variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control 
material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all 
sources, includes specimen validity testing, per day; 15-21 drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0482 is supported in the medical record. Specifically, the lab report clearly shows that 
15-21 drug classes were tested in this case. Please note, we counted the classes based on the separately billable 
tests from the CPT Handbook. Additionally, the Plan has not forwarded any evidence to support why CPT code 
80307 is not eligible for payment. It is the burden of the Health Plan to substantiate their denial with evidence. 
In this case, the Plan's denial has not been substantiated so we must find in your favor. Also, the record 
indicates that this provider was directed by the Plan to not obtain records. With this direction, it is inappropriate 
for the Plan to deny these services based on the physician signature. Based on this information, we decided that 
Medicare rules for coverage of the drug testing services have been met. Therefore, we decided that the Plan has 
to pay for the drug testing services provided on December 19, 2018.  
 
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 core buildup including any pins, when required and clinical 
crown lengthening hard tissue services (D2950, D4249) provided on December 3, 2021. 
 
You asked the Plan to pay for the core buildup including any pins, when required and clinical crown 
lengthening hard tissue services. You say that the services should be covered as you disagree with the denial. 
The Plan denied your request. The Plan says the services denied correctly as they do not fall within 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 core 
buildup including any pins, when required and clinical crown lengthening hard tissue services (D2950, D4249) 
provided on December 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the extraction (D7210) for tooth # 5 provided on 
December 14, 2021. 
 
You asked the Plan to reimburse you for the dental service. You say that you had 28 teeth extracted. You say 
that you were not aware the provider was out of network prior to receiving the services. You also say that these 
services should be covered. The Plan denied your request. The Plan says the claim processed correctly. 
 
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 and extractions are listed as covered, 
the record shows that tooth # 5 was extracted on January 22, 2021. Therefore, we decided that the Plan does not 
have to reimburse you for the extraction (D7210) for tooth # 5 provided on December 14, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81238, 81226, 81335, 81230, 81241, 
81291, and 81240) provided on August 26, 2021. 
 
You asked the Plan to pay for codes 81238, 81226, 81335, 81230, 81241, 81291, and 81240. You say that you 
would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the 
services are not covered 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. 
 
We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT code 81479. Therefore, we decided that the Plan does not have 
to pay for the laboratory services (81238, 81226, 81335, 81230, 81241, 81291, and 81240) provided on August 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) and a panoramic 
radiographic image (D0330) provided on April 7, 2022. 
 
You asked the Plan to pay for a limited oral evaluation and a panoramic radiographic image. You say that you 
do not understand why a dentist's evaluation would not be covered. You also say that you had an infected tooth 
and asked how the dentist would know what extent your infections were without the oral evaluation or 
panoramic radiographic image. The Plan denied your request. The Plan says according to your EOC, there is no 
coverage for these services. The Plan also says that the records indicate that you did not contact the Plan prior 
to the date of service to verify benefits and provider eligibility. 
 
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 does not include 
limited oral evaluations (D0140) and panoramic radiographic images (D0330). 
 
We looked at the file, the Plan's rules, and Medicare's rules. Limited oral evaluations (D0140) and panoramic 
radiographic images (D0330) are not among those covered under this benefit. Therefore, we decided that the 
Plan does not have to pay for a limited oral evaluation (D0140) and a panoramic radiographic image 
(D0330) provided on April 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on September 24, 2021. 
 
You asked the Plan to pay for the services provided. You say that a copy of the labs was provided for reference. 
The Plan denied your request. The Plan says an explanation of benefits from the primary insurance carrier is 
needed. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the 
provider to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible 
for the services provided until the primary insurer has denied the claim for these services. Therefore, we 
decided that the Plan does not have to pay for the lab services provided on September 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on February 1, 2022. 
 
You asked the Plan to pay for an evaluation. You say that you were told multiple times that you would not be 
charged for the services. The Plan denied your request. The Plan says this service is covered by the Plan's 
dental benefits; however, your benefits for one exam every six months 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 Plan's coverage rules apply in this case. The Plan covers one exam 
(D0140) every six months. 
 
We looked at this case file, the Plan's rules, and Medicare rules. The record shows the Plan paid for a limited 
oral evaluation provided on January 11, 2022; therefore, the benefit for an exam has been exhausted. Therefore, 
we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on February 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve complete upper denture (D5110), and partial lower 
denture (D5214). 
 
You asked the Plan to pre-approve dentures. You say that you are having issues with a tooth. You also say that 
you need the tooth to be pulled out. The Plan denied your request. The Plan says dentures are covered once 
every 5 plan years. The Plan also says that the frequency limit has been reached. 
 
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 and dentures are covered once every 5 
plan years, the frequency limit has been reached. The record shows that the Plan paid for a complete upper 
denture you received on November 23, 2021, and a partial lower denture you received on December 14, 2020. 
Therefore, we decided that the Plan does not have to pre-approve complete upper denture (D5110), and partial 
lower denture (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a complete lower 
denture (D5120). 
 
You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says your request exceeds the allowable benefit for these items. 
 
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 complete 
upper and lower dentures once every five years.  
 
We looked at the case file and the Plans rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically, the Plan contract states that complete upper and lower 
dentures are covered once every five years. The record shows that you previously received these items on 
January 22, 2019; therefore, your request exceeds the allowable benefit. Therefore, we decided that the Plan 
does not have to pre-approve a complete upper denture (D5110) and a complete lower denture (D5120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown on tooth # 14 (D2740). 
 
You asked the Plan to pre-approve a crown. You say that you disagree with the denial of a crown on tooth #14. 
The Plan denied your request. The Plan says this service is covered by the Plan's dental benefit; however, your 
benefit for no more than two crowns per arch 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 covers one crown 
every five years per tooth, no more than four crowns per calendar year with no more than two crowns per arch. 
 
We looked at this case file, the Plans rules, and Medicare rules. The record shows the Plan approved coverage 
for crowns on tooth #s 2 and 4 provided on the same date of service and tooth #s 2, 4, 14 are in the same arch; 
therefore, the benefit for no more than two crowns per arch has been exhausted. Therefore, we decided that the 
Plan does not have to pre-approve a crown on tooth # 14 (D2740).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on March 15, 2021. 
 
You asked the Plan to pay for the lab services. You say that you would like this claim reprocessed based on the 
medical records. The Plan denied your request. The Plan says you billed with an incorrect place of service on 
the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on March 15, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81206, 81292, and 81301) provided 
on June 28, 2021. 
 
You asked the Plan to pay for codes 81206, 81292, and 81301. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered 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.  
We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT code 81479. Therefore, we decided that the Plan does not have 
to pay for the laboratory services (81206, 81292, and 81301) provided on June 28, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that SNF care is medically necessary. The Plan 
denied your request. The Plan says you do not meet the coverage 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 services. Our reviewer says that 
SNF services are not medically necessary. Our physician reviewer found that based on the documentation 
provided, you do not qualify for SNF coverage. You do not have documented skilled nursing needs. You do not 
have documented skilled therapy needs. Daily skilled services are not shown to be required to establish a 
maintenance program or to prevent deterioration of your condition. Your care needs are custodial and 
intermittent and can, as a practical matter, be provided at a lower level of care (ex. home, assisted living, long 
term care). 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve SNF services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve homemaker services (S5130). 
 
You asked the Plan to pre-approve homemaker services. The Plan denied your request. The Plan says 
homemaker services are not covered by the enrollee's plan. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of homemaker services have not been met. Specifically, we find that the services at issue in this case 
are considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve 
homemaker services (S5130).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an occlusal guard (D9944) provided on February 18, 2022. 
 
You asked the Plan to pay for an occlusal guard (D9944). You say that you feel the occlusal guard is a medical 
necessity. The Plan denied your request. The Plan says the prosthetic dental service is not included on the 
enrollee's benefit plan. 
 
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 an 
occlusal guard (D9944) provided on February 18, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve panniculectomy surgery. 
 
You asked the Plan to pre-approve panniculectomy surgery. You say that this procedure is necessary. The Plan 
denied your request. The Plan says the requested surgery is not medically reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve panniculectomy surgery. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that you are a 42-year-old woman with a medical history that includes bowel 
obstruction and colostomy with reversal, chronic kidney disease, bilateral hydronephrosis, and endometriosis. 
You have presented to the surgeon because you are "displeased with the appearance of her abdominal wall and 
would like to have the excess skin which overhangs removed." No pain, open wounds or rashes are reported. 
The physical exam was notable for redundant abdominal skin and subcutaneous tissue.  
 
 The documentation does not support that panniculectomy surgery is medically reasonable and necessary in this 
case. No functional condition is identified for which panniculectomy surgery would be medically reasonable 
and necessary. Rather, the documentation supports that the requested panniculectomy is cosmetic in nature and 
not eligible for coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of panniculectomy surgery have not been met. Therefore, we decided that the Plan 
does not have to pre-approve panniculectomy surgery.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the routine vision hardware provided on January 12, 
2022.  
You asked the Plan to pay more for the routine vision hardware. You say that you confirmed that you have a $0 
balance and believe the letter was sent to you in error. The Plan denied your request. The Plan says this claim 
processed with the maximum allowance of $200. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers up to $200 every two calendar years for routine vision hardware. 
 
We looked at the file and the Plan's rules. The record shows that you met the routine vision hardware allowance 
while processing this claim for the January 12, 2022 date of service, and your routine vision hardware 
allowance has been exhausted. Based on this information, we decided that the Plan's rules for coverage of the 
routine vision hardware have not been met. Therefore, we decided that the Plan does not have to pay more for 
the routine vision hardware provided on January 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), first intraoral 
periapical x-ray (D0220), and additional intraoral periapical x-ray (D0230) provided on December 1, 2021 by a 
Medicare opt out provider. 
 
You asked the Plan to pay for the comprehensive oral evaluation and intraoral periapical x-rays. You say that 
you thought you could go to any dental provider and request reimbursement. The Plan denied your request. The 
Plan says these services are not covered by Original Medicare because the treating provider has opted out of 
the Medicare programs. 
 
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 received by a provider who has opted out of Medicare. Therefore, we decided that the 
Plan does not have to pay for the comprehensive oral evaluation (D0150), first intraoral periapical x-ray 
(D0220), and additional intraoral periapical x-ray (D0230) provided on December 1, 2021 by a Medicare opt 
out provider.