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

 
We decided that the Plan does not have to pay for F2 (prothrombin, coagulation factor ii) (eg, hereditary 
hypercoagulability) gene analysis, 20210g>a variant (81240) and F5 (coagulation factor v) (eg, hereditary 
hypercoagulability) gene analysis, leiden variant (81241) provided August 2, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the claim denied for medical records. You 
have uploaded the medical records for billing clinic for the date of services 8/02/2021. The Plan denied your 
request. The Plan says does not meet Medicare NCD/LCD criteria. 
 
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. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay 
for F2 (prothrombin, coagulation factor ii) (eg, hereditary hypercoagulability) gene analysis, 20210g>a variant 
(81240) and F5 (coagulation factor v) (eg, hereditary hypercoagulability) gene analysis, leiden variant (81241) 
provided August 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for crowns on tooth #12 and #14 (D2740) provided by a network 
provider on November 6, 2020. 
 
You asked the Plan to pay for the crowns on tooth #12 and #14 (D2740). You say that the x-ray shows your 
crown and the supporting tooth is in poor condition. You say the crowns are medically necessary. The Plan 
denied your request. The Plan says the need for the crowns did not meet criteria and therefore, was not covered. 
 
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 the crowns on 
tooth #12 and #14 (D2740) when the services are medically necessary and reasonable.  
 
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 the crowns on tooth #12 and #14 (D2740). 
Our reviewer says that the services are not medically necessary. Our physician reviewer found you supplied x-
rays of the tooth #12 and #14 and limited clinical notes, but neither of these pieces of information indicate there 
is a defect in the teeth that require crown placement. The x-rays provided appear to have been taken after the 
crowns were placed, this means that the underlying condition of the teeth is unknown. Pre-treatment x-rays are 
necessary to allow assessment of the condition of the teeth. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the crowns on tooth #12 and #14 (D2740) have not been met. Therefore, we 
decided that the Plan does not have to pay for crowns on tooth #12 and #14 (D2740) provided by a network 
provider on November 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), osseous 
surgeries (D4260 and D4261), drugs or medicaments dispensed in the office for home use (D9630), and 
occlusal adjustment (D9951) provided on February 17, 2022, and February 24, 2022. 
 
You asked the Plan to pay for the comprehensive oral evaluation, osseous surgeries, drugs or medicaments, and 
occlusal adjustment. You say that you are on fixed income and have already spent close to $2,910 to avoid 
other serious medical conditions due to gum disease. The Plan denied your request. The Plan says the 
comprehensive oral evaluation exceeds the frequency limitation in your benefit plan. The Plan also says that 
osseous surgery, drugs or medicaments, and occlusal adjustment are not covered benefits under your dental 
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, osseous surgery (codes D4260 and 
D4261), drugs or medicaments dispensed in the office for home use (D9630), and occlusal adjustment (D9951) 
are not among those covered under this benefit. The contract says that comprehensive oral evaluation (D0150) 
is limited to one procedure every three plan years. The record shows that you received a comprehensive oral 
evaluation (D0150) on November 5, 2020 and your comprehensive oral evaluation (D0150) benefit has been 
exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation 
(D0150), osseous surgeries (D4260 and D4261), drugs or medicaments dispensed in the office for home use 
(D9630), and occlusal adjustment (D9951) provided on February 17, 2022, and February 24, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services provided to the enrollee on December 22, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says this was not reported correctly. 
 
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 the denied codes is: 
 
CPT 74230: 
 
Radiologic examination, swallowing function, with cineradiography/videoradiography, including scout neck 
radiograph(s) and delayed image(s), when performed, contrast (eg, barium) study 
 
CPT 74240: 
 
Radiologic examination, upper gastrointestinal tract, including scout abdominal radiograph(s) and delayed 
image(s), when performed; single-contrast (eg, barium) study 
 CPT 92611: 
 
Motion fluoroscopic evaluation of swallowing function by cine or video recording 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the denied codes would be 
excluded from coverage as portable x-ray services. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for radiology services provided to the enrollee on December 22, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve outpatient mental health services to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve outpatient mental health services to be provided by an OON provider. You 
say that the services are necessary. The Plan denied your request. The Plan says there are in-network providers 
that are able to provide these services. Therefore, coverage criteria have not been met. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
outpatient mental health services to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the endodontic therapy (D3330) provided on February 17, 2022. 
 
You asked the Plan to pay for the endodontic therapy. You say that you had to have an emergency root canal 
done, and had to pay in full at the time of service. The Plan denied your request. The Plan says this service is 
not a covered benefit under your dental plan. The Plan also says that you did not become effective with the 
supplemental dental rider until March 1, 2022 which is after this date of service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 the 
endodontic therapy (D3330) provided on February 17, 2022.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve compounded drugs and supplies for an implanted intrathecal 
infusion pump for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the pain pump is refilled in the office. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested services are medically reasonable and necessary. Our physician reviewer found this is standard 
therapy with an intrathecal pump. The requested medication is medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pre-
approve compounded drugs and supplies for an implanted intrathecal infusion pump for the enrollee.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional imaging services provided to the enrollee on 
February 12, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says this is a duplicate claim. 
 
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 71045 is "Radiologic examination, chest; single view." 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the records only show a single 
view chest x-ray done on 2/12/22. No additional examination is present in the records. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for additional imaging services provided to the enrollee on February 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection (E2311), expandable controller 
(E2377) and expandable controller harness (E2313). 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that your upper limb strength and function are adequate for you to be 
able to control the power options using their own switches which are included in the allowance of these power 
options. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. The requested 
electrical accessories are not medically necessary as you have use of the upper extremity and can operate and control the power options using the switches that are included in the basic wheelchair. Our physician reviewer 
found that your condition does not meet criteria for coverage of these services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an electronic connection (E2311), expandable controller (E2377) and expandable 
controller harness (E2313).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on February 24, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you are short staffed and unable to obtain prior 
authorization for the service. The Plan denied your request. The Plan says the service was provided out-of-
network and was 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 the office visit provided on February 24, 2022, by 
an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit and x-rays (99212, 73030) 
provided on January 11, 2022. 
 
You asked the Plan to waive the copayment for the office visit and x-rays. You say that the services should be 
covered as you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied 
correctly based on 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 $25 
copayment for Physician/Practitioner Services, Including Doctors Office Visits and a $15 copayment for 
Outpatient Diagnostic Tests and Therapeutic Services and Supplies. 
 
 
  You have been asked to pay a $25 copayment for an office visit and a $30 copayment for two x-rays ($15 x 2 = 
$30). This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for an office visit and x-rays (99212, 73030) 
provided on January 11, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for dental services provided on December 17, 2021. 
 
You asked the Plan to pay for the dental services. You say that the dental services should be covered. The Plan 
denied your request. The Plan says that the claim will be partially reprocessed. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not provided the reason for the partial payment of the 
claim or why the remainder of the claim is not paid. Therefore, we decided that the Plan has to pay for dental 
services provided on December 17, 2021.  
 
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 an oral evaluation (dental code D0150) provided on January 
13, 2022. 
 
You asked the Plan to pay for an oral evaluation. You say that it is a new plan year, and this service should not 
have been denied. The Plan denied your request. The Plan says the denial of payment for this service is correct, 
because one examination is covered every 3 plan years and you previously received an exam on January 5, 2021. 
 
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 1 exam every 
3 plan years. 
 
  We looked at the file, the Plan's rules, and Medicare rules. You previously received a covered exam on January 
5, 2021; therefore, the benefit was exhausted for date of service January 13, 2022. Therefore, we decided that 
the Plan does not have to pay for an oral evaluation (dental code D0150) provided on January 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an extraction on tooth #6 (D7210) provided on March 16, 2022. 
 
You asked the Plan to pay for an extraction. You say that you were in a lot of pain and the doctor saw you 
immediately. You also say that you doctor knows what is best for your health. The Plan denied your request. 
The Plan says extractions (D7210) is not covered by your routine dental 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 an 
extraction on tooth #6 (D7210) provided on March 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prolonged service in the inpatient or observation setting 
(99356) provided on October 27, 2021. 
 You asked the Plan to pay for the prolonged service in the inpatient or observation setting. You say that you 
would like this claim reprocessed based on the medical records. The Plan denied your request. The Plan says 
the documentation does not support the services as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99356 is prolonged service in the inpatient or observation 
setting, requiring unit/floor time beyond the usual service; first hour (List separately in addition to code for 
inpatient or observation Evaluation and Management service). 
 
We find that CPT code 99356 is not supported in the medical record. Specifically, the medical records do not 
sufficiently specify the time spent with the enrollee. Without the time specified, we cannot corroborate the 
services as billed. Based on this information, we decided that Medicare rules for coverage of the prolonged 
service in the inpatient or observation setting have not been met. Therefore, we decided that the Plan does not 
have to pay for the prolonged service in the inpatient or observation setting (99356) provided on October 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve expandable controller, including all related electronics 
and mounting hardware, upgrade provided at initial issue (CPT code E2377), electronic connection between 
wheelchair controller and two or more power seating system motors, including all related electronics, indicator 
feature, mechanical function selection switch, and fixed mounting hardware (CPT code E2311), harness for 
upgrade to expandable controller, including all fasteners, connectors and mounting hardware (CPT code 
E2313), power seat elevation system (CPT code E2300) and cup holder (CPT code K0108). 
 
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. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The upgraded electronics (electronic connector to 3 power features) is not medically necessary. They are 
necessary when there is a medical need to control 2 or more power features though the joystick. The notes do 
not show a medical need to control the power features through the joystick. The power features 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. The seat elevator is statutorily not covered as it does not 
serve a primary, medical purpose, and the cup holder is not covered as it does not serve a primary medical 
purpose. Therefore, we decided that the Plan does not have to pre-approve expandable controller, including all 
related electronics and mounting hardware, upgrade provided at initial issue (CPT code E2377), electronic 
connection between wheelchair controller and two or more power seating system motors, including all related 
electronics, indicator feature, mechanical function selection switch, and fixed mounting hardware (CPT code 
E2311), harness for upgrade to expandable controller, including all fasteners, connectors and mounting 
hardware (CPT code E2313), power seat elevation system (CPT code E2300) and cup holder (CPT code 
K0108).