Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on March 23, 2022. 
 
You asked the Plan to pay for an evaluation. You say that you had the same service before, and it was covered. 
The Plan denied your request. The Plan says a limited oral evaluation (D0140) 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 a limited 
oral evaluation (D0140) provided on March 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on August 12, 2021 billed with 
codes 81206, 81292, and 81301. 
 
You asked the Plan to pay for the genetic testing billed. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says this testing was not billed with the appropriate coding. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes, 
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 genetic testing 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 August 12, 2021 billed with codes 81206, 81292, and 81301.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a surface filling on tooth #11 provided on April 27, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were told the provider was in-network. 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 a surface filling on tooth #11 provided on April 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an oral surgeon. 
 
You asked the Plan to pay for dental services. You say that you need these services provided. The Plan denied 
your request. The Plan says services provided by an oral surgeon are not covered. 
 
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 dental 
services when the services are provided by a general dentist.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of dental services have not been met. Therefore, we decided that the Plan does not have to pay for 
dental services provided by an oral surgeon.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a removable unilateral partial denture (D5281) provided on 
February 9, 2022. 
 
You asked the Plan to pay for a partial denture. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says a removable unilateral partial denture (D5281) is not covered by 
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 a 
removable unilateral partial denture (D5281) provided on February 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 4, 2021 billed with 
codes 81206 and 81292. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the services were 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 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 4, 2021 billed with codes 81206 and 81292.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit (99214), eye exams (92014), and 
scanning computerized ophthalmic diagnostic imagings (92134) provided from January 27, 2022, to March 22, 
2022. 
 
You asked the Plan to pay for the outpatient office visit, eye exams, and scanning computerized ophthalmic 
diagnostic imagings. You say that you underwent a cataract surgery that left you unable to see clearly, and 
these were post-operative visits. You also say that you feel you should not be held responsible for $40 
copayments for these visits. The Plan denied your request. The Plan says the claims processed correctly as 
billed by the provider in accordance with your plan benefit, as the provider billed these visits as specialist vists. 
The Plan also says the provider advised the Plan that they removed your $40 cost-share on their end for the for 
January 27, 2022 visit. 
 
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.  
We looked at the file and the Plan's rules. You are responsible for a $40 copayment for each Medicare-covered 
eye exam. The record shows that these exams were provided for diagnoses of presence of intraocular lens, dry 
eye syndrome of bilateral lacrimal glands, open angle with borderline findings, high risk, bilateral, and drusen 
(degenerative) of macula, bilateral. Based on this information, we decided that the Plan's rules for coverage of 
the outpatient office visit, eye exams, and scanning computerized ophthalmic diagnostic imagings have not 
been met. Therefore, we decided that the Plan does not have to pay for the outpatient office visit (99214), eye 
exams (92014), and scanning computerized ophthalmic diagnostic imagings (92134) provided from January 27, 
2022, to March 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the COVID-19 vaccine rendered on December 23, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim must be submitted to Original Medicare. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide these services. The 
Plan contract states that claims for COVID-19 vaccine administration for 2020 to 2021 should be submitted to 
Original Medicare. 
 
The file shows that the enrollee received a COVID-19 vaccination on December 23, 2021. The Plan does not 
offer a supplemental benefit for these services. The COVID-19 vaccine is covered by Original Medicare. 
Therefore, we decided that the Plan does not have to pay for the COVID-19 vaccine rendered on December 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infectious agent detection by nucleic acid (DNA or 
RNA), Human Papillomavirus (HPV), high risk types (87624) provided October 6, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the medical records provided support the 
necessity of the services in dispute. The Plan denied your request. The Plan says these services are not covered 
by Medicare. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered.  
 
CMS has determined that the evidence is sufficient to add Human Papillomavirus (HPV) testing once every 
five years as an additional preventive service benefit under the Medicare program for asymptomatic 
beneficiaries aged 30 to 65 years in conjunction with the Pap smear test. The records show that the enrollee is 
not within the covered age range for the test completed. Therefore, we decided that the Plan does not have to 
pay for the infectious agent detection by nucleic acid (DNA or RNA), Human Papillomavirus (HPV), high risk 
types (87624) provided October 6, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481, 87640, 87641, 87653, 87150, and 
87798 billed for date of service August 9, 2021. 
 
You asked the Plan to pay for procedure codes 87481, 87640, 87641, 87653, 87150, and 87798. The Plan 
denied your request. The Plan says payment for these codes is bundled into other services.  
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 codes 
87481, 87640, 87641, and 87653 are column II codes to column I code 87150. We have also confirmed that 
code 87150 is a column II code to column I code 87500 and code 87798 is a column II code to column I code 
87801. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim 
submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure codes 87481, 87640, 87641, 87653, 87150, and 87798 billed for date of service August 9, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supply allowance for therapeutic continuous glucose 
monitor (CGM) provided on November 18, 2021. 
 
You asked the Plan to pay for the supply allowance for therapeutic CGM. You say that you would like the plan 
to reconsider their denial. The Plan denied your request. The Plan says the documentation is missing required 
information. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. Review of the file 
shows that the documentation includes a delivery slip; however, the shipping date does not match the date of 
service billed. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the supply allowance for 
therapeutic continuous glucose monitor (CGM) provided on November 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bone replacement graft for ridge preservation (D7953) 
provided on March 8, 2022. 
 
You asked the Plan to pay for the bone replacement graft. You say that this service should be covered. You 
also say the crown will not be finished until the Plan pays the $445 for this service. 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 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 bone 
replacement graft for ridge preservation (D7953) provided on March 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), surgical extraction 
(D7210), and inhalation of nitrous oxide/analgesia (D9230) provided on December 15, 2021, and December 
22, 2021. 
 
You asked the Plan to pay for the periodic oral evaluation, surgical extraction, and inhalation of nitrous 
oxide/analgesia. You say that the Plan provided false information to the provider saying you still had $1,000 of 
the maximum annual limit left for the 2021 plan year. The Plan denied your request. The Plan says you have 
exhausted the annual maximum of $1,500 that has been set in the subscriber agreement. 
 
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 Plan offers a $1,500 annual dental 
benefit maximum. The contract says that after your annual maximum benefit maximum has been met, you are 
responsible for the full charges of any additional dental services. The record shows that you met the annual 
maximum benefit on September 23, 2021, and your annual maximum benefit has been exhausted. Therefore, 
we decided that the Plan does not have to pay for the periodic oral evaluation (D0120), surgical extraction 
(D7210), and inhalation of nitrous oxide/analgesia (D9230) provided on December 15, 2021, and December 
22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the caries risk assessment and documentation (D0603), 
tobacco counseling (D1320), and oral hygiene instructions (D1330) provided on March 22, 2022. 
 
You asked the Plan to pay for the caries risk assessment and documentation, tobacco counseling, and oral 
hygiene instructions. You say that you were under the impression that these services would be covered. You 
also say that you do not have the means to pay for these services. The Plan denied your request. The Plan says 
these services are not covered under 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 pay for the caries 
risk assessment and documentation (D0603), tobacco counseling (D1320), and oral hygiene instructions 
(D1330) provided on March 22, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skin biopsy (11102) provided on January 17, 2022. 
 
You asked the Plan to pay for the skin biopsy (11102). You say that the payment for medical care provided is 
incorrect and a corrected payment of $190.53 should be made. The Plan denied your request. The Plan says 
CPT 11102 has an MUE value of 1 but 2 units were billed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 11102 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the skin 
biopsy (11102) have not been met. Therefore, we decided that the Plan does not have to pay for the skin biopsy 
(11102) provided on January 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown on tooth #15 (D2740) provided on April 14, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were not aware of the limitations when you 
called to add the additional dental coverage in March. 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 12, 2018. 
Therefore, we decided that the Plan does not have to pay for a crown on tooth #15 (D2740) provided on April 
14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on March 
21, 2022. 
 
You asked the Plan to pay for the dental services. You say that this was not a general examination. You also 
say your dentist referred you to an oral surgeon. 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 2, 2022. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) 
provided on March 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on June 23, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that the PC and TC for diagnostic services are separately 
payable when furnished in different payment localities. 
 
We looked at the file and Medicare rules. The file shows that the PC and TC were not performed in different 
payment localities. 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 pay for the laboratory services 
rendered on June 23, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the services you need can be provided safely in other settings. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The 
complexity of your nursing, medical and rehabilitation needs do not require an acute rehab hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, at an intensive rehabilitation therapy 
program. You continue to have a need for skilled therapy with ongoing safety concerns and a potential for 
functional improvement. There is no indication that you would require skilled rehabilitation in an IRF, 
participating in rehab services 15 hours a week, under the supervision of a physician with at least 3 visits 
weekly to regain or maintain her functional status. You can receive further services at a lower level of care. Our 
physician reviewer found that your condition does not meet Medicare criteria for IRF 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on August 30, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 81599 is not supported. 
 
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 81599 is unlisted multianalyte assay with algorithmic 
analysis. 
 
We find that CPT code 81599 is not supported in the medical record. Specifically, there is no documentation or 
laboratory report to support the services were performed. 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 
pay for the laboratory services rendered on August 30, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a home COVID-19 test purchased on January 26, 2022.
You asked the Plan to pay for this test kit. You say that this test should be paid for by the Plan. The Plan denied
your request. The Plan says at the time of purchase, the health plans were not authorized to
reimburse for this testing. Maximus overturned the Plans denial. The Plan requested a reopen and stated that
Maximus did not apply the correct coverage criteria.
The Plan is correct in this case. The Plan follows Medicare rules. The rules explicitly say that screening tests,
with the exception of the few tests listed in the Medicare rules section, are not covered.
At the time of purchase, home test kits were only covered when dispensed at no charge by a government
program or when provided by a facility. This test was purchased commercially and was not covered for
reimbursement at that time by the health plans. Therefore, we decided that the Plan does not have to pay for a
home COVID-19 test purchased on January 26, 2022.