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

 
We decided that the Plan does not have to pay for the eye refraction (92015) provided on March 4, 2022. 
 
You asked the Plan to pay for the eye refraction. The Plan denied your request. The Plan says a refraction is 
only covered when billed as part of the routine eye exam. The Plan also says that this claim was processed 
correctly. 
 
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 refractions when it is billed as part of a routine eye exam. 
 
We looked at the file and the Plan's rules. The record shows that you received a medical eye exam on this date 
of service. Based on this information, we decided that the Plan's rules for coverage of the eye refraction have 
not been met. Therefore, we decided that the Plan does not have to pay for the eye refraction (92015) provided 
on March 4, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve Image Guided Radiation Therapy (IGRT). 
 
You asked the Plan to pre-approve these services. You say that you need this to stop the spread of cancer. The 
Plan denied your request. The Plan says that that the clinical documentation provided for review by your 
provider does not show that daily picture studies are required in the treatment of your cancer. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically 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 these services. Our reviewer says that 
the requested services are considered medically reasonable and necessary in this case. While, the intent is 
clearly palliative in this case, the treatment is not typical for palliation (i.e. palliation of a simple bone 
metastasis). The treatment of a bulky abdominal mass, in close proximity to the kidneys and bowel, would 
likely benefit from image-guidance to assure accurate localization of the target and to minimize exposure of 
normal tissue, which even with palliative doses can be problematic with large abdominal masses. Our physician 
reviewer found that your condition meets 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 been met. Therefore, we decided that the Plan has to pre-
approve Image Guided Radiation Therapy (IGRT).  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (0202U) provided on December 12, 
2021. 
 
You asked the Plan to pay for code 0202U. 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. 
 
The Plan must follow Medicare rules. Medicare rules say that code 0202U is not covered. 
 
We looked at the file and Medicare rules. Per LCA A57338, the billed code, 0202U, is a non-covered code. 
Based on this information, we decided that Medicare rules for coverage of code 0202U have not been met. 
Therefore, we decided that the Plan does not have to pay for the laboratory services (0202U) provided on 
December 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic visits provided on February 15, 2022, 
February 21, 2022, February 23, 2022, February 28, 2022, March 2, 2022, March 7, 2022, March 9, 2022, 
March 14, 2022, March 16, 2022, March 21, 2022, March 24, 2022, March 28, 2022, March 30, 2022, April 4, 
2022, April 6, 2022, April 12, 2022, April 14, 2022, and April 20, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the chiropractic visits. You say that you would like the Plan to cover the visits 
because you were advised to see a chiropractor for your pain. The Plan denied your request. The Plan says the 
rendering provider is an OON provider and there was no referral from an in-network provider or an approved 
authorization. Also, the service rendered was not urgent or emergent. 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 chiropractic visits provided on February 15, 
2022, February 21, 2022, February 23, 2022, February 28, 2022, March 2, 2022, March 7, 2022, March 9, 
2022, March 14, 2022, March 16, 2022, March 21, 2022, March 24, 2022, March 28, 2022, March 30, 2022, 
April 4, 2022, April 6, 2022, April 12, 2022, April 14, 2022, and April 20, 2022, by an out-of-network (OON) 
provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 30, 2021 billed with 
codes 81206, 81235, 81292, 81301 and 81321. 
 
You asked the Plan to pay for the genetic testing billed. The Plan denied your request. The Plan says the 
services were billed incorrectly. 
 
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 30, 2021 billed with codes 81206, 81235, 81292, 81301 and 81321.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FANCC genetic testing provided on January 29, 2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered 
benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that the MolDX Team has determined that testing for 
the FANCC is not a Medicare benefit and is a statutorily excluded service. In addition to single gene testing, 
MolDX will also deny panels of tests that include the FANCC gene.  
 
We looked at the file and Medicare rules. Per LCA A53628, the requested FANCC genetic testing is not a 
covered benefit. Based on this information, we decided that Medicare rules for coverage of the testing have not 
been met. Therefore, we decided that the Plan does not have to pay for the FANCC genetic testing provided on 
January 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve extractions (D7210) and comprehensive oral evaluation 
(D0150). 
 
You asked the Plan to pre-approve extraction (D7210) and comprehensive oral evaluation (D0150). You say 
that you would like to request reconsideration of the denied authorization. The Plan denied your request. The 
Plan says the supplemental Dental Services benefit of the member's contract only provides coverage for dental 
services when they are performed by a participating general dentist and that dental services performed 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. 
 
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 if they are received from an oral surgeon. Therefore, we decided that 
the Plan does not have to pre-approve extractions (D7210) and comprehensive oral evaluation (D0150).
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for a crown (D2750) provided on January 18, 2022. 
 
You asked the Plan to pay for a crown. You say that you have not met your annual maximum and you want the 
Plan to pay for the service. The Plan denied your request. The Plan says that you do not meet the criteria for 
coverage. 
 
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. There are no medical records included in the casefile to show how the Plan 
supports their denial. The Plan does not indicate why payment should not be made for crowns in this case. 
Therefore, we decided that the Plan has to pay for a crown (D2750) provided on January 18, 2022.  
 
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 pre-approve therapeutic parenteral drug, single administration 
(D9610), bone replacement graft  retained natural tooth  first site in quadrant (D4263) and osseous surgery 
(including elevation of a full thickness flap and closure)  four or more contiguous teeth or tooth bounded 
spaces per quadrant (D4260). 
 
You asked the Plan to pre-approve administration of a therapeutic parenteral drug, bone replacement graft and 
osseous surgery. You say that this treatment is necessary to retain your natural tooth and prevent further dental 
issues and expense. The Plan denied your request. The Plan says these services are not covered under your 
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 pre-approve 
therapeutic parenteral drug, single administration (D9610), bone replacement graft  retained natural tooth  
first site in quadrant (D4263) and osseous surgery (including elevation of a full thickness flap and closure)  
four or more contiguous teeth or tooth bounded spaces per quadrant (D4260).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services (D7140, D9230, D7210, D5214, D5820, 
D3321, D3310, D2950, D2750) provided from April 21, 2021, to September 28, 2021  
 
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 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 dental 
services (D7140, D9230, D7210, D5214, D5820, D3321, D3310, D2950, D2750) provided from April 21, 
2021, to September 28, 2021
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81345 billed for date of service January 26, 
2022. 
 
You asked the Plan to pay for procedure code 81345. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment for code 81345 is bundled into 
payment for code 0089U. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 81345 
is a column II code to column I code 0089U. 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 code 81345 billed for date of service January 26, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (83789) provided on January 14, 
2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed based 
on the medical records. The Plan denied your request. The Plan says this code is not eligible for separate 
payment. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Medicare rules say that specimen validity testing is not covered separately. 
 
The services at issue in this case are for the purpose of specimen validity testing. 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 the laboratory services (83789) provided on January 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for extractions (D7140 x4) and an upper immediate 
denture (D5130) provided on March 2, 2022. 
 
You asked the Plan to pay more for the dental services. You say that the Plan should have processed the 
extractions first and you want them to pay an additional 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 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 more for extractions (D7140 x4) and an upper 
immediate denture (D5130) provided on March 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided by a 
network provider on April 14, 2022. 
 
You asked the Plan to pay for the comprehensive oral evaluation (D0150). You say that the provider never told 
you what services were going to be performed during the visit. 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 16, 2021. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) 
provided by a network provider on April 14, 2022.
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for code 95938. We decided that the Plan does not have to pay for codes 
95886 and 95907.  
 
You asked the Plan to pay for codes 95938, 95886, and 95907. You say that you would like the Plan to 
reconsider their denial of payment. The Plan says that the services are not covered as billed. 
 
We decided that the Plan has to pay for code 95938.  
 
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. The Plan denied payment for code 95938 as a suspected duplicate to another 
claim the Plan said they paid for. However, the Plan has provided no claim that shows code 95938 was 
previously paid for. As this is the Plans only denial reason for this code, we find the Plan has not supported 
their reasoning for denial of payment based on Medicare criteria. Therefore, we decided that the Plan has to 
pay for code 95938.  
 
We also decided that the Plan does not have to pay for codes 95886 and 95907. 
 
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 
95886 and 95907 are column II codes to column I code 95861 with a modifier indicator of 0. The column II 
code is therefore not payable. Based on the claim submitted, Medicare billing criteria have not been met. 
Therefore, we decided that the Plan does not have to pay for codes 95886 and 95907. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (83789) provided on February 9, 
2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed based 
on the medical records. The Plan denied your request. The Plan says this code is not supported in the record. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Medicare rules say that specimen validity testing 
is not covered separately. 
 
The services at issue in this case are for the purpose of specimen validity testing. 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 the laboratory services (83789) provided on February 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene panel testing provided on June 7, 2021. 
 
You asked the Plan to pay for the testing services. You say that the testing assists in the treatment of cancer. 
The Plan denied your request. The Plan says a panel code should be billed rather than individual gene codes. 
 
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 gene panel was not billed with a single code as required. Based on this information, we 
decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan 
does not have to pay for the gene panel testing provided on June 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bitewings (D0274), prophylaxis (D1110) and a 
comprehensive oral evaluation (D0150) provided on March 24, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were unaware this was a non-participating 
dentist with the Plan. You say that the attendant didn't say anything to you after making a copy of your 
insurance card. 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 bitewings (D0274), prophylaxis (D1110) and a comprehensive oral evaluation (D0150) provided on 
March 24, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the low dose computed tomography (LDCT), thorax, for lung 
cancer screening (71271) provided on March 14, 2022. 
 You asked the Plan to pay for the lung cancer screening with LDCT. You say that per the coding team, the 
requested code is valid and correct. The Plan denied your request. The Plan says the enrollee criteria have not 
been met. 
 
The Plan must follow Medicare rules. Medicare rules say that evidence is sufficient to cover, under Medicare 
Part B, a lung cancer screening counseling and shared decision-making visit, and annual screening for lung 
cancer with low dose computed tomography (LDCT), as an additional preventive service benefit under the 
Medicare program, only if all of the following eligibility criteria are met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lung cancer screening with LDCT have not been met. Specifically, the enrollee's age does not 
fall within the eligible range of 50 to 77 years. Therefore, we decided that the Plan does not have to pay for the 
low dose computed tomography (LDCT), thorax, for lung cancer screening (71271) provided on March 14, 
2022.