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

 
We decided that the Plan does not have to pay for the lab testing services provided on July 8, 2021. 
 
You asked the Plan to pay for the testing services. You say that treatment sought was a covered service. The 
Plan denied your request. The Plan says one code must be submitted for the panel. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
The file shows that the obesity gene panel was billed with multiple codes. 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 lab testing services provided on July 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay the in network rate for the limited oral evaluation (D0140) 
provided on February 9, 2022, by the out of network dentist. 
 
You asked the Plan to pay the in network rate for the limited oral evaluation. You say that your tooth broken in 
half. You say that your dentist referred you to an oral surgeon. You say that you assumed the services would be 
covered since you were referred by your primary dentist. You also say that the full amount should be paid. 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 limited oral evaluation is listed as 
covered, the frequency limit of once per calendar year has been exceeded. The record shows that the Plan paid 
for a limited oral evaluation that you received on February 7, 2022. Therefore, we decided that the Plan does 
not have to pay the in network rate for the limited oral evaluation (D0140) provided on February 9, 2022, by 
the out of network dentist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for extractions (D7210) provided by an out-of-network provider 
on October 25, 2021. 
 
You asked the Plan to pay for extractions. You say that you would like the Plan to pay for this. The Plan denied 
your request. The Plan says this claim has been correctly denied. 
 
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 extractions 
when the services are provided by a participating provider. 
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of extractions have not been met. Therefore, we decided that the Plan does not have to pay for 
extractions (D7210) provided by an out-of-network provider on October 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pontic (D6245) and two retainer crowns (D6740 x2). 
 
You asked the Plan to pre-approve the pontic and retainer crowns. You say that you would like these services 
to be covered because you have no tooth in the place where the bridge is needed to hold your tooth in place. 
The Plan denied your request. The Plan says these services are not covered under your benefit package. 
 
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 a 
pontic (D6245) and two retainer crowns (D6740 x2).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the molecular pathology testing (CPT code(s): 81206, 81292, 
and 81301) provided on September 19, 2021.  
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. 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. 
 
The denial remains upheld as non-covered as Medicare denies coverage when a laboratory assays two or more 
genes in a patient in parallel. Those two or more genes will be considered part of the same panel. A panel 
constitutes a single procedural service, so one CPT code must be submitted for the panel. 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 molecular pathology testing (CPT code(s): 
81206, 81292, and 81301) provided on September 19, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgery services coded as 49560 provided on October 15, 2021. 
 
You asked the Plan to pay for the surgery services. You say that you would like this claim reprocessed based 
on the medical records. The Plan denied your request. The Plan says the operative report does not support 
separate payment for 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 49560 is repair initial incisional or ventral hernia; 
reducible. 
 
 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 surgery services. Our reviewer says that the 
documentation does not support payment for CPT code 49560 as billed. Our reviewer found although hernia 
repair is documented in the operative report, this procedure was not performed at a different incision site. 
Therefore, it would not be reported separately from the procedure coded 44130 which was previously approved 
for payment. 
 
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 surgery services have not been met. Therefore, we decided that the Plan 
does not have to pay for the surgery services coded as 49560 provided on October 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services to be rendered by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the dental services. You say that you would like to continue going to this 
same provider that you have been going to for over 10 years. You also say that you trust this provider to follow 
up with your periodontics issue. The Plan denied your request. The Plan says the requested service is available 
in-network, and going OON is not medically necessary at this time. The Plan also says that there are 6 in-
network providers within a 50-mile radius of your zip code. 
 
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 OON. Therefore, we decided that the Plan does not have to pre-approve dental 
services to be rendered by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140), periapical additional 
radiographic image (D0230), cone beam computed tomography (D0364), pulp vitality tests (D0460), and 
endodontic therapy (D3330), provided by a participating provider on January 12, 2022. 
 
You asked the Plan to pay for a limited oral evaluation, periapical additional radiographic image, cone beam 
computed tomography, pulp vitality tests, and endodontic therapy. You say that you had dental coverage on the 
date of these services. The Plan denied your request. The Plan says this claim has been processed correctly. 
 
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, D0140, D0364, D0460 and D3330 are 
not among those covered under this benefit. D0220 and D0230 was provided on January 12, 2022. Therefore, 
we decided that the Plan does not have to pay for a limited oral evaluation (D0140), periapical additional 
radiographic image (D0230), cone beam computed tomography (D0364), pulp vitality tests (D0460), and 
endodontic therapy (D3330), provided by a participating provider on January 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for endodontic therapy (D3330) provided by a participating 
provider on February 10, 2022. 
 
You asked the Plan to pay for endodontic therapy. You say that you made sure that this provided was in-
network. You say that you would like the Plan to pay for this. The Plan denied your request. The Plan says 
D3330 is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
endodontic therapy (D3330) provided by a participating provider on February 10, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an expandable control system. 
 
You asked the Plan to pre-approve an expandable control system. The Plan denied your request. The Plan says 
that there is not a medical need to control the power options through a joystick. 
 
The Plan follows Medicare rules. Medicare rules say that wheelchair options and accessories are only covered 
under certain medical indications. 
 
The file shows that an expandable control system was requested with codes E2377, E2311, and E2313. 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 an expandable control system. Our 
physician reviewer found that the enrollee has a medical history of stroke with left sided weakness, spinal cord 
injury with paraparesis of bilateral lower limbs, right rotator cuff injury who uses power wheelchair for 
mobility. Per clinical documentation, the Plan will cover a group 3 power wheelchair with power tilt, recline 
and elevating leg rests thus an expandable controller to operate power functions through joystick would meet 
the criteria. In addition, the enrollee has documented spasticity and upper limb dysfunction that would make 
this medically 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 an expandable control system have been met. Therefore, we decided that the 
Plan has to pre-approve an expandable control system.  
 
 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 gingival irrigation (D4921), an unspecified periodontal 
procedure (D4999), and oral hygiene instructions (D1330), provided by a participating provider on January 24, 
2022. 
 
You asked the Plan to pay for gingival irrigation, an unspecified periodontal procedure, and oral 
hygiene instructions. You say that this should be covered because it is considered deep cleaning. The Plan 
denied your request. The Plan says the rendered dental services are not covered 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 gingival irrigation (D4921), an unspecified periodontal procedure (D4999), and oral hygiene instructions (D1330), 
provided by a participating provider on January 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician's services to be provided by you. 
 
You asked the Plan to pre-approve physician's services. The Plan denied your request. The Plan says the 
member must use network providers to get medical care and services. The only exceptions are emergencies, 
urgently needed services when the network is not available, out of area dialysis services are cases in which the 
member's Plan authorizes use of out-of-network providers. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve 
physician's services to be provided by you.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the SNF admission. You say that the requested admission to a SNF is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a SNF is not 
medically necessary. 
 
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 the SNF admission. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found based on the medical records 
provided there is no documentation that the enrollee requires the services on an inpatient basis, only in a skilled 
nursing facility setting. 
 
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 SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services provided on January 18, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered. 
 
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. Medicare rules say that a contract 
provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by 
the plan unless notice is provided that the services will not be covered. The plan follows these rules. 
 
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 did not specify whether the ordering physician was in-network or out-
of-network with the Plan. The documentation submitted does not include prior notice from the Plan that these 
tests would not be covered. Without this information, we cannot determine whether the lab order made 
constituted plan-directed care. Therefore, we decided that the Plan has to pay for the laboratory services 
provided on January 18, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (G0482) provided January 12, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed services. 
 
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 
(G0482) provided January 12, 2021.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the radiologic examination (71045) provided on December 5, 2021. 
 
You asked the Plan to pay for code 71045. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says that the services are not covered as billed. 
 
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 71045 as a column II code to column I code 
71046. However, the file does not contain any evidence that the provider submitted a claim for payment of the 
column I code, 71046. We find that the Plan has provided insufficient evidence to support their denial of 
payment for code 71045-26. Therefore, we decided that the Plan has to pay for the radiologic examination 
(71045) provided on December 5, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on June 23, 2021. 
 
You asked the Plan to pay for the laboratory services. 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 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 laboratory 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 the laboratory services provided on June 23, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services (72193) provided January 25, 2022. 
 
You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the service billed has a bundled relationship with another code billed 
and is not separately payable. 
 
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 72193 is a column II code to column I code 74177 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 radiology services 
(72193) provided January 25, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapy services (97530) provided September 6, 2021. 
 
You asked the Plan to pay for the therapy services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the billed code. 
 
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 CPT code 97530 is not supported in the medical record. Specifically, the services were performed 
in the home setting by a therapy assistant. There is a more appropriate code for this service (G0152). Based on 
this information, we decided that Medicare rules for coverage of the therapy services have not been met. 
Therefore, we decided that the Plan does not have to pay for therapy services (97530) provided September 6, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (G0481) provided on November 4, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the services were not emergent or pre-authorized. 
 
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 services at issue in this appeal. The Plan did not pre-approve the service 
at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided 
that the Plan does not have to pay for lab services (G0481) provided on November 4, 2021.