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

 
We decided that the Plan does not have to pay for an unspecified preventive procedure (D1999), and a resin-
based composites (D2330 and D2391) provided by a participating provider on November 24, 2021. 
 
You asked the Plan to pay for an unspecified preventive procedure and a resin-based composites. You say that 
you do not agree with these charges. The Plan denied your request. The Plan says D1999 is not a covered 
benefit. The Plan says that the benefit limit for D2330 and D2391 have 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. The Plan does not cover an 
unspecified preventive procedure. The Plan does cover two resin-based composites per calendar year. 
 
We looked at the file and Medicare rules. Evidence was provided to show that D2330 and D2391 was paid for 
teeth #20 and #21. Based on this information, we decided that the Plan's rules for coverage of a resin-based composites have already been met. An unspecified preventive procedure is not a covered benefit. Therefore, we 
decided that the Plan does not have to pay for an unspecified preventive procedure (D1999), and a resin-based 
composites (D2330 and D2391) provided by a participating provider on November 24, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service December 
21, 2021. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service December 21, 
2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head/brain 
rendered on December 22, 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 separately payable. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
The provider submitted a claim for procedure codes 70450 (CT head/brain) and 70496 (computed tomography 
angiography of the head). Code 70450 is a column II code with a modifier indicator of 1 when billed with 
column I code 70496. Code 70450 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan of the 
head/brain rendered on December 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for vision item or service, miscellaneous, Tint, photochromatic, 
per lens and Anti-reflective coating, per lens provided on October 26, 2021. 
 You asked the Plan to pay for vision item or service, miscellaneous, Tint, photochromatic, per lens and Anti-
reflective coating. The Plan denied your request. The Plan says the member received vision items, which are 
explicitly excluded; therefore, the vision items are not covered by the Plan. 
 
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine 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. The file shows that the Plan does not cover additional lens options 
including, but not limited to, Deluxe, Premium or Platinum progressive lenses, blended bifocal, Hi Index, 
tinting, scratch coating, UV or anti-reflective coating, and polycarbonate. Therefore, we decided that the Plan 
does not have to pay for vision item or service, miscellaneous, Tint, photochromatic, per lens and Anti-
reflective coating, per lens provided on October 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Transitional care management services provided on October 
7, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for Transitional care management services. You say that the member could not 
choose an in-network internal medicine as they do not provide services in the patients place of residence. The 
Plan denied your request. The Plan says prior authorization is required for an out-of-network office visit. 
 
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 Transitional care management services provided 
on October 7, 2021 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cataract surgery provided on September 7, 2021, to 
September 28, 2021, by an out-of-network (OON) provider. 
 
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 were rendered by an out-of-network provider without prior authorization. 
 
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 cataract surgery provided on September 7, 
2021, to September 28, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Consultation and report on referred slides prepared 
elsewhere (88321-59) provided on October 8, 2020. 
 
You asked the Plan to pay for code 88321-59. 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 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 88321 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 code 
88321-59 have not been met. Therefore, we decided that the Plan does not have to pay for the Consultation and 
report on referred slides prepared elsewhere (88321-59) provided on October 8, 2020.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pre-approve the Envisia Genomic Classifier test provided to the enrollee on 
September 26, 2021. 
 
You asked the Plan to pre-approve the services. You say that this is a nationally covered service. The Plan 
denied your request. The Plan says that the attached documentation does not show that the clinical criteria were 
met. 
 
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 the services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found the Envisia Genomic Classifier is a tissue based multi-analyte assay with algorithm analysis test 
(hereafter called Envisia) for interstitial lung disease (ILD) patients who are suspected of idiopathic pulmonary 
fibrosis (IPF) and who do not have a definitive usual interstitial pneumonia (UIP) pattern by high resolution 
computed tomography (HRCT) or other known cause of ILD. IPF suspicion increases significantly in patients 
greater than 60 years of age when HRCT is not definitive, and comorbidities in this population make clinicians 
reluctant to perform surgical lung biopsy to obtain a diagnosis due to significant procedure morbidity and 
mortality. Envisia testing is performed on less-invasive bronchoscopy transbronchial biopsy samples and is 
intended to provide a categorical UIP or Non-UIP result that along with clinical and radiographic information 
may guide treatment without the need or risk of surgical lung biopsy. The review has determined that the 
services at issue in this case are 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 the Envisia Genomic Classifier test provided to the enrollee on September 26, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement of the copayment for the magnetic resonance 
angiography (MRA) of the head (70546) provided on December 3, 2021. 
 
You asked the Plan to issue reimbursement. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service 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 $125 
copayment for advanced imaging services provided at a freestanding radiological facility.    
 
 You have been asked to pay a $125 copayment for the advanced imaging service provided at a freestanding 
radiological facility. 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 issue reimbursement of the copayment for the magnetic 
resonance angiography (MRA) of the head (70546) provided on December 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an opt-out provider on October 
29, 2020. 
 
You asked the Plan to pay for dental services. You say that you were recommended to this dentist to remove an 
infected impacted tooth. The Plan denied your request. The Plan says the rendering dentist has opted-out of 
Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for dental 
services provided by an opt-out provider on October 29, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for quantitative sensory testing provided on August 17, 2021. 
 
You asked the Plan to pay for quantitative sensory testing. The Plan denied your request. The Plan says 
quantitative sensory testing is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for quantitative sensory testing. Our reviewer 
says that the requested quantitative sensory testing is not considered medically reasonable and necessary in this 
case. Our physician reviewer found that quantitative sensory testing (QST) systems are used for the 
noninvasive assessment and quantification of sensory nerve function in patients with symptoms of or the potential for neurologic damage or disease. Types of sensory testing include current perception threshold 
testing, pressure-specified sensory testing (PSST), vibration perception threshold testing, and thermal sensory 
testing. Information on sensory deficits identified using QST has been used in research settings to better 
understand neuropathic pain. QST systems measure and quantify the amount of physical stimuli required for 
sensory perception to occur. As sensory deficits increase, the perception threshold of QST will increase, which 
may be informative in documenting the progression of neurologic damage or disease. QST has not been 
established for use as a sole tool for diagnosis and management but has been used with standard evaluative and 
management procedures (e.g., physical, and neurologic examination, monofilament testing, pinprick, grip and 
pinch strength, Tinel sign, and Phalen and Roos Test) to enhance the diagnosis and treatment-planning process, 
and to confirm physical findings with quantifiable data. Stimuli used in QST includes touch, pressure, pain, 
thermal (warm and cold), or vibratory stimuli. The clinical value and effectiveness of quantitative sensory 
testing in the setting of amyloidosis, peripheral neuropathy, and pseudo-claudication have not been 
demonstrated in the peer-reviewed literature. The review has determined that quantitative sensory testing at 
issue in this case is not medically reasonable or 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 quantitative sensory testing have not been met. Therefore, we decided that the 
Plan does not have to pay for quantitative sensory testing provided on August 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the automatic external defibrillator provided on July 15, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the automatic external defibrillator. You say that you cannot reasonably know 
when a prior authorization is required. You say the claim at issue meets Medicare coverage. The Plan denied 
your request. The Plan says no prior authorization was obtained. 
 
 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 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 automatic external defibrillator provided on 
July 15, 2021, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from 
December 8, 2021, to December 13, 2021. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that the Plan should not pay 
the provider anything since you were released without the surgery being completed. The Plan denied your 
request. The Plan says the proper copayment was applied for the services that were rendered. 
 
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 $100 
copayment for Inpatient Care per day, for days 1 to 5. With December 9, 2021, being the first day charged of 
the inpatient stay and the date of discharge was December 13, 2021, there was 4 total days chargeable as the 
copayment. The total amount of the copayment for the 4 days was $400 ($100 copayment per day x 4 days). 
 
  You have been asked to pay a $400 copayment for the inpatient hospital stay. The inpatient hospital stay falls 
within the Inpatient hospital care benefit category. 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 inpatient hospital stay provided from December 8, 2021, to December 13, 2021.  
 
Your complaint about your experience with this provider is not a valid appeal for medical coverage. This part 
of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950) 
provided December 29, 2021. 
 
You asked the Plan to pay for the core buildup. You say that this service should be covered. The Plan denied 
your request. The Plan says this service is 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 pay for the core 
buildup, including any pins when required (D2950) provided December 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gingival irrigation (D4921 x 4), and localized delivery of 
antimicrobial agents (D4381 x 2) provided on November 26, 2021. 
 
You asked the Plan to pay for the gingival irrigation and localized delivery of antimicrobial agents. You say 
that it does not make sense that you only had 3 quadrants treated. You also say that you should not have been 
charged. The Plan denied your request. The Plan says that gingival irrigation and localized delivery of 
antimicrobial agents are not listed as covered services. 
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 gingival irrigation and localized 
delivery of antimicrobial agents are not among those covered under this benefit. Therefore, we decided that the 
Plan does not have to pay for the gingival irrigation (D4921 x 4), and localized delivery of antimicrobial agents 
(D4381 x 2) provided on November 26, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve unlisted molecular pathology procedure (Lymphedema Panel) (CPT code 81479).

You asked the Plan to pre-approve the laboratory services. You say that the enrollee was referred to you due to having an unusual case of lymphedema; therefore, needing a genetic evaluation to determine whether or not there may be an underlying genetic ethology to explain the enrollee's problems and lead to changes in their health management. You state there are many genetic causes of lymphatic abnormalities that so not have a distinctive phenotype; therefore, the only way to diagnose them is by a multi-gene panel. The Plan denied your request. The Plan says a review of the authoritative medical literature indicate that this testing is not an FDA approved genetic test and has not been shown to directly impact treatment or management. The Plan states exome testing is unlikely to impact therapeutic decision making in the clinical management of the enrollee.

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 laboratory services. Our physician reviewer found the medical records provided do not meet the requirements listed in the LCD for Medicare coverage.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pre-approve unlisted molecular pathology procedure (Lymphedema Panel) (CPT code 81479).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an out-of-network provider on 
September 23, 2021. 
 
You asked the Plan to pay for dental services. You say that you do not feel like in-network providers do a good 
job. 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 Plans coverage rules apply in this case. The Plan covers dental 
services when the services are provided in-network. 
 
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 out-of-network provider on September 23, 2021.