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

 
We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung 
cancer screening (71271). 
 
You asked the Plan to pre-approve the requested LDCT scan. You say that you are requesting a reconsideration 
of the Plan's denial as this test is medically necessary. The Plan denied your request. The Plan says the enrollee 
does not meet criteria for coverage of this service. 
 The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung 
cancer screening for enrollees who meet all the criteria described in the Medicare rules section of this letter.  
 
We reviewed the case file and Medicare rules. Based on this information, we find that the enrollee does not 
meet Medicare criteria for coverage of this service. Specifically, the rules say that Medicare covers one annual 
LDCT scan for lung cancer screening for enrollees who are between 55 and 77 years of age. Therefore, we 
decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung 
cancer screening (71271).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on August 19, 2021, billed with 
codes 81286, 81404, 81405, 81406, 81407, 81408, and 81439. 
 
You asked the Plan to pay for the genetic testing. The Plan denied your request. The Plan says NGS panel 
testing should be billed using one Current Procedural Terminology (CPT) code on the claim. 
 
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 have 
not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
August 19, 2021, billed with codes 81286, 81404, 81405, 81406, 81407, 81408, and 81439.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient skilled nursing facility (SNF) care provided 
from October 1, 2021, through October 11, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the enrollee did not meet criteria for coverage 
of the skilled nursing facility care provided. 
 
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 pay for the SNF care provided from October 1, 
2021, through October 11, 2021. Our reviewer says that the inpatient skilled nursing facility care provided was 
not medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that daily 
skilled services were not required. The enrollee was receiving only part-time therapy. As a practical matter, this 
enrollee did not require the services on an inpatient basis, only in a skilled nursing facility setting. The services 
provided from 10/01/2021 through 10/11/2021 appear custodial in this case. 
 
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 care provided from October 1, 2021, through October 11, 2021 have 
not been met. Therefore, we decided that the Plan does not have to pay for the inpatient skilled nursing facility 
(SNF) care provided from October 1, 2021, through October 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service April 29, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that this service was necessary and is supported 
in the medical record. The Plan denied your request. The Plan says procedure code 99100 is considered 
bundled and 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 procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service April 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial maxillary denture adjustment (D5421), a 
comprehensive oral evaluation (D0150), and intraoral imaging (D0210), provided by an out-of-network 
provider. 
 
You asked the Plan to pre-approve the dental services. You say that you need these services done. The Plan 
denied your request. The Plan says dental services from an out-of-network provider 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. 
 
You are requesting 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 pre-approve a partial 
maxillary denture adjustment (D5421), a comprehensive oral evaluation (D0150), and intraoral imaging 
(D0210), provided by an out-of-network provider.
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 the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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. Our 
physician reviewer found the enrollee does not require the intensity of services provided at an IRF. 
Specifically, the enrollee is not shown to be able to tolerate fifteen hours per week of rehabilitative services and regular physician evaluation. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), and a panoramic 
radiographic image (D0330) provided on May 23, 2022. 
 
You asked the Plan to pay for the dental services. You say that you thought the services would be covered. The 
Plan denied your request. The Plan says your benefit for the services 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested items or services was exhausted on date of service April 27, 2022. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), and a 
panoramic radiographic image (D0330) provided on May 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 8, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider is out-of-network, and it was determined 
these services can be received in-network. 
 
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 an office visit provided on June 8, 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 August 27, 2021 billed with 
codes 81225, 81226, 81230, 81240, 81241, 81291, & 81335 
. 
 
You asked the Plan to pay for the genetic testing billed. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
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 
August 27, 2021 billed with codes 81225, 81226, 81230, 81240, 81241, 81291, & 81335 
.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services rendered on December 20, 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 28320 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 28320 is repair, nonunion or malunion; tarsal bones. 
 
We find that CPT code 28320 is not supported in the medical record. Specifically, there is no documentation of 
repair of a nonunion or malunion of tarsal bones. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met.  
 
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 20680 is a column II code to column I code 
20670. 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 the surgical services rendered on December 20, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2740) and a core build-up (D2950) provided by a 
participating provider on April 7, 2022. 
 
You asked the Plan to pay for a crown and a core build-up. You say that you should be covered for one crown a 
year. The Plan denied your request. The Plan says the rendered dental services are not covered 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 crown 
(D2740) and a core build-up (D2950) provided by a participating provider on April 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy-duty extra wide hospital bed represented by 
code E0303. 
 
You asked the Plan to pre-approve E0303. You say that you suffer with back leg and neck issues. You say that 
you had a bed but that you had to take it back because it was too small. You say that you are currently sleeping 
on the floor. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that a heavy duty extra wide hospital bed is covered 
if the beneficiary meets one of the criteria for a fixed height hospital bed and the beneficiary's weight is more 
than 350 pounds but does not exceed 600 pounds. 
 
We looked at the file and Medicare rules. The records show that you weigh 176 pounds. Based on this 
information, we decided that Medicare rules for coverage of E0303 have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a heavy-duty extra wide hospital bed represented by code E0303.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an endodontic therapy (D3330) provided by an out-of-
network provider on May 5, 2022. 
 
You asked the Plan to pay for an endodontic therapy. You say that you were told that you were covered. The 
Plan denied your request. The Plan says the rendered dental work 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 an 
endodontic therapy (D3330) provided by an out-of-network provider on May 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay the full amount for a filling (D2391) for tooth #5 provided on 
June 9, 2022. 
 
You asked the Plan to pay the full amount for the dental service. You say that this dental procedure should have 
been covered. The Plan denied your request. The Plan says you have been charged the correct cost sharing 
amount. Your contract with the Plan clearly says that you must pay 20% coinsurance for Class 2 basic services. 
The Plan also says that the filling was paid at the allowed amount of an amalgam, as this would be the least 
costly method of treatment. 
 
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 processed filling at the least costly 
method of a metal crown. 
 
The record shows the Plan paid their share of your filling under code D2140, which is a amalgam filling. You 
have been asked to pay $61.80 for the filling for tooth #18. This means 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 pay the full amount for a 
filling (D2391) for tooth #5 provided on June 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral exam (D0120) with caries risk assessment 
(D0603) and bitewing X-rays (D0274) provided on May 24, 2022. 
 
You asked the Plan to pay for the dental services. You say that the dental office assured you that the services 
would be covered in full. 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 May 6, 2022. Therefore, 
we decided that the Plan does not have to pay for the periodic oral exam (D0120) with caries risk assessment 
(D0603) and bitewing X-rays (D0274) provided on May 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gloves. 
 
You asked the Plan to pre-approve gloves. You say that the enrollee is dependent on others to take care of him 
due to his diagnosis and condition. You say that the enrollee needs assistance with bathing, toileting, and 
general activities of daily living (ADLs.) You say that, due to hygiene concerns, it is highly recommended if 
not mandatory for health aids to be wearing gloves when assisting with care. The Plan denied your request. The 
Plan says the requested items are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.  The rules also say that Medicare does not pay for OTC items.  
 
Gloves do not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Gloves are considered an OTC item. Therefore, 
we decided that the Plan does not have to pre-approve gloves.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve eight physical therapy visits. 
 
You asked the Plan to pre-approve therapy visits. You say that the additional physical therapy is medically 
necessary. The Plan denied your request. The Plan says the remaining eight physical therapy visits are not 
medically necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy visits. Our reviewer says that 
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that the provided records do not document any acute or unstable 
medical conditions or injuries which would necessitate any further skilled therapy visits beyond what have 
already been approved. The two additional therapy visits approved should be adequate to teach a home exercise 
program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of therapy visits have not been met. Therefore, we decided that the Plan does not 
have to pre-approve eight physical therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Dexcom G6 sensor.

You asked the Plan to pre-approve a Dexcom G6 sensor. You say that you disagree with the Plan's denial. The Plan denied your request. The Plan says you do not meet criteria for the requested device.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan.



We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a Dexcom G6 sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G6 sensor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oxygen concentrator and shipping charges received on 
March 11, 2022. 
 
You asked the Plan to pay for the oxygen concentrator and shipping charges. You say that you disagree with 
the Plan's denial. The Plan denied your request. The Plan says payment cannot be made for items received by a 
provider who has opted out of the Medicare program. 
 
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 items 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 the 
oxygen concentrator and shipping charges received on March 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Vitamin D, 25 hydroxy, includes fraction(s), if performed 
(82306) provided May 19, 2022. 
 You asked the Plan to pay for the laboratory service. You say that you are asking for an appeal review of the 
vitamin D denied test. Please see the attached notes showing why the provider ordered the test. The Plan denied 
your request. The Plan says this service is not a Medicare benefit for the diagnoses listed on the claim and is 
done for screening purposes. 
 
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. 
 
The test at issue in this appeal, the laboratory service, was requested solely for screening purposes. Medicare 
does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay 
for Vitamin D, 25 hydroxy, includes fraction(s), if performed (82306) provided May 19, 2022.