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

 
We decided that the Plan does not have to pre-approve general anesthesia (D9222, D9223) and therapeutic 
parenteral drugs (D9610). 
 
You asked the Plan to pre-approve anesthesia and drug administration. You say that these services are 
necessary for the enrollee's dental procedure. The Plan denied your request. The Plan says these services are 
not covered by the Plan's dental 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 pre-approve 
general anesthesia (D9222, D9223) and therapeutic parenteral drugs (D9610).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on August 12, 2021 billed with 
codes 81230, 81291, 81240, 81241, 81335. 
 
You asked the Plan to pay for the genetic testing billed. You say that the medical records provided support the 
necessity of the services in dispute. The Plan denied your request. The Plan says does not meet Medicare 
NCD/LCD criteria. 
 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 12, 2021 billed with codes 81230, 81291, 81240, 81241, 81335.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the consultation (D9310) and panoramic x-ray (D0330) 
provided on May 23, 2022. 
 
You asked the Plan to pay for the consultation and panoramic x-ray. You say that you believe these services 
should be covered. The Plan denied your request. The Plan says the consultation is not covered under the Plan. 
The Plan also says that the panoramic x-ray exceeds the maximum allowed per period. 
 
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 consultation (D9310) is not among 
those covered under this benefit. The contract says that panoramic x-ray (D0330) is limited to one procedure 
every three plan years. The record shows that you received a panoramic x-ray (D0330) on September 2, 2021, 
and your panoramic x-ray (D0330) benefit has been exhausted. Therefore, we decided that the Plan does not 
have to pay for the consultation (D9310) and panoramic x-ray (D0330) provided on May 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for extractions (D7140 x2, D7210), and removal of torus 
mandibularis (D7473) provided on December 23, 2021. 
 
You asked the Plan to pay for the dental services. You say that you want the Plan to pay for these services. The 
Plan denied your request. The Plan says your benefit for the extractions has already been exhausted. 
Additionally, removal of torus mandibularis 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, certain limitations apply. The record 
shows your benefit for the extractions was exhausted on date of service December 23, 2021. Additionally, 
removal of torus mandibularis is not a covered benefit. Therefore, we decided that the Plan does not have to 
pay for extractions (D7140 x2, D7210), and removal of torus mandibularis (D7473) provided on December 23, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for biologic materials to aid in tissue regeneration (D4265) 
provided on May 4, 2022. 
 
You asked the Plan to pay for biologic materials to aid in tissue regeneration. You say that you cannot afford to 
pay these charges. The Plan denied your request. The Plan says the service at issue 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 biologic 
materials to aid in tissue regeneration (D4265) provided on May 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care provided on February 11, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the nursing facility care. You say that it is the facilities responsibility to obtain 
prior authorization and you would like reimbursement for the service provided. The Plan denied your request. 
The Plan says the rendering provider is an OON provider and there was no approved 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 nursing facility care provided on February 11, 
2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an amalgam (D2140) provided by a participating provider on 
June 2, 2022. 
 
You asked the Plan to pay for an amalgam. You say that you disagree with these services. The Plan denied 
your request. The Plan says the correct charges have been applied. 
 
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. 
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of an amalgam have been met and the claim has been processed correctly. Therefore, we decided that 
the Plan does not have to pay for an amalgam (D2140) provided by a participating provider on June 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a limited oral evaluation (D0140), and an intraoral 
periapical radiographic image (D0220) provided on May 2, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you want the Plan to pay for these 
services. The Plan denied your request. The Plan says you are responsible for any charged amount above the 
Plans cost-sharing amount when your services are received from an out-of-network provider. 
 
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 have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 more for a limited oral evaluation (D0140), and an 
intraoral periapical radiographic image (D0220) provided on May 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system (E2300). 
 
You asked the Plan to pre-approve a power seat elevation system. You say that you have limited mobility and 
have been updated to fit the need for a power wheelchair. The Plan denied your request. The Plan says 
Medicare does not consider the power seat elevation to be medical in nature and therefore it is not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does 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. Therefore, we 
decided that the Plan does not have to pre-approve a power seat elevation system (E2300).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Continuous intraoperative neurophysiology monitoring 
(G0453) provided on May 3, 2022. 
 
You asked the Plan to pay for code G0453. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the records do not support the billing of code G0453. 
 
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 G0453 is Continuous intraoperative neurophysiology 
monitoring, from outside the operating room (remote or nearby), per patient, (attention directed exclusively to one patient) each 15 minutes (list in addition to primary procedure). 
 
We find that CPT code G0453 is not supported in the medical record. Specifically, the submitted medical 
records do not indicate the monitoring time to support that continuous intraoperative neurophysiology 
monitoring, from outside the operating room, each 15 minutes was performed. Based on this information, we 
decided that Medicare rules for coverage of code G0453 have not been met. Therefore, we decided that the 
Plan does not have to pay for the Continuous intraoperative neurophysiology monitoring (G0453) provided on 
May 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Mass spectrometry and tandem mass spectrometry 
(83789) provided on April 4, 2022. 
 
You asked the Plan to pay for code 83789. 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 providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of code 83789 have not been met. Specifically, we find that the testing described by the billed code is 
considered specimen validity testing which is not separately payable. Therefore, we decided that the Plan does 
not have to pay for the Mass spectrometry and tandem mass spectrometry (83789) provided on April 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 24 units of ultrasonic guidance for 
radiation therapy (G6001). 
 
You asked the Plan to pre-approve 24 units of ultrasonic guidance. You say that the requested services are a 
medical necessity for the enrollee. The Plan denied your request. The Plan says medical-necessity rules for 
coverage of the requested services have not been met. 
 
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 pre-approve 24 units of ultrasonic guidance. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found that the requested services are a technology for which need has not been 
established by published data or supported by consensus guidelines.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 24 units of ultrasonic guidance have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an additional 24 units of ultrasonic guidance for radiation therapy 
(G6001).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mass spectrometry testing (83789) billed for date of service 
March 16, 2022. 
 
You asked the Plan to pay for mass spectrometry testing. You say that you have provided medical records to 
support the services at issue. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of mass spectrometry testing have not been met. Specifically, we find that the testing described by the 
billed code is considered specimen validity testing which is not separately payable. Therefore, we decided that 
the Plan does not have to pay for mass spectrometry testing (83789) billed for date of service March 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 18, 2022, billed with 
codes 81227, 81230, 81231, 81232, 81306, 81328, 81335, 81401, 0031U, 0032U, and 0033U. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like this claim reprocessed 
based on the medical records. The Plan denied your request. The Plan says this claim has not been billed as 
required by Medicare billing regulations. 
 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 
March 18, 2022, billed with codes 81227, 81230, 81231, 81232, 81306, 81328, 81335, 81401, 0031U, 0032U, 
and 0033U.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an endosteal implant on tooth #19 (D6010), 
prefabricated abutment on tooth #19 (D6056), and an abutment supported crown on tooth #19 (D6058). 
 
You asked the Plan to pre-approve the dental services. The Plan denied your request. The Plan says an 
endosteal implant (D6010), prefabricated abutment (D6056), and an abutment supported crown (D6058) are 
not covered by your routine dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 an 
endosteal implant on tooth #19 (D6010), prefabricated abutment on tooth #19 (D6056), and an abutment 
supported crown on tooth #19 (D6058).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the four removals of lateral exostosis (D7471 x4) and 
therapeutic parenteral drug (D9610) provided on March 24, 2022. 
 
You asked the Plan to pay for the removals of lateral exostosis and therapeutic parenteral drug. You say that 
you would like to be reimbursed for the over payment you made. The Plan denied your request. The Plan says 
these services are not covered expenses under your dental plan. The Plan also says that you did not contact the 
Plan prior to the date of service to verify benefits and provider eligibility. 
 
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 four 
removals of lateral exostosis (D7471 x4) and therapeutic parenteral drug (D9610) provided on March 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home health visit provided on April 28, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the home health visit. You say that the service provided to the enrollee was 
medically necessary and you would like the claim processed for payment. 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 a home health visit provided on April 28, 2022, by 
an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the upper partial denture (D5225) provided on January 28, 
2021. 
 
You asked the Plan to pay for the dental item. You say that you were in an accident on September 9, 2020. You 
say that a month later your teeth began to hurt. You say that you were advised you needed another root canal 
and implant or a bridge. You also say that you were advised it would be covered 100% under medical. The Plan denied your request. The Plan says the partial denture was dental in nature. The Plan also says the denture 
is not covered under your medical coverage. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for the upper partial denture (D5225) 
provided on January 28, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the magnetic resonance imaging, spinal canal and
contents (72148).

You asked the Plan to pre-approve the MRI. You say that you are appealing the denial. The Plan denied your
request. The Plan says the requested MRI is not reasonable and necessary under Medicare guidelines.

The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 MRI. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the enrollee has a normal neuro exam and there are no red flags to mandate immediate MRI
exam. The enrollee had a physical therapy (PT) evaluation of August 5, 2022 and PT was unable to reproduce
the symptoms and the enrollee was discharged from PT, so the required 6 week trial for same is not relevant.
Of note, an electromyography or nerve conduction study has not been done and there is no plain x-ray report of
the lumbar spine. There is no evaluation by neurology or ortho to direct the workup. Without any of these items
the medical necessity of MRI of the lumbar spine has not been established.

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 MRI have not been met. Therefore, we decided that the Plan does not have
to pre-approve the magnetic resonance imaging, spinal canal and contents (72148).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 18, 2022. 
 
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 the DOS of the test/service must be the date the 
specimen was collected. 
 
We find that code 0242U is not supported in the medical record. Specifically, there is no documentation 
describing genetic testing on a sample collected on the date of service at issue. Therefore, we decided that the 
Plan does not have to pay for the laboratory services provided on January 18, 2022.