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

 
We decided that the Plan does not have to pay for the cardiac risk assessment genetic screening testing (CPT 
code 81404) provided on April 14, 2021. 
 
You asked the Plan to pay for the cardiac risk assessment genetic screening testing. You say that the claim 
should be paid. The Plan denied your request. The Plan says prior to cardiovascular genetic testing, for chief 
complain of follow-up. 
 
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 cardiac risk assessment genetic screening testing, 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 the cardiac risk assessment genetic screening testing (CPT code 81404) 
provided on April 14, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implantation of the Aurora Spine ZIP Interspinous 
Fixation device. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that the clinical value and effectiveness of the Aurora Spine ZIP 
Interspinous Fixation device in the setting of spinal stenosis has not been demonstrated in the peer-reviewed 
literature. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. There is limited 
published, large-scale, long-term peer-reviewed literature that shows this request to be an effective and/or safe treatment for the noted pathology. There is no compelling rationale presented or extenuating circumstances 
noted to support the medical necessity of this request as an exception. Our physician reviewer found that the 
enrollee's condition does not meet criteria for coverage of these services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve implantation of the Aurora Spine ZIP Interspinous Fixation device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable control system. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
enrollee is able to control the power options using their own switches. 
 
The Plan follows Medicare rules. Medicare rules say that wheelchair options and accessories are only covered 
under certain medical indications.  
 
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 requested services. Our physician 
reviewer found that the enrollee has a medical history including paraplegia, previous right lower extremity 
amputation and nerve pain. She has been authorized to have a group 3 power wheelchair with multiple power 
options. The requested electrical accessories are not considered medically necessary. The enrollee does have 
use of the upper extremity and can operate and control the power options using the switches that are included in 
the basic wheelchair. 
 
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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an expandable control system.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive orthodontic treatment of the adult 
dentition (D8090). 
 
You asked the Plan to pre-approve a comprehensive orthodontic treatment. You say that you are in pain and 
unable to eat properly. The Plan denied your request. The Plan says this service is not covered under your plan. 
 
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 
comprehensive orthodontic treatment of the adult dentition (D8090).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99053 billed for date of service March 3, 2021. 
 You asked the Plan to pay for procedure code 99053. You say that these services were billed correctly. The 
Plan denied your request. The Plan says separate payment is not made for this service. 
 
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 99053 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99053 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of procedure code 99053 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 99053 billed for date of service March 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lower extremity prosthesis, not otherwise specified 
(L5999). 
 
You asked the Plan to pre-approve a lower extremity prosthesis. You say that the requested item is needed for 
your replacement prosthetic leg. The Plan denied your request. The Plan says this item is experimental or 
investigational. Since this component is experimental and not found to be safe and effective, it is not reasonable 
and necessary for your condition. A standard socket has been approved.  
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 L5999 must not be used to bill for any features or functions included in the socket or 
addition codes. Specifically, use of code L5999 is incorrect coding, unbundling. Based on this information, we 
decided that Medicare rules for coverage of a lower extremity prosthesis have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a lower extremity prosthesis, not otherwise specified 
(L5999).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services provided from January 7, 2020, to June 
17, 2020 by the out of network dentist. 
 
You asked the Plan to pay for the dental services. You say that you did not know you only had a 12 month time 
limit on submitting the claim. The Plan denied your request. The Plan says  
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the dental services was not filed until February 22, 2022. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the dental services provided from January 7, 2020, to June 17, 
2020 by the out of network dentist.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 81230, 81240, 81241, 
81249, 81291, and 81408) provided on August 12, 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. 
 
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. Therefore, we decided that the Plan does not have to pay for the 
laboratory services (CPT code(s): 81230, 81240, 81241, 81249, 81291, and 81408) provided on August 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the removal of torus mandibularis (D7473), and conscious 
sedation (D9243, D9239) provided on January 19, 2022. 
 
You asked the Plan to pay for the dental services. You say that it was your understanding with the plan 
representative that all procedures would be covered along with sedation. The Plan denied your request. The 
Plan says the claim denied 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, the removal of torus mandibularis is 
not among those covered under this benefit. The record shows that conscious sedation is only covered with other covered services. Since the primary service is not covered, neither is the sedation. Therefore, we decided 
that the Plan does not have to pay for the removal of torus mandibularis (D7473), and conscious sedation 
(D9243, D9239) provided on January 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removal of impacted tooth - soft tissue (D7220). 
 
You asked the Plan to pre-approve removal of impacted tooth. You say that the enrollee needs this service. The 
Plan denied your request. The Plan says this service is not covered under the enrollee's 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 
removal of impacted tooth - soft tissue (D7220).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services for a patient of extreme age (99100) 
provided on July 17, 2021.  
You asked the Plan to pay for anesthesia services for a patient of extreme age. You say that you have provided 
records to support the service billed. 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 must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99100 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99100 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of anesthesia services for a patient of extreme age have not been met. Therefore, we decided that the Plan does 
not have to pay for anesthesia services for a patient of extreme age (99100) provided on July 17, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from July 
4, 2021, through July 14, 2021. 
 
You asked the Plan to pay for the SNF services. You say that it is felt that Medicare payment can be made for 
these services. The Plan denied your request. The Plan says upon review, it was decided to approved payment 
for a set of the dates at issue. However, the enrollee did not have daily skilled needs from July 4 through July 14. 
 
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 services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee is a 51-year-old female who 
was hospitalized due to a fall and pneumonia. From a nursing perspective, the beneficiary received oral 
medications. The beneficiary had stable vital signs. She was treated for insomnia. Her oral intake was good, 
and her lungs were clear. Regarding rehabilitation services, the beneficiary received physical and occupational 
therapy evaluations only and was independent with functional mobility and daily living activities. 
 
There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. 
For the dates at issue, this beneficiary did not meet severity of illness or intensity of service criteria for an 
inpatient basis 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 services have not been met. Therefore, we decided that the Plan does 
not have to pay for the skilled nursing facility (SNF) services provided from July 4, 2021, through July 14, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a diagnostic mammogram and 
tomosynthesis performed on September 8, 2021. 
 
You asked the Plan to waive the coinsurance for the mammogram and tomosynthesis. You say that the extra 
imaging was part of your preventive visit and should be covered. The Plan denied your request. The Plan says 
the correct coinsurance was applied. 
 
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 no coinsurance, copayment, or deductible for screening mammograms. A separate cost sharing may apply if 
additional services are provided. 
 
Your contract with the Plan also clearly says that you must pay a 20% coinsurance for outpatient X-rays. 
 
Service Allowed Amount 20% Coinsurance 
Diagnostic Mammogram $95.97 $19.19 
Tomosynthesis $26.74 $5.35 
Total:  $24.54 
 
The record shows you had additional diagnostic imaging on the left breast. Therefore, you have been asked to 
pay $24.54, which is 20% of the allowed amount for the mammogram and tomosynthesis. The mammogram 
and tomosynthesis fall within the Breast Cancer Screening 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 coinsurance for a diagnostic mammogram and tomosynthesis performed on September 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an addition, endoskeletal system, above knee or hip 
disarticulation, alignable system (L5920) and an addition to lower extremity, test socket, hip disarticulation 
(L5626). 
 
You asked the Plan to pre-approve an alignable system feature and a test socket. You say that you desperately 
need your prosthetic leg that was recommended. The Plan denied your request. The Plan says the notes do not 
show why a third socket is reasonable and necessary. The Plan also says that the notes do not show that an 
alignable system is damaged beyond repair and cannot be used for approved socket. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a physician 
order. 
 
The record does not contain a valid physician order, or relevant medical records which support medical 
necessity for the supplies provided in this case. Medicare rules show that more than 2 sockets are not 
reasonable and necessary unless there is documentation in the medical record that justifies the need. You have 
been approved for 2 sockets. The record does not show why a third socket is reasonable or necessary. The 
record also does not show why your current alignable system cannot be used with the replacement socket. 
Therefore, we decided that the Plan does not have to pre-approve an addition, endoskeletal system, above knee 
or hip disarticulation, alignable system (L5920) and an addition to lower extremity, test socket, hip 
disarticulation (L5626).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical placement of implant body: endosteal implant 
(D6010), deep sedation/general anesthesia  first 15 minutes (D9222) and deep sedation/general anesthesia  
each subsequent 15-minute increment (D9223) provided May 6, 2021. 
 
You asked the Plan to pay for the endosteal implant and deep sedation/general anesthesia. You say that the 
providre waited more than 6 months after the services were rendered before submitting the claim. The Plan 
denied your request. The Plan says you have exhausted your dental allowance for 2021. 
 
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 the endosteal 
implant up to a $1,500 maximum payment per person total per Benefit Year on all services. 
 
We looked at the file and Medicare rules. At the time the claim was processed, you had reached your annual maximum payment amount. Therefore, we decided that the Plan does not have to pay for the surgical 
placement of implant body: endosteal implant (D6010), deep sedation/general anesthesia  first 15 minutes 
(D9222) and deep sedation/general anesthesia  each subsequent 15-minute increment (D9223) provided May 
6, 2021.  
 
Your complaint about the amount of time between when the services were rendered and when the claim was 
submitted and processed 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81206, 81210, 81235, 81275, 81276, 
81301, 81311, 81321, 81309 and 81194) provided on August 11, 2021. 
 You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says this claim has denied correctly. 
 
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 (81206, 81210, 81235, 81275, 81276, 81301, 
81311, 81321, 81309 and 81194) provided on August 11, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81321, 81206, 81210, 81235, 81272, 
81275, 81276, 81292, 81301, and 81311) provided on July 28, 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 providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT code 81479. Therefore, we decided that the Plan does not have 
to pay for the laboratory services (81321, 81206, 81210, 81235, 81272, 81275, 81276, 81292, 81301, and 
81311) provided on July 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the adjunctive pre-diagnostic dental test (dental code D0431) 
you received on January 1, 2022. 
 
You asked the Plan to pay for the adjunctive pre-diagnostic dental test. You say that due to your underlying 
medical issues, you need to do a deep cleaning on your teeth to prevent bacteria that can affect your health 
conditions. You said that your dentist recommended this procedure. The Plan denied your request. The Plan 
says this service is not covered under your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan's dental benefit 
includes coverage only for the specific dental codes listed in your dental benefits chart. Dental code D0431 is 
not listed as a covered service, regardless of the medical necessity of the service. 
 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 
adjunctive pre-diagnostic dental test (dental code D0431) you received on January 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diagnostic casts (D0470) provided on March 3, 2022. 
 
You asked the Plan to pay for the dental service. You say that your dental card indicates a $0 copayment. The 
Plan denied your request. The Plan says diagnostic cast is not listed as a covered service. 
 
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 diagnostic cast is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the diagnostic casts 
(D0470) provided on March 3, 2022.