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

 
We decided that the Plan does not have to pay for the laboratory services (81404 and 81479) provided on May 
4, 2021. 
 
You asked the Plan to pay for the laboratory services (81404 and 81479). 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. 
 
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 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 laboratory 
services (81404 and 81479) provided on May 4, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on March 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 were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.  
 
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results 
and was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on March 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81206 and 81292) provided on 
September 29, 2021. 
 
You asked the Plan to pay for codes 81206 and 81292. 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 (81206 and 81292) provided on September 29, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the behavioral assessment services (96127) provided on 
December 22, 2021. 
 
You asked the Plan to pay for code 96127. 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. In this case, we have confirmed that code 96127 
is a column II code to column I code 90837 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for the behavioral assessment services (96127) provided on December 22, 2021.
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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically necessary.

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 treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation 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 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 pre-approve the various dental services (D4341, D4381, D4921, 
D9630, D0210, and D0150) provided from March 14, 2022, through March 22, 2022. 
 
You asked the Plan to pre-approve the various dental services. You say that you believe you are being 
overcharged for the services you received. The Plan denied your request. The Plan says the claims have 
processed correctly based on the Plan's contract. 
 
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 periodontal scaling and 
root planing, delivery of antiomicrobial agents, gingival irrigation, and drugs or medication are not among 
those covered under this benefit. In addition, coverage had already been exhausted for the comprehensive oral 
exam and complete X-ray services Therefore, we decided that the Plan does not have to pre-approve the various dental services (D4341, D4381, D4921, D9630, D0210, and D0150) provided from March 14, 2022, 
through March 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hospital outpatient clinic visit (G0463) and related services 
(36415, 86592, 86695, 86696, 93005, G0402) provided on August 24, 2021. 
 
You asked the Plan to pay for a hospital outpatient clinic visit. You say that you have provided records to 
support the services 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 the denied codes are not supported in the medical record. Specifically, a review of the file shows 
that the claim was not billed with condition code G0. Billing multiple medical visits in the same day requires 
this condition code. Based on this information, we decided that Medicare rules for coverage of a hospital 
outpatient clinic visit have not been met. Therefore, we decided that the Plan does not have to pay for a hospital 
outpatient clinic visit (G0463) and related services (36415, 86592, 86695, 86696, 93005, G0402) provided on 
August 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the restorative dental procedure (code D2999) and the 
prefabricated post and core addition to crown (code D2954) you received on February 15, 2022. 
 
You asked the Plan to pay for the restorative dental procedure (code D2999) and the prefabricated post and 
core addition to crown (code D2954). You say that you lost a crown while you were traveling and were able to 
get it repaired.  You said that because this was an emergency procedure, this should be covered. The Plan 
denied your request. The Plan says these services are not covered under your dental benefit. 
 
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. This benefit includes coverage 
only for those dental services explicitly listed in your Comprehensive chart.  Neither code D2999 
nor code D2954 are listed as covered services in this chart.  This means these services are not covered for any 
reason, including emergencies or when you are out-of-area.  
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 
restorative dental procedure (code D2999) and the prefabricated post and core addition to crown (code D2954) 
you received on February 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services you received from April 3, 2019, to October 
9, 2019. 
 
You asked the Plan to pay for the dental services. You say that your dental center was not aware of your dental 
coverage. The Plan denied your request. The Plan says you did not file your claim for these dental services in a 
timely manner. 
 
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 16, 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 dental services you received from April 3, 2019, to October 9, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hot or cold pack therapy (97010) provided on January 12, 2022. 
 
You asked the Plan to pay for code 97010. 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 CPT code 97010 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 97010 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of code 97010 have not been met. Therefore, we decided that the Plan does not have to pay for the hot or cold 
pack therapy (97010) provided on January 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay additionally for the dental services (D0330 and D0140) provided 
on February 9, 2022. 
 
You asked the Plan to pay additionally for dental codes D0330 and D0140. You say that you would like the 
Plan to reconsider your request. The Plan denied your request. The Plan says your dental provider is an out-of-
network provider. Non-network dentists have not agreed to provide services at contracted fees. If a member 
sees an out-of-network dentist, the coinsurance level will apply to the average negotiated in-network fee 
schedule (INFS) in their area. The member is responsible for the difference between the INFS and dentists' 
charged fees when visiting an out-of-network dentist per your contract with the 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. 
 
We looked at the file and the Plan's contract. The file shows that your dental provider is an out-of-network provider. Non-network dentists have not agreed to provide services at contracted fees. If a member sees an out-
of-network dentist, the coinsurance level will apply to the average negotiated in-network fee schedule (INFS) 
in their area. The member is responsible for the difference between the INFS and dentists' charged fees when 
visiting an out-of-network dentist per your contract with the Plan. Therefore, we decided that the Plan does not 
have to pay additionally for the dental services (D0330 and D0140) provided on February 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gingival irrigation (D4921) provided on February 19, 2022. 
 
You asked the Plan to pay for gingival irrigation. You say that the services at issue were a necessity for your 
care. The Plan denied your request. The Plan says rules for payment for dental services have not been met. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for gingival 
irrigation (D4921) provided on February 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that you are having back pain after being on your 
feet for a period of time because of the unevenness in your legs. The Plan denied your request. The Plan says 
this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection of chemical agent into multiple incompetent 
veins of one leg. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this 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 pre-approve the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the documentation does not support the medical necessity of the treatment in question. There are no 
complaints referable to her varicose veins. It is documented numerous times that she has no edema or 
ulcerations. Bulging varicose veins and spider veins are documented; the the status of her arterial perfusion is 
unclear. It is not medically necessary to treat asymptomatic varicose veins and spider veins. 
 
 
 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 not been met. Therefore, we decided that the Plan does not 
have to pre-approve injection of chemical agent into multiple incompetent veins of one leg.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prophylaxis (D1110) provided by an out-of-network provider 
on February 24, 2022. 
 
You asked the Plan to pay for prophylaxis. You say that you were never informed that this provider was out-of-
network. The Plan denied your request. The Plan says services provided by an out-of-networ provider are not 
covered. 
 
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 prophylaxis 
when the services are medically necessary and reasonable.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of prophylaxis have not been met. Therefore, we decided that the Plan does not have to pay for 
prophylaxis (D1110) provided by an out-of-network provider on February 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power mobility device and related accessories.
You asked the Plan to pre-approve a power mobility device. You say that this device is medically necessary for your condition. The Plan denied your request. The Plan says this is not covered by Medicare or the Plan.
The Plan follows Medicare rules. Medicare rules say that a power mobility device is subject to the criteria listed 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 a power mobility device. Our reviewer says that the requested power mobility device is not medically reasonable and necessary. Our physician reviewer found that you have a mobility deficit due to being a bilateral lower extremity amputee. The documentation indicates that you have pain which impacts the ability to perform MRADLs safely. You also appear to be able to perform feeding, grooming, dressing and toileting and transfers currently independently per a March 8 wheelchair assessment. The documentation does not reveal objective treating physician exam findings in a medical progress report supporting that the patient requires a power wheelchair. There are no objective physician physical exam findings of strength, endurance, range of motion, or coordination, presence of pain, or deformity or absence of one or both upper or lower extremities. The documentation is not clear that the home is appropriate for a wheelchair as there are no objective detailed measurements of the home indicating that your home provides adequate access between rooms, maneuvering space, and surfaces for use of the manual wheelchair that is requested. The criteria for coverage have not been met for the requested base power wheelchair and the subsequent accessories. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a power mobility device have not been met. Therefore, we decided that the Plan does not have to pre-approve a power mobility device and related accessories.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cone beam computed tomography (dental code D0365) 
you received on January 24, 2022. 
 
You asked the Plan to pay for the cone beam computed tomography. You say that this service was needed to be 
able to tell if your bone graft was accepted. 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. Your Plan's dental benefit 
includes coverage only for those dental services explicitly listing in your Evidence of Coverage's Benefit Chart. 
Cone beam computed tomography (code D0365) is not listed as a covered 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 cone 
beam computed tomography (dental code D0365) you received on January 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive periodontal evaluation - new or 
established patient (D0180) provided January 25, 2022. 
 
You asked the Plan to pay for the comprehensive periodontal exam. You say that you would like this service 
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 
comprehensive periodontal evaluation - new or established patient (D0180) provided January 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the special anesthesia service (99100) provided on 
November 19, 2021. 
 You asked the Plan to pay for code 99100. 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 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 code 99100 have not been met. Therefore, we decided that the Plan does not have to pay for the special 
anesthesia service (99100) provided on November 19, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips (A0100). 
 
You asked the Plan to pre-approve additional trips. You say that you need more trips. The Plan denied your 
request. The Plan says additional trips beyond the 24 allowed per year are not covered. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage.  For that reason, the Plans coverage rules apply in this case. The Plan covers a maximum of 24 one-way trips 
per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips (A0100).