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

 
We decided that the Plan does not have to pay for the genetic testing provided on July 30, 2021, billed with 
codes 81408, 81407, 81439 and 81286. 
 
You asked the Plan to pay for the genetic testing billed. You say that these services were medically necessary 
and are supported in the medical record. The Plan denied your request. The Plan says these services were not 
billed appropriately. 
 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 
July 30, 2021, billed with codes 81408, 81407, 81439 and 81286.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for frames (V2025), progressive lenses (V2781), anti-reflective 
coating (V2750), a visual field examination (92081), the taking of fundus photographs (92250), and a 
refraction and any necessary prescription of lenses (92015) provided on June 1, 2022. 
 
You asked the Plan to pay for frames (V2025), progressive lenses (V2781), anti-reflective coating (V2750), a 
visual field examination (92081), the taking of fundus photographs (92250), and a refraction and any necessary 
prescription of lenses (92015). You say that you contacted the provider and the provider verified that you were 
covered prior to your exam. You also say that after your tests and fitting, the technician advised your out-of-
pocket expense would be $720. You also say that you are being asked to pay an additional $220. The Plan 
denied your request. The Plan says according to the members EOC, he/she is responsible for any amount over 
the $130 for the routine eye exam. The Plan also says that the other services are not covered because they do 
not meet the criteria for coverage.  
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers outpatient physician services for the diagnosis and treatment of diseases and injuries 
of the eye, including treatment for age-related macular degeneration, and one pair of eyeglasses or contact 
lenses after each cataract surgery that includes insertion of an intraocular lens. The Plan excludes eye testing 
and eye imaging services are excluded from this benefit. 
 
We looked at the file and the Plan's rules. The coverage of frames, progressive lenses, anti-reflective coating, a 
visual field examination, the taking of fundus photographs, and a refraction and any necessary prescription of 
lenses, are not covered by the Plan since they do not meet the necessary criteria. Based on this information, we 
decided that the Plan's rules for coverage of frames (V2025), progressive lenses (V2781), anti-reflective 
coating (V2750), a visual field examination (92081), the taking of fundus photographs (92250), and a 
refraction and any necessary prescription of lenses (92015) have not been met. Therefore, we decided that the 
Plan does not have to pay for frames (V2025), progressive lenses (V2781), anti-reflective coating (V2750), a 
visual field examination (92081), the taking of fundus photographs (92250), and a refraction and any necessary 
prescription of lenses (92015) provided on June 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing procedures (83789) for a drug-test specimen 
billed for date of service April 8, 2022. 
 
You asked the Plan to pay for validity testing. You say that you have provided medical 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 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 validity 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 validity testing procedures (83789) for a drug-test specimen billed for date of 
service April 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical extractions (D7210) of tooth #'s 16 and 32. 
 
You asked the Plan to pre-approve the surgical extractions. The Plan denied your request. The Plan says there 
is no submitted evidence to suggest a need for a surgical approach for tooth #'s 16 and 32. 
 
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 surgical 
extractions when the services are medically necessary and reasonable.  
 
 
  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 surgical extractions. Our reviewer 
says that the requested surgical extractions of teeth #16 and #32 would not be considered medically necessary 
at this time. Our physician reviewer found tooth #16 is noted as being over-erupted and periodontally involved, 
and would not clearly require any removal of bone in order to extract the tooth. Tooth #32 is also noted as 
having periodontal involvement. Our reviewer found that the supplied documentation does not include any 
clinical notes that indicate that bone had to be removed in order to remove either tooth. Our physician reviewer 
also found that as there is no clear indication that bone has to be removed, and the condition of the supporting 
bone was already compromised, there would be no medical necessity for the requested surgical extractions of 
tooth #'s 16 or 32. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the surgical extractions have not been met. Therefore, we decided that the Plan 
does not have to pre-approve surgical extractions (D7210) of tooth #'s 16 and 32.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services billed with codes 80053, 85025, and 86769 
provided on March 16, 2022. 
 
You asked the Plan to pay for the lab services. You say that you have provided medical records to support 
payment. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 The Plan must follow Medicare rules. Medicare rules say that, for 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 lab 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 lab services billed with codes 80053, 85025, and 86769 provided on March 
16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 4 standard, power wheelchair (K0878) and a 
bath/shower chair (E0240). 
 You asked the Plan to pre-approve a power wheelchair and a bath/shower chair. You say that the requested 
items are medically necessary for the enrollee. The Plan denied your request. The Plan says the requested 
wheelchair is not needed for use in the home and therefore denied as not reasonable and necessary by the Plan. 
The Plan also says that shower chairs are not covered because they are not primarily medical in nature. 
 
The Plan follows Medicare rules. Medicare rules say that a group 4 PWC have added capabilities that are not 
needed for use int he home. Therefore, if these wheelchairs are provided, they will be denied as not reasonable 
and necessary. Medicare rules also say that shower chairs are not covered because they are not primarily 
medical in nature.  
 
The LCD confirms that a group 4 wheelchair is not covered and will be denied as not reasonable and necessary. 
This means that Medicare rules for coverage of a PMD have not been met. While a shower chair may be 
appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that 
the Plan does not have to pre-approve a group 4 standard, power wheelchair (K0878) and a bath/shower chair 
(E0240).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 11721 billed for date of service March 7, 
2022. 
 You asked the Plan to pay for procedure code 11721. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 11721 is bundled into payment for code 11750. 
 
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 11721 
is a column II code to column I code 11750. This claim has not been billed with an appropriate modifier to 
bypass the edit. The -59 modifier is not supported as a separate and distinct procedural service. Based on the 
claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have 
to pay for procedure code 11721 billed for date of service March 7, 2022.
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 6, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that you would like this claim reprocessed and 
approved for payment based on Medicare guidelines. 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 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay the in-network rate for the cone beam computed tomography 
(CT) (D0364), pulp vitality test (D0460), limited oral evaluation (D0140), periapical x-ray (D0220), bitewing 
x-ray (D0270), and root canal (D3320) provided from February 12, 2022, to February 26, 2022. 
 
You asked the Plan to pay the in-network rate for the dental services. You say that the provider was in-network. 
You say that you received the services at an out-of-network office. You also say that you feel you were taken 
advantage of by not getting the full disclosure of the difference in the amount. The Plan denied your request. 
The Plan says the provider in this case is not in-network at the location where the services were received. The 
Plan says that services received at an out-of-network location cannot be processed as in-network. 
 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. 
Additionally, the cone beam CT and pulp vitality test are not among those covered under this benefit. 
Therefore, we decided that the Plan does not have to pay the in-network rate for the cone beam computed 
tomography (CT) (D0364), pulp vitality test (D0460), limited oral evaluation (D0140), periapical x-ray 
(D0220), bitewing x-ray (D0270), and root canal (D3320) provided from February 12, 2022, to February 26, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes A4550 and A4649 billed for date of service 
October 1, 2021. 
 
You asked the Plan to pay for procedure codes A4550 and A4649. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says procedure codes A4550 and 
A4949 are 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 A4550 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code A4550 is not separately payable. We also find that procedure code A4649 has a status indicator 
of P on the Physician Fee Schedule. This means that procedure code A4649 is not separately payable. Based on 
this information, we decided that Medicare rules for coverage of procedure codes A4550 and A4649 have not 
been met. Therefore, we decided that the Plan does not have to pay for procedure codes A4550 and A4649 
billed for date of service October 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dental single-film X-Ray (D0220) and pre-diagnostic 
test (D0431). 
 
You asked the Plan to pre-approve the dental services. You say that your dentist would like to do these services 
to diagnose the root cause of your issue. 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 single-film X-Ray was exhausted on date of service May 31, 2022. 
Additionally, the requested pre-diagnostic test is not covered by the Plan. Therefore, we decided that the Plan 
does not have to pre-approve a dental single-film X-Ray (D0220) and pre-diagnostic test (D0431).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral - periapical each additional radiographic image 
on June 21, 2022. 
 
You asked the Plan to pay for the dental services. You say that you do not understand the denial of the 
frequency 
limitation being exceeded. 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 June 21, 2022. Therefore, 
we decided that the Plan does not have to pay for an intraoral - periapical each additional radiographic image 
on June 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a removal of torus mandibularis (D7473). 
 
You asked the Plan to pre-approve the removal of torus mandibularis. You say that you need this procedure 
because you are having trouble eating and cannot speak clearly. The Plan denied your request. The Plan says 
this service is not covered under your benefit package. 
 
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 
removal of torus mandibularis (D7473).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan has paid the full $1,800 dental benefit for services provided from January 17, 2022, 
through February 1, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are requesting reimbursement for the dental 
services received on January 17, 2022, through February 1, 2022. 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 February 1, 2022. 
Therefore, we decided that the Plan has paid the full $1,800 dental benefit for services provided from January 
17, 2022, through February 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on May 31, 
2022. 
 
You asked the Plan to pay for the dental service. You say that the provider told you the dental services would 
be covered, and you did not know this dental service would be denied. The Plan denied your request. The Plan 
says the denial of payment for the periodontal maintenance is correct, because it is not covered by the Plan. 
Also, the Plan verified the enrollee did not contact the Plan 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 
periodontal maintenance (D4910) provided on May 31, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the revascularization services coded 37220 and 37224 
provided on February 26, 2021. 
 
You asked the Plan to pay for the revascularization services. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the services billed are not supported by the documentation. 
 
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 37220 is revascularization, endovascular, open or 
percutaneous, iliac artery, unilateral, initial vessel; with transluminal angioplasty. 
 
The CPT Code Manual definition of code 37224 is revascularization, endovascular, open or percutaneous, 
femoral, popliteal artery(s), unilateral; with transluminal angioplasty 
 
We find that CPT codes 37220 and 37224 are not supported in the medical record. Specifically, the operative 
report did not include documentation of an open or percutaneous endovascular revascularization for the initial 
vessel, of a unilateral iliac artery, with transluminal angioplasty; therefore, code 37220 cannot be verified. 
The operative report did not include documentation of an open or percutaneous endovascular revascularization 
of a unilateral femoral or popliteal artery(s), with transluminal angioplasty; therefore, code 37224 cannot be 
verified. 
 
Based on this information, we decided that Medicare rules for coverage of the revascularization services have 
not been met. Therefore, we decided that the Plan does not have to pay for the revascularization services coded 
37220 and 37224 provided on February 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core build up on tooth #3 (D2950) provided on May 16, 
2022. 
 
You asked the Plan to pay for core build up. You say that this procedure was medically necessary. The Plan 
denied your request. The Plan says core build up (D2950) is not covered by 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. 
 
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 core build 
up on tooth #3 (D2950) provided on May 16, 2022.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share charged for a nuclear diagnostic test and Medicare Part B injection provided on August 9, 2021.
You asked the Plan to waive this cost share. You say that you do not believe this cost share is correct. The Plan denied your request. The Plan says this cost share was charged based on the claim submitted by the provider and the Plan contract agreement. Maximus partially overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct Plan contract language. The Plan provided the cost break down and Medicare allowable for each service provided and indicates Maximus provided no billing regulation that supports their overturn of the Medicare Part B injection.
The Plan is correct in this case. 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 cost share for nuclear diagnostic services and Medicare Part B administered drugs. Based on the information provided, 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 cost share charged for a nuclear diagnostic test and Medicare Part B injection provided on August 9, 2021.