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

We decided that the Plan does not have to pay for the molecular pathology testing (CPT code(s):  81206, 81292, and 81301) provided on August 24, 2021.

You asked the Plan to pay for the testing. 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 molecular pathology testing (CPT code(s):  81206, 81292, and 81301) provided on August 24, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services (81206, 81301, and 81311) 
provided on September 1, 2021. 
 
You asked the Plan to pay for the genetic testing services. 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 in 
accordance with Medicare billing regulations. 
 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 looked at the file and Medicare rules. In this case, the services provided should have been billed as a single 
procedural service. Based on this information, we decided that Medicare rules for coverage of the genetic 
testing services have not been met. Therefore, we decided that the Plan does not have to pay for the genetic 
testing services (81206, 81301, and 81311) provided on September 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental service provided by an out-of-network (OON) dentist 
on January 18, 2022. 
 
You asked the Plan to pay for dental service. You say that your dental benefits were misrepresented to you. The 
Plan denied your request. The Plan says the denial of payment for these services is correct, because the Plan 
does not offer coverage for out-of-network dental services. 
 
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 when performed by an out-of-network dentist. Therefore, we decided 
that the Plan does not have to pay for dental service provided by an out-of-network (OON) dentist on January 
18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the localized delivery agent (D4381 x2) and medications 
dispensed in-office for home use (D9630) provided by a network provider on March 30, 2022. 
 
You asked the Plan to pay for the localized delivery agent (D4381 x 2) and the medications dispensed in-office 
for home use (D9630). You say that you believe the services should be covered. You say you denied the use of 
the "numbing agent" the provider used. The Plan denied your request. The Plan says the services are not 
covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the localized delivery agent (D4381 
x2) and medications dispensed in-office for home use (D9630) are not among those covered under this benefit. 
Therefore, we decided that the Plan does not have to pay for the localized delivery agent (D4381 x2) and 
medications dispensed in-office for home use (D9630) provided by a network provider on March 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided by a network 
provider on February 8, 2022. 
 
You asked the Plan to pay for the limited oral evaluation (D0140). You say that you were referred by your 
dentist to a surgeon to remove your back tooth. You say this should be covered as a one-time visit per 
specialty. The Plan denied your request. The Plan says the service exceeded the frequency limitation in the 
benefit plan. 
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare, the Plan also has a maximum benefit of one 
limited oral evaluation (D0140). The requested service is not covered because the Plan paid for a limited oral 
evaluation on January 28, 2022, which exhausted your benefit.  
 
Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided by a 
network provider on February 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care services (99291) provided on November 24, 
2021. 
 
You asked the Plan to pay for code 99291. 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 99291 
is a column II code to column I code 12011. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the critical care services (99291) provided on November 24, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drugs or medicaments dispensed in the office for home 
use (D9630), the topical application of fluoride varnish (D1206), and the unspecified preventive procedure 
(D1999) provided on March 1, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not a covered benefit under 
your contractual policy.  
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 services provided in this case are 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
drugs or medicaments dispensed in the office for home use (D9630), the topical application of fluoride varnish 
(D1206), and the unspecified preventive procedure (D1999) provided on March 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services (81295, 81298) provided on 
August 20, 2021. 
 You asked the Plan to pay for the genetic testing services. You say that you would like these codes reprocessed 
and approved for payment. The Plan denied your request. The Plan says these codes have denied correctly as 
they are considered bundled into the procedure code 81432. 
 
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 codes 
81295 and 81298 are both column II codes to column I code 81432 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 genetic testing services (81295, 81298) 
provided on August 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup for tooth #5, 6, 9, and 10 (D2950), pontic 
for tooth #8 (D6245), and crown for tooth #5, 6, 9, and 10 (D6740) provided on February 16, 2022. 
 
You asked the Plan to pay for the core buildup, pontic, and crowns. You say that you were told some of the 
charges would be covered because the damage was caused by an accident. The Plan denied your request. The 
Plan says the services you received are not covered by your supplemental 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 the core 
buildup for tooth #5, 6, 9, and 10 (D2950), pontic for tooth #8 (D6245), and crown for tooth #5, 6, 9, and 10 
(D6740) provided on February 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a Tempus gene panel (81206, 81210, 81301) provided on 
August 10, 2021. 
 You asked the Plan to pay for a Tempus gene panel. You say that this was medically necessary. The Plan 
denied your request. The Plan says this was not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules also say that the submission of claims 
using individual gene CPT codes, when either 5-50 or more than 50 gene panels are ordered, is considered 
incorrect coding. 
 
We find that CPT codes 81210, 81235, 81245, 81272, 81275, 81276, 81310, 81311, and 81315 are not 
supported in the medical record. Specifically, these codes were used to report components of a panel, which is 
considered incorrect coding. Based on this information, we decided that Medicare rules for coverage of a 
Tempus gene panel have not been met. Therefore, we decided that the Plan does not have to pay for a Tempus 
gene panel (81206, 81210, 81301) provided on August 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental medication (code D9999) provided on January 27, 2022. 
 
You asked the Plan to pay for dental medication. You say that you are a new member and was informed the 
services were emergent. The Plan denied your request. The Plan says that dental medication is not covered by 
the Plan. 
 
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. 
 
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 dental 
medication (code D9999) provided on January 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the adjunctive pre-diagnostic test (dental code D0431) 
provided on January 26, 2022. 
 
You asked the Plan to pay for the adjunctive pre-diagnostic test. You say that the procedure should be covered 
under a preventative exam. The Plan denied your request. The Plan says the denial for the service is correct, 
because the code that was billed is not listed in the table of covered dental service codes. 
 
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 
adjunctive pre-diagnostic test (dental code D0431) provided on January 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the routine vision services rendered on September 13, 2021. 
 
You asked the Plan to pay for these services. You say that you are owed $100 for the contact lenses you 
purchased. The Plan denied your request. The Plan says services from an out-of-network provider are not 
covered. 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 these services when they are obtained from a network provider. 
 
We looked at the file and the Plan's rules. The file shows that you received services from a provider not in the 
Plans vision care network. Based on this information, we decided that the Plan's rules for coverage of these 
services have not been met. Therefore, we decided that the Plan does not have to pay for the routine vision 
services rendered on September 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an out-of-network provider on 
March 8, 2022. 
 
You asked the Plan to pay for dental services. You say that you believe the Plan should pay for this. The Plan 
denied your request. The Plan says services provided by an out-of-network 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 Plan's coverage rules apply in this case. The Plan covers covered 
dental services when the services are provided by a participating provider. 
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of dental services have not been met. Therefore, we decided that the Plan does not have to pay for 
dental services provided by an out-of-network provider on March 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services (81230, 81240, 81241, 81249, 
81291, 81408, 81335) provided on September 25, 2021. 
 You asked the Plan to pay for the genetic testing services. 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 in 
accordance with Medicare coding regulations. 
 
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 looked at the file and Medicare rules. In this case, the services provided should have been billed as a single 
procedural service. Based on this information, we decided that Medicare rules for coverage of the genetic 
testing services have not been met. Therefore, we decided that the Plan does not have to pay for the genetic 
testing services (81230, 81240, 81241, 81249, 81291, 81408, 81335) provided on September 25, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate for the enrollee. 
 
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 bone marrow aspirate in the 
setting of spinal fusion surgery 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. Detailed 
documentation is not evident regarding a specific indication provided to support the request for bone marrow 
aspirate for the approved surgery. There is a lack of large volume, long-term peer-reviewed outcome studies to 
support the use of bone marrow aspirate for this enrollees medical condition. 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 bone marrow aspirate for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical tooth removal (D7210) provided on February 3, 2022. 
 
You asked the Plan to pay for the tooth removal. You say that the procedure was medically necessary and 
should be authorized. The Plan denied your request. The Plan says the service you received is not covered by 
your supplemental dental benefits. 
 
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. 
 
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 
surgical tooth removal (D7210) provided on February 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral - periapical x-ray (D0220) provided on January 
6, 2022. 
 
You asked the Plan to pay for an x-ray. You say that the doctor felt it was necessary to take an x-ray to 
determine the prognosis for needing a crown. The Plan denied your request. The Plan says that an intraoral - 
periapical x-ray is not covered by your supplemental 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 an 
intraoral - periapical x-ray (D0220) provided on January 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral exam (D0120) provided on February 17, 2022. 
 
You asked the Plan to pay for a periodic oral exam. You say that the services were approved but you received a 
denial letter after receiving the services. The Plan denied your request. The Plan says the denial of payment for 
this service is correct. The Plan says your tooth history shows that you received a periodic oral exam (D0120) 
on December 16, 2021. Furthermore, the Plan explains one exam is covered every six months which means you 
would not be eligible for another exam until June 16, 2022. 
 
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. The Plan covers one periodic 
oral exam every six months. 
 
We looked at the file, the Plan's rules, and Medicare's rules. You previously received a covered periodic oral 
exam on December 16, 2021. This means the benefit was already exhausted for date of service February 17, 
2022. Based on this information, we decided that the Plan does not have to pay for a periodic oral exam 
(D0120) provided on February 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an opt-out provider on January 3, 2022. 
 
You asked the Plan to pay for dental services. You say that the Plan said it was okay to go to this provider. The 
Plan denied your request. The Plan says the rendering dentist has opted-out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for dental 
services provided by an opt-out provider on January 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a mandibular denture reline (D5731) provided on December 
13, 2021. 
 
You asked the Plan to pay for the mandibular denture reline. You say that there is no waiting period indicated 
in the Plan benefits. The Plan denied your request. The Plan says denture reline procedures are limited to one 
per calendar year. The Plan says you have already met the benefit limit. 
 
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, there is a limit to the number of 
denture reline procedures covered. Only one reline is covered per calendar year. The record shows the Plan has covered the maxillary reline, and the benefit is now exhausted. Therefore, we decided that the Plan does not 
have to pay for a mandibular denture reline (D5731) provided on December 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for treatment planning (D9450), complete x-rays (D0210), a 
comprehensive oral evaluation (D0150) provided on March 14, 2022. 
 
You asked the Plan to pay for the treatment planning, x-rays, and oral evaluation. You say that you were not 
told about the additional cost. The Plan denied your request. The Plan says treatment planning is not a covered 
service under your dental benefits. The Plan also says that your benefit for the x-rays and oral evaluation have 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the treatment planning is not among 
those covered under this benefit. The dental benefit limits the coverage of the x-rays to once every 5 calendar 
years. The dental benefit also limits the coverage of the oral evaluation to once every 3 calendar years. The
record shows your benefit for the x-rays and the oral evaluation has already been exhausted. Therefore, we 
decided that the Plan does not have to pay for treatment planning (D9450), complete x-rays (D0210), a 
comprehensive oral evaluation (D0150) provided on March 14, 2022.