Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for medical equipment and supplies provided 
on February 22, 2022. 
 
You asked the Plan to waive the coinsurance for medical equipment and supplies. You say that you shouldn't 
be charged for this. The Plan denied your request. The Plan says the coinsurance applied is correct. 
 
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 20% 
coinsurance for durable medical equipment, oxygen/ oxygen equipment and related supplies.  
 
You have been asked to pay $142.01 which is 20% of the allowed amount medical equipment and supplies. 
The allowed amount is $710.08 (20% x $710.08= $142.01). Medical equipment and supplies falls within the 
Durable Medical Equipment (DME) and Related Supplies 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 medical equipment and supplies provided on February 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the second opinion to be provided by an out-of-network 
provider. 
 
You asked the Plan to pre-approve the out-of-network services. You say that the in-network doctor dismissed 
your concerns. The Plan denied your request. The Plan says medically necessary care is available in network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the second opinion to be provided by an out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the repair atrial septal defect (33641) provided on January 
14, 2022. 
 
You asked the Plan to pay for the repair atrial septal defect (33641). You say that the CPT code was denied for 
inclusive, but modifier XU was billed on the claim. You say that the medical records should be reviewed. The 
Plan denied your request. The Plan says procedure code 33120 was approved. The Plan also says procedure 
code 33641 is considered inclusive to procedure code 33120. 
 
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 33641 is repair atrial septal defect, secundum, with 
cardiopulmonary bypass, with or without patch. 
  We asked our coder 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 repair atrial septal defect (33641). Our reviewer says that 
the documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer found the 
operative report describes creation of a large iatrogenic atrial septal defect in order to incise and free mass. In 
this case, repair of septal defect would be inclusive in the primary procedure as this procedure would be 
performed in order to perform the mass excision. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the repair atrial septal defect (33641) have not been met. Therefore, we decided 
that the Plan does not have to pay for the repair atrial septal defect (33641) provided on January 14, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nerve conduction tests, an office visit and an x-ray of the 
spine provided from January 24, 2022, to April 2, 2022, by an out-of-network (OON) provider.  
 You asked the Plan to pay for nerve conduction tests, an office visit, and an x-ray of the spine. You say that 
you would like a reassessment of all of your medical claims for 2022. The Plan denied your request. The Plan 
says your plan excludes coverage for this out-of-network service, and there was no referral. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested providers in the case are not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
 
We also decided that the Plan does not have to waive the copayment for a specialist office visit and a magnetic 
resonance imaging (MRI) of the spine provided from January 24, 2022, to April 2, 2022. 
 
You also asked the Plan to waive the copayment for a specialist office visit and a magnetic resonance imaging 
(MRI) of the spine. The Plan also says you were charged the correct cost sharing amount. 
 
The rules also 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 
a $120 copayment for each Medicare-covered diagnostic radiology service other than computed tomography 
(CT) scans performed by a provider other than your primary care physician. Your contract with the Plan also 
says that you must pay a $12 copayment for physician specialist services. 
 
You have been asked to pay a $120 copayment for a magnetic resonance imaging (MRI) of the spine. A 
magnetic resonance imaging (MRI) of the spine falls within the Outpatient diagnostic tests and therapeutic 
services and supplies benefit category. You have also been asked to pay a $12 copayment for each office visit 
for two visits. An office visit falls within the physician/practitioner services, including doctors office visits.  
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 pay for nerve conduction tests, an office visit and an x-ray 
of the spine provided from January 24, 2022, to April 2, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120) and prophylaxis (D1110) 
provided on February 16, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says the dental services were received from an out-of-network provider 
and are not covered by your supplemental 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 record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a periodic oral evaluation (D0120) and prophylaxis (D1110) provided on February 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prophylaxis (D1110) provided on January 24, 2022. 
 
You asked the Plan to pay for prophylaxis. You say that your 2021 Plan provided an annual allowance of $250 
for dental work and you were unaware of the policy changes. The Plan denied your request. The Plan says 
dental related services are excluded from coverage. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for prophylaxis (D1110) provided on 
January 24, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services rendered on November 29, 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 procedure code 27220 is not supported. 
 
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 27220 is closed treatment of acetabulum (hip socket) 
fracture(s); without manipulation. 
 
We find that CPT code 27220 is not supported in the medical record. Specifically, the records do not support an 
actual fracture to the acetabulum. 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 pay for the surgical 
services rendered on November 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for prophylaxis (D1110), a periodic oral evaluation 
(D0120), and bitewings (D0274), provided by an out-of-network provider on March 8, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you would like the Plan to pay for all of 
this. The Plan denied your request. The Plan says you are responsible for any charged amount above the Plans 
cost-sharing amount when your services are received from an out-of-network provider. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to pay more for prophylaxis (D1110), a periodic oral 
evaluation (D0120), and bitewings (D0274), 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 provided on November 30, 2021 billed 
with codes 81210, 81235, 81272, and 81206. 
 
You asked the Plan to pay for the genetic testing billed. 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 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 
November 30, 2021 billed with codes 81210, 81235, 81272, and 81206.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 8, 2021 billed with 
codes 81206 and 81292. 
 
You asked the Plan to pay for the genetic testing billed. 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 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 
April 8, 2021 billed with codes 81206 and 81292.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) stay. 
 
You asked the Plan to pre-approve a SNF stay. The Plan denied your request. The Plan says there is no need for 
daily skilled therapy services to be provided by a skilled therapist on a daily basis and there are no daily skilled 
nursing needs. 
 
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 pre-approve a SNF stay. Our reviewer says that the 
enrollee does not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee does not 
have daily skilled nursing needs that requires the specialized skill, knowledge, and judgment of a skilled 
professional nurse. The enrollee does not have daily skilled therapy needs that requires the specialized skill, 
knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled nursing 
and/or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Although the enrollee has skilled therapy 
needs, these needs are not on a daily basis. Based on this information, we decided that Medicare rules for 
coverage of a SNF stay have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
skilled nursing facility (SNF) stay.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Genvisc. 
 
You asked the Plan to pre-approve Genvisc. You say that it is your medical opinion that the treatment sought is 
clinically supported and medically necessary. The Plan denied your request. The Plan says the enrollee does 
not have any stated contraindications to the preferred products. The Plan also says that the enrollee has not tried 
any of the preferred agents, and no rationale was provided for use of the non-preferred product for safety or 
efficacy.  
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Genvisc. Our reviewer says that 
Genvisc is not reasonable and necessary. Our physician reviewer found there is no indication that the the 
enrollee has tried and failed the required drug(s). Our reviewer also found that there is no indication that the 
Plan's required drug(s) would likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Genvisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Genvisc.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on November 30, 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 are not covered. 
 
The Plan must follow Medicare rules. The rules say that genetic testing procedures submitted under CPT code 
81455 are denied as not medically necessary. 
 
We looked at the file and Medicare rules. The services are billed under code 81455. 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 pay for the laboratory services rendered on November 30, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services rendered on November 11, 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 that the services were not provided for the enrollee. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan states that the services were not rendered by the provider; however, the 
records contain a laboratory report for the enrollee and the date of service at issue. The Plan has not provided 
any documentation or Medicare rules to support that the services cannot be covered. Therefore, we decided that 
the Plan has to pay for the laboratory services rendered on November 11, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for replacement batteries (A4630), lead wires (A4557), and 
leads (A4595) for a transcutaneous electrical stimulator provided on January 28, 2022. 
 You asked the Plan to pay for replacement batteries, lead wires, and leads. You say that the requested items 
were a necessity for the enrollee's care. 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 codes A4630, A4557 and A4595 have a status indicator of X on the Physician Fee Schedule. 
This means that CPT codes A4630, A4557 and A4595 are not separately payable. Based on this information, 
we decided that Medicare rules for coverage of replacement batteries, lead wires, and leads have not been met. 
Therefore, we decided that the Plan does not have to pay for replacement batteries (A4630), lead wires 
(A4557), and leads (A4595) for a transcutaneous electrical stimulator provided on January 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) and x-
ray of lower jaws, upper jaws and teeth (70355) provided April 1, 2022. 
 
You asked the Plan to pay for the limited oral exam and x-ray of lower jaws, upper jaws and teeth. You say that 
these services were medically necessary. The Plan denied your request. The Plan says these services are not 
covered under your medical or 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 
limited oral evaluation - problem focused (D0140) and x-ray of lower jaws, upper jaws and teeth (70355) 
provided April 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing coded 81401, 81403, 81404, 81405, 
81406, 81407, 81479, and 81408 provided on September 14, 2021.  
You asked the Plan to pay for the genetic testing. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 
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 genetic testing 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 genetic 
testing coded 81401, 81403, 81404, 81405, 81406, 81407, 81479, and 81408 provided on September 14, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on December 1, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services were billed 
incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that if one laboratory procedure evaluates multiple 
genes using a next generation sequencing procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, ultianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis CPT code.  
 
We looked at the file and Medicare rules. In this case, the requested genetic testing was billed with multiple 
codes on separate claims. Per Medicare rules, the testing should be reported with one unit of one CPT code. 
Based on this information, we decided that Medicare rules for coverage of the testing have not been met. 
Therefore, we decided that the Plan does not have to pay for the genetic testing provided on December 1, 2021.