Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral - complete series of radiographic images 
(D0210) provided March 30, 2022. 
 
You asked the Plan to pay for the complete series of x-rays. You say that this service should be covered. The 
Plan denied your request. The Plan says you have exceeded the frequency limit for this service. 
 
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 the complete 
series of x-rays once every 36 months.  
 
We looked at the file and Medicare rules. The Plan provided documentation showing that a complete series of 
x-rays was previously covered on March 3, 2021. Based on this information, we decided that the Plan's 
frequency limit for coverage of the complete series of x-rays has been exceeded. Therefore, we decided that the 
Plan does not have to pay for the intraoral - complete series of radiographic images (D0210) provided March 30, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive metabolic panel provided on January 12, 2022. 
 
You asked the Plan to pay for the testing services. You say that testing of specific substances found in blood is 
covered. The Plan denied your request. The Plan says how the enrollee came to the servicing provider cannot 
be determined. 
 
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 file shows that the testing was ordered as part of a general exam without abnormal findings. Medicare does 
not cover this test solely for screening purposes. There are no medical records to show that the testing was 
ordered for a specific medical problem. The Plan made multiple attempts to obtain additional information, with 
no success. Based on this information, we decided that the Medicare rules for coverage have not been met. 
Therefore, we decided that the Plan does not have to pay for the comprehensive metabolic panel provided on 
January 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established 
patient (D0150) provided January 13, 2022. 
 
You asked the Plan to pay for the comprehensive oral exam. You say that the Plan should cover proper care. 
The Plan denied your request. The Plan says you have exceeded the frequency limit for this service. 
 
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 the 
comprehensive oral exam once every three plan years.  
 
We looked at the file and Medicare rules. The Plan provided documentation showing that a comprehensive 
exam was previously covered on July 8, 2020. Based on this information, we decided that the Plan's frequency 
limit for coverage of the comprehensive oral exam has been exceeded. Therefore, we decided that the Plan does 
not have to pay for the comprehensive oral evaluation - new or established patient (D0150) provided January 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on October 5, 2021, billed with 
codes 81206, 81210, and 81301. 
 
You asked the Plan to pay for the genetic testing. You say that this is medically necessary testing. The Plan 
denied your request. The Plan says this must be billed with a single code. As such, only 7 of the 10 line items 
are approved to be paid. 
 
The Plan must follow Medicare rules. Medicare 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 testing is an NGS panel which 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 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
October 5, 2021, billed with codes 81206, 81210, and 81301.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 81206, 81162, 81301, and 
81311 provided on October 21, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services billed are 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 CPT code. 
 We find that CPT codes 81206, 81162, 81301, and 81311 are not supported in the medical record. Specifically, 
when a laboratory assays two or more genes in an enrollee in parallel, those two or more genes will be 
considered part of the same panel. A panel constitutes a single procedural service, so one code must be 
submitted for the panel. Based on this information, we decided that Medicare rules for coverage of the 
laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the 
laboratory services coded 81206, 81162, 81301, and 81311 provided on October 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an excision of a benign lesion (D7411) provided on January 
20, 2022. 
 
You asked the Plan to pay for an excision of a benign lesion (D7411). You say that the lesion was causing you 
pain and discomfort and believe the service should be covered under the dental plan. The Plan denied your 
request. The Plan says an excision of a benign lesion is an oral surgery service. The excision of a benign lesion 
does not qualify for 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 
excision of a benign lesion (D7411) provided on January 20, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested LTACH admission is 
medically necessary. The Plan denied your request. The Plan says the requested LTACH admission is not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH admission is not medically necessary. Our physician reviewer found the enrollee 
was admitted with hemorrhagic stroke and requires total care.  The record indicates that the enrollee requires 
acute care services for pressure wound before transitioning to a lower level of care. The enrollee continues to 
receive acute care services, and these have not been denied. The medical record does not indicate that the 
enrollee requires services that he is not currently receiving but that would be available at the LTACH facility. 
The elements of the coverage rules are not satisfied. The requested service cannot be recommended. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mass spectrometry and tandem mass spectrometry, not 
elsewhere specified, analyte not elsewhere specified (83789) provided December 15, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that please review the attached claim and accept 
this as a medical necessity appeal. The Plan denied your request. The Plan says the documents received do not support that the procedure or service was distinct or independent from other services performed, therefore, the 
use of the 59 modifier 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, we have confirmed that code 
83789-59 is a column II code to column I code 80307 and G0481 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 mass spectrometry and tandem mass spectrometry, 
not elsewhere specified, analyte not elsewhere specified (83789) provided December 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis (L1851) and the additional lower extremity suspension sleeve (L2397), provided on December 28, 2021.
You asked the Plan to pay for the knee orthosis and the additional lower extremity suspension sleeve. You say that the items are medically necessary. The Plan denied your request. The Plan says there is no documentation of trauma to the knee, and no documentation of imaging performed to evaluate the left knee.
The Plan must follow Medicare rules. Medicare rules say that knee orthosis, with an adjustable flexion and extension joint that provides both medial-lateral and rotation control (L1843, L1845, L1851, L1852), are covered if the beneficiary has had recent injury to or a surgical procedure on the knee(s) We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the knee orthosis and the additional lower extremity suspension sleeve have not been met. Specifically, there is no indication of recent injury or surgery to the knee. Therefore, we decided that the Plan does not have to pay for the knee orthosis (L1851) and the additional lower extremity suspension sleeve (L2397), provided on December 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete upper denture (D5110) and the complete lower 
denture (D5120) provided by a participating provider on May 4, 2021. 
 
You asked the Plan to pay for the complete upper denture (D5110) and the complete lower denture (D5120). 
You say that you chose this Plan because you were told that dentures were covered. 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the complete upper denture (D5110) 
and the complete lower denture (D5120)are not among those covered under this benefit. Therefore, we decided 
that the Plan does not have to pay for the complete upper denture (D5110) and the complete lower denture 
(D5120) provided by a participating provider on May 4, 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 IRF admission is medically necessary. 
The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
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 
enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the 
enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an 
interdisciplinary approach to rehabilitation care. The enrollee was admitted for sepsis, pneumonia, and a urinary tract infection. Medical problems are stable. There are no complex nursing or rehabilitation needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, in an intensive rehabilitation therapy program. While the enrollee has a need for physical and/or 
occupational therapy, there is no documentation of a need for an intensive 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator (SCS). 
 
You asked the Plan to pre-approve a spinal cord stimulator. You say that you would like the Plan to reconsider 
their denial. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria. 
 
The Plan must follow Medicare rules. The rules say that a spinal cord stimulator trial can be covered only for 
patients who have undergone careful screening, evaluation and diagnosis by a multidisciplinary team prior to 
implantation. Such screening must include a psychological evaluation.  
 
The file does not show that a psychological evaluation has been conducted in conjunction with this request for 
a spinal cord stimulator trial. Therefore, we decided that the Plan does not have to pre-approve a spinal cord 
stimulator (SCS).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140), cone beam imaging 
(D0380), and incomplete endodontic therapy (D3332) provided on September 10, 2021. 
 
You asked the Plan to pay for imaging and endodontic therapy. You say that you were told the provider was in-
network and services were covered by the Plan. The Plan denied your request. The Plan says cone beam 
imaging (D0380) and incomplete endodontic therapy (D3332) are not covered by your routine 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 a 
limited oral evaluation (D0140), cone beam imaging (D0380), and incomplete endodontic therapy (D3332) provided 
on September 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve expandable controller, including all related electronics 
and mounting hardware, upgrade provided at initial issue (CPT code E2377), electronic connection between 
wheelchair controller and two or more power seating system motors, including all related electronics, indicator 
feature, mechanical function selection switch, and fixed mounting hardware (CPT code E2311), harness for 
upgrade to expandable controller, including all fasteners, connectors and mounting hardware (CPT code 
E2313), and power seat elevation system (CPT code E2300). 
 
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your 
request. The Plan says the DME is not necessary. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the DME have not been met. Upgraded electronics (electronic 
connection, expandable controller and harness) cannot be covered per Medicare rules. They are necessary when 
there is a medical need to control power options though the joystick. The notes do not show a medical need to 
control the power options through the joystick. The power options can be controlled using their own switches. 
These switches can be made any size without asking for a separate request. They can be made from any 
material without asking for a separate request. All of this can be done without the need to use the joystick to 
control the power features. The seat lift does not serve a primary medical purpose. This cannot be covered. 
Please talk to your doctor about this. Therefore, we decided that the Plan does not have to pre-approve 
expandable controller, including all related electronics and mounting hardware, upgrade provided at initial 
issue (CPT code E2377), electronic connection between wheelchair controller and two or more power seating 
system motors, including all related electronics, indicator feature, mechanical function selection switch, and 
fixed mounting hardware (CPT code E2311), harness for upgrade to expandable controller, including all 
fasteners, connectors and mounting hardware (CPT code E2313), and power seat elevation system (CPT code 
E2300).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pathology services provided on December 9, 2021, billed 
with codes 88112 and 88342. 
 
You asked the Plan to pay for the pathology services as billed. You say that this should be paid in full. The 
Plan denied your request. The Plan says a required modifier was not used for the denied codes. 
 
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 
88112 and 88342 are column II codes in relation to column I code 88188. 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 pathology services provided on 
December 9, 2021, billed with codes 88112 and 88342.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the consultation - diagnostic service provided by dentist or 
physician other than requesting dentist or physician (D9310), cone beam computed tomography (CT) capture 
and interpretation with limited field of view  less than one whole jaw (D0364), intraoral - periapical first 
radiographic image (D0220), intraoral - periapical each additional radiographic image (D0230), and pulp 
vitality tests (D0460) provided October 5, 2021. 
 
You asked the Plan to pay for the dental consultation, cone beam CT scan, periapical first and additional x-ray 
and the pulp vitality tests. You say that these services were medically necessary. The Plan denied your request. 
The Plan says these services are not covered under the enrollees 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 
consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician 
(D9310), cone beam computed tomography (CT) capture and interpretation with limited field of view  less 
than one whole jaw (D0364), intraoral - periapical first radiographic image (D0220), intraoral - periapical each 
additional radiographic image (D0230), and pulp vitality tests (D0460) provided October 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for extractions (D7140 and D7250) provided on May 19, 2021. 
 
You asked the Plan to pay for the extractions. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the extractions denied correctly under your medical benefit. The Plan also 
says you do not have supplemental dental benefits. 
 
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. Additionally, these services do not qualify for coverage under your medical benefits. 
Therefore, we decided that the Plan does not have to pay for extractions (D7140 and D7250) provided on May 
19, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S2900 billed for date of service October 21, 2021. 
 
You asked the Plan to pay for procedure code S2900. You say that you have provided medical records, so this 
claim should be paid. The Plan denied your request. The Plan says you billed this service with an invalid code. 
 
The Plan must follow Medicare rules. Medicare rules say that procedure code S2900 is excluded from 
Medicare coverage.  There may be a different code for this service that may be payable under Medicare. We 
looked at the file and Medicare rules. Based on this information, we decided that there is no coverage for this 
code as billed. Therefore, we decided that the Plan does not have to pay for procedure code S2900 billed for 
date of service October 21, 2021.