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

 
We decided that the Plan does not have to pay for the gene panel provided on September 16, 2021. 
 
You asked the Plan to pay for the testing services. You say that the panel detects certain somatic alterations. 
The Plan denied your request. The Plan says one code must be submitted for the panel. 
 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 the rules. The claim shows the gene panel was billed with multiple codes. If a single 
procedure is performed, only one code with one unit of service may be reported for the procedure. Based on 
this information, we decided that Medicare rules for coverage of the testing services have not been met. 
Therefore, we decided that the Plan does not have to pay for the gene panel provided on September 16, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from 
December 3, 2021, to December 24, 2021. 
 
You asked the Plan to pay for the SNF care provided from December 3, 2021, to December 24, 2021. You say 
that the services are coverable under the Medicare Act. The Plan denied your request. The Plan says the 
enrollee did not receive daily skilled care on the dates of service in this case. 
 
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 pay for the SNF care. Our reviewer says that the 
enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not 
have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled 
professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, 
knowledge, and judgment of a skilled professional therapist. The enrollee did 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. Based on this information, we decided that 
Medicare rules for coverage of the SNF care have not been met. Therefore, we decided that the Plan does not 
have to pay for the skilled nursing facility (SNF) care provided from December 3, 2021, to December 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a porcelain/ceramic crown (D2740) provided on March 7, 2022. 
 
You asked the Plan to pay for the crown. You say that the crown was pre-authorized. The Plan denied your 
request. The Plan says the crown is not covered by your current supplemental dental benefits. 
 
Therefore, we decided that the Plan does not have to pay for a porcelain/ceramic crown (D2740) provided 
on March 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services (81206 and 81292) provided on 
April 21, 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 documentation. The Plan denied your request. The Plan says these codes have not been 
billed according to 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 find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT code 81479. Therefore, we decided that the Plan does not have 
to pay for the genetic testing services (81206 and 81292) provided on April 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral evaluation provided on January 10, 2022. 
 
You asked the Plan to pay for the oral evaluation. You say that the benefit plan allows one evaluation per year 
which seems inadequate when medical or dental problems are more complicated than one doctor visit might 
solve. The Plan denied your request. The Plan says the service is only covered one procedure per plan year, and 
per your claim history, services were already covered on January 6, 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 procedure 
per plan year. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the benefit for the requested service 
was exhausted on January 6, 2022. Therefore, we decided that the Plan does not have to pay for the oral 
evaluation provided on January 10, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the catheter and angiography services provided on November 
15, 2021. 
 
You asked the Plan to pay for the services provided. You say that the guidelines do allow for separate charges. 
The Plan denied your request. The Plan says the codes cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
The file shows that codes 36222 and 36223 were billed together, as well as 36225 and 36226. These codes are 
eligible for payment when billed in these code pairs. The medical records provided do not show that the 
services billed with the -59 modifier were a distinct procedural service. The services were an integral part of 
the primary procedure.  
 
In this case, the CPT Code Manual definition of code 75710 is angiography, extremity, unilateral, radiological 
supervision and interpretation. We find that the angiography is included in the catheter placement procedures. 
Providers should not unbundle, but bill with the most comprehensive code available. Based on this information, 
we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided 
that the Plan does not have to pay for the catheter and angiography services provided on November 15, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene panel testing provided from May 28, 2021, to May 
29, 2021. 
 
You asked the Plan to pay for the services provided. You say that the panel detects somatic alterations. The 
Plan denied your request. The Plan says one code must be submitted for the panel. 
 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 the rules.  If a single procedure is performed, only one HCPCS/CPT code with one 
unit of service may be reported for the procedure. The claim provided billed the gene panel with multiple 
codes. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, 
we decided that the Plan does not have to pay for the gene panel testing provided from May 28, 2021, to May 
29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on March 2, 2022. 
 
You asked the Plan to pay for an evaluation. You say that you tried to find an in-network provider in your 
travel radius. The Plan denied your request. The Plan says that a limited oral evaluation (D0140) 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 a limited 
oral evaluation (D0140) provided on March 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service (81292) provided on July 12, 2021. 
 
You asked the Plan to pay for code 81292. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 We find that the denied CPT code is not supported in the medical record. Specifically, the testing at issue in 
this case should be reported with CPT code 81479. Therefore, we decided that the Plan does not have to pay for 
the laboratory service (81292) provided on July 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implant supported porcelain crown (D6065) and a 
metal crown (D6063). 
 
You asked the Plan to pre-approve an implant supported porcelain crown (D6065) and a metal crown (D6063). 
You say that the process for the dental implant has already been started. You say that you cannot eat well and 
need the second part of the process to be completed.  The Plan denied your request. The Plan says this service 
is not covered by the Plan's 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 pre-approve an 
implant supported porcelain crown (D6065) and a metal crown (D6063).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental implants (D6010). 
 
You asked the Plan to pre-approve the dental implants. You say that the services should be covered as you 
disagree with the charges. The Plan denied your request. The Plan says the services denied correctly as they do 
not fall under 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 pre-approve 
dental implants (D6010).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene panel provided on March 18, 2021. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says one code must 
be submitted for the panel. 
 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 claim shows that the gene panel was billed with multiple codes. If a single procedure is performed, only 
one code with one unit of service may be reported for the procedure. Based on this information, we decided 
that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan 
does not have to pay for the gene panel provided on March 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crown restoration (D6063) and implants (D6065) on 
teeth # 2-11, 13-15, and 18-26. 
 
You asked the Plan to pre-approve crown restoration and implants. You say that you do not agree with the 
denial of dental services. The Plan denied your request. The Plan says that crown restoration (D6063) and 
implants (D6065) are not covered by your denial 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 pre-approve 
crown restoration (D6063) and implants (D6065) on teeth # 2-11, 13-15, and 18-26.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection between wheelchair controller 
and two or more power seating system motors, phone holder, USB charger, expandable controller, and harness. 
 
You asked the Plan to pre-approve an electronic connection between wheelchair controller and two or more 
power seating system motors, phone holder, USB charger, expandable controller, and harness. 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 criteria for the requested items. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
Review of the file shows that although there are three approved power options on the approved wheelchair, 
there is no medical need to control these power options through the joystick. The documentation shows that the 
enrollee is able to perform self-feeding, upper body dressing, and grooming with set up. The enrollee has a four 
to five out of five upper limb strength. This means that the enrollees upper limb strength and function are 
adequate for the enrollee to be able to control the power options using their own switches which are included in 
the allowance of the power options. The phone holder and USB charger at issue in this appeal do not serve a 
purpose that is primarily medical in nature. This item is available to the general public and would be helpful 
even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve an 
electronic connection between wheelchair controller and two or more power seating system motors, phone 
holder, USB charger, expandable controller, and harness.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Vitamin D 25 hydroxy testing (82306) provided on 
November 23, 2021. 
 
You asked the Plan to pay for Vitamin D 25 hydroxy testing. You say that this should be covered. The Plan 
denied your request. The Plan says this was not related to the enrollee's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that the measurement of 25(OH) Vitamin D levels 
will be considered medically reasonable and necessary for limited diagnosis codes. Diagnosis R53.82 is not 
listed as supporting medical necessity. 
 
We looked at the file and Medicare rules. This testing was not billed with a diagnosis that supports medical 
necessity. Based on this information, we decided that Medicare rules for coverage of Vitamin D 25 hydroxy 
testing have not been met. Therefore, we decided that the Plan does not have to pay for Vitamin D 25 hydroxy 
testing (82306) provided on November 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal scaling and root planning - one three teeth 
per quadrant tooth (code D4342) for teeth #9, #16, #17, and #24 provided on March 24, 2022. 
 
You asked the Plan to pay for the periodontal scaling and root planning. You say that you were told by the 
provider that the service was covered. The Plan denied your request. The Plan says he Plan says this service is 
covered by the Plan's dental benefits; however, your benefit for the periodontal scaling and root planning on the 
same tooth per 24 months has 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. The Plan covers the 
periodontal scaling and root planning 1 per consecutive 24 months. 
 
  We looked at this the file, the Plans rules, and Medicare rules. The Plan approved coverage for the periodontal 
scaling and root planning for teeth #9, #16, #17, and #24 on June 20, 2020; therefore, the benefit for the 
periodontal scaling and root planning has been exhausted. Based on this information, we decided 
that the Plan's rules for coverage of the periodontal scaling and root planning have not been met. Therefore, we 
decided that the Plan does not have to pay for the periodontal scaling and root planning - one three teeth per 
quadrant tooth (code D4342) for teeth #9, #16, #17, and #24 provided on March 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for a periodic oral evaluation (D0120), 
bitewings x-rays (D0274), and prophylaxis (D1110) provided on January 13, 2022. 
 
You asked the Plan to waive the cost share for an evaluation, x-rays, and prophylaxis. You say that you saw 
this dental group last year and the claims were paid in full. The Plan denied your request. The Plan says you 
have been charged the correct cost sharing amount. 
 
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 50% 
coinsurance for out-of-network dental services. The contract also says you may be billed by the out-of-network 
provider for any amount greater than the payment made by the Plan to the provider. 
 
The record shows you received dental services from an out-of-network provider. The record also shows that 
you are responsible for $40, which is the total billed amount minus the allowed amount. You have also been 
asked to pay 50% of the allowed amount as coinsurance for an evaluation, x-ray, and prophylaxis.    
Code Total Billed Amount Allowed Amount 50% Coinsurance Billed Amount Above the 
Allowed Amount 
D0120 $35 $22 $11 $13 
D0274 $42 $31 $15.50 $11 
D1110 $67 $51 $25.50 $16 
Total   $52 $40 
 
You have been asked to pay a total of $92 ($52 total coinsurance + $40 billed amount above the allowed 
amount = $92). An evaluation, dental x-ray, and prophylaxis falls within the Dental Services 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 cost share for a periodic oral evaluation (D0120), bitewings x-rays 
(D0274), and prophylaxis (D1110) provided on January 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional payment for the crown - porcelain/ceramic 
(D2740) provided January 10, 2022. 
 
You asked the Plan to provide additional payment for the crown. You say that this treatment was necessary. 
The Plan denied your request. The Plan says this service been paid on the least costly method of treatment. 
 
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 50% of the 
cost of crowns. This benefit states that if the Plan determines that a less expensive alternate procedure, service, 
or course of treatment can be performed in place of a proposed treatment to correct a dental condition; and the 
alternate treatment will produce a professionally satisfactory result, then the maximum the Plan will allow will 
be the charge for the less expensive treatment. 
 
 We reviewed the file and Medicare rules. In this case the Plan determined that the least costly treatment option 
is a crown - porcelain fused to predominantly base metal (D2751). The Plan has provided coverage for 50% of 
the cost of a porcelain fused to predominantly base metal crown. This means you have been asked to pay the 
correct amount according to your contract with the Plan. Therefore, we decided that the Plan does not have to 
provide additional payment for the crown - porcelain/ceramic (D2740) provided January 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the maximum allowed for oral evaluation (dental code 
D0140) provided on February 7, 2022. 
 
You asked the Plan to pay more for the maximum allowed for oral evaluation. You say that you would like 
reconsideration of the claim because it was medically necessary to see an OON provider. The Plan denied your 
request. The Plan says the oral evaluation is covered under the platinum, but the maximum allowed 
charge was paid; therefore, the enrollee was responsible for the difference. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the Plan is only obligated to pay the 
allowed amount for the limited oral evaluation. You are responsible for any amount greater than the payment 
made by the Plan to the out-of-network provider. 
 
The total amount billed by the OON provider was $85 and the maximum allowed amount paid was $32. The 
member responsibility left over after the Plan paid the maximum allowed amount was $53 ($85 provider billed 
- $32 total amount allowed). Therefore, $53 was charged as member liability. We looked at the file, the Plan's 
rules, and Medicare rules. Based on this information, we decided that the 
Plan's rules to pay for the maximum allowed charge was correctly processed. Therefore, we decided that the 
Plan does not have to pay more for the maximum allowed for oral evaluation (dental code D0140) provided on 
February 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81206 and 81292) provided on 
March 23, 2021. 
 
You asked the Plan to pay for codes 81206 and 81292. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT code 81479. Therefore, we decided that the Plan does not have 
to pay for the laboratory services (81206 and 81292) provided on March 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81301 and 81479) provided on 
October 1, 2021. 
 
You asked the Plan to pay for codes 81301 and 81479. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT code 81479 only. Therefore, we decided that the Plan does not 
have to pay for the laboratory services (81301 and 81479) provided on October 1, 2021.