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

 
We decided that the Plan does not have to pay for the laboratory services rendered on September 20, 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 were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.   
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and 
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on September 20, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room services (99283) provided on December 
27, 2021. 
 
You asked the Plan to pay for code 99283. 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 99283 
is a column II code to column I code 99285. 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 emergency room services (99283) provided on December 27, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diagnostic casts (D0470), pulp vitality tests (D0460), 
topical application of fluoride varnish (D1206), and crowns (D2740) provided on March 16, 2021, and April 
14, 2021. 
 
You asked the Plan to pay for the diagnostic casts, pulp vitality tests, topical application of fluoride varnish, 
and crowns. You say that you are on a fixed income and this bill is highly problematic to your financial 
stability. The Plan denied your request. The Plan says these services are not covered expenses under your 
dental plan. 
 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 
diagnostic casts (D0470), pulp vitality tests (D0460), topical application of fluoride varnish (D1206), and 
crowns (D2740) provided on March 16, 2021, and April 14, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 8 home health physical therapy visits, 8 occupational 
therapy visits, 9 skilled nursing service visits, and 17 aide visits. 
 You asked the Plan to pre-approve 8 home health physical therapy visits, 8 occupational therapy visits, 9 
skilled nursing service visits, and 17 aide visits. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 8 home health physical therapy visits, 8 
occupational therapy visits, 9 skilled nursing service visits, and 17 aide visits. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found based on the medical records provided 
there is no documentation that further skilled therapy services are required to effectively provide treatment, 
care, and/or services in order to improve the enrollee's level of function, or to establish/perform a maintenance 
program to maintain the patient's level of function and/or prevent deterioration. The enrollee has received 11 
occupational therapy visits and 10 physical therapy visits thus far including additional visits approved as 
recently as May 5, 2022. Provided records do not document any acute or unstable medical conditions or 
changes in medication or treatment which would necessitate any further skilled therapy visits beyond what 
have already been approved. No medical notes from the enrollees treating physician are provided documenting 
an order or need for additional skilled therapy 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 8 home health physical therapy visits, 8 occupational therapy visits, 9 skilled 
nursing service visits, and 17 aide visits have not been met. Therefore, we decided that the Plan does not have 
to pre-approve 8 home health physical therapy visits, 8 occupational therapy visits, 9 skilled nursing service 
visits, and 17 aide visits.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Opdivo. 
 
You asked the Plan to pre-approve Opdivo. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
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 Opdivo. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found Opdivo is only approvable first line in 
combination with folfox. As this is not first line there is no role for Opdivo as a single agent. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Opdivo have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Opdivo.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for the crown (D2740) provided on 
December 14, 2021. 
 
You asked the Plan to pay an additional amount for the dental service. You say that you feel that the claim 
denied in error. The Plan denied your request. The Plan says the claim processed correctly. 
 
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 and crown is listed as covered, there is a 70% coinsurance that applies to this service when received in network. This is a contractual obligation you 
agreed to when you enrolled in the Plans dental coverage. Therefore, we decided that the Plan does not have to 
pay an additional amount for the crown (D2740) provided on December 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the wheelchair accessories. 
 
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. The upgraded electronics (expandable 
controller, harness) are not medically necessary. They are necessary when there is a medical need to control 
power options through 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 request 
for extra payment for the leg rests, calf pads, and switch is still denied. Leg rests, calf pads, and switch are 
already included with approved wheelchair. Therefore, we decided that the Plan does not have to pre-approve 
the wheelchair accessories.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation provided on 
November 18, 2021. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that the copayment 
should be waived since you were admitted to the hospital. 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 a $265 
copayment for each ambulance trip.  The file shows that you were kept in the hospital under observation only, not admitted as an inpatient. 
Therefore, you have been asked to pay $200, which is less than the $265 copayment for the ambulance 
transportation. The ambulance transportation falls within the Ambulance 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 copayment for ambulance transportation provided on November 18, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of the Coflex spacer during spinal 
decompression surgery. 
 
You asked the Plan to pre-approve the Coflex spacer. You say that the requested services should be approved 
due to medical necessity. The Plan denied your request. The Plan says the spinal surgery has been approved, 
except for the use of the Coflex device which is experimental. 
 
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 the Coflex spacer. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Coflex device is experimental. More research is needed to show safety and 
efficacy.  
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 Coflex spacer have not been met. Therefore, we decided that the Plan does 
not have to pre-approve placement of the Coflex spacer during spinal decompression surgery.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services (81292, 81295, 81321, 
81408,81479) provided on May 11, 2021. 
 
You asked the Plan to pay for the genetic testing services. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says this claim has not been billed 
appropriately based on Medicare billing regulations. 
 
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, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. In this case, the services have not been billed correctly based on 
Medicare rules requiring only one CPT code that reflect the services rendered. 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 (81292, 81295, 81321, 81408,81479) 
provided on May 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous revascularization of lower extremity. 
 
You asked the Plan to pre-approve percutaneous revascularization of lower extremity. You say that the services 
are necessary. The Plan denied your request. The Plan says medical necessity has not been established. 
Therefore, coverage criteria have not been met. 
 
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 percutaneous revascularization of lower 
extremity. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found there is no documentation of failure of conservative 
therapy or documentation of occlusive arterial disease by ultrasound. The review has determined that the 
items/services at issue in this case are not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of percutaneous revascularization of lower extremity have not been met. 
Therefore, we decided that the Plan does not have to pre-approve percutaneous revascularization of lower 
extremity.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS system. 
 
You asked the Plan to pre-approve a CardioMEMS system. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 a CardioMEMS system. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found nonetheless, there remains a dearth of randomized, blinded clinical studies examining 
long-term clinical outcomes establishing the value of CardioMEMS in enrollee management. As a result, at this 
time the CardioMEMS system would not be considered medically appropriate and necessary in this enrollees 
clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a CardioMEMS system have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMS system.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the molecular pharmacogenetic testing coded as 81227, 
81230, 81240, 81241, 81291, 81335 and 81355 provided September 13, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that kindly review and process the claim 
towards payment. The Plan denied your request. The Plan says does not meet Medicare NCD/LCD criteria 
 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 find that CPT code 81227, 81230, 81240, 81241, 81291, 81335 and 81355 is not supported in 
the medical record. Specifically, 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 pane. If a single procedure is performed, 
only one HCPCS/CPT 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 laboratory services have not been met. 
Therefore, we decided that the Plan does not have to pay for the molecular pharmacogenetic testing coded as 
81227, 81230, 81240, 81241, 81291, 81335 and 81355 provided September 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on September 7, 2021. 
 
You asked the Plan to pay for the laboratory services. 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.  
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 test 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 laboratory 
services provided on September 7, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation provided on 
November 30, 2021. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that the cost is too high 
for a short trip. 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 a $325 
copayment for each ambulance trip.  
 
You have been asked to pay $285.36, which is less than the $325 copayment for the ambulance transportation. 
The ambulance transportation falls within the Ambulance 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 copayment for ambulance transportation provided on November 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance (D4910) provided by a participating 
provider on January 28, 2022. 
 
You asked the Plan to pay for periodontal maintenance. You say that you believe this is a scam. The Plan 
denied your request. The Plan says the rendered dental service is not a covered benefit. 
 
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 
periodontal maintenance (D4910) provided by a participating provider on January 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve an office visit. You say that you need a second opinion. The Plan denied 
your request. The Plan says the services have been requested from an out-of-network provider. 
 
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 
an office visit to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 1, 2021, billed with 
codes 81206 and 81292. 
 
You asked the Plan to pay for the genetic testing as billed. You say that this testing was medically necessary 
and should be covered. The Plan denied your request. The Plan says this should have been billed with a single 
panel code. Therefore, only 11 of the 13 billed codes are approved for payment. 
 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 procedure that was not billed with a single 
panel code. Based on this information, we decided that Medicare rules for coverage of the genetic testing as 
billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing 
provided on March 1, 2021, billed with codes 81206 and 81292.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the reline complete mandibular denture (indirect) (D5751) 
provided January 25, 2022. 
 
You asked the Plan to pay for the reline complete lower denture. You say that you feel both the upper and 
lower dentures should be covered. The Plan denied your request. The Plan says you have already used your 
benefit 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 Plans coverage rules apply in this case. The Plan covers one reline of 
a complete upper or lower denture per calendar year.  
 We looked at file and Medicare rules. The Plan provided documentation showing that they are covering one 
complete denture reline provided January 25, 2022. Based on this information, we decided that the Plan's 
frequency limit has been exceeded with the reline of the complete lower denture. Therefore, we decided that 
the Plan does not have to pay for the reline complete mandibular denture (indirect) (D5751) provided January 
25, 2022.