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

 
We decided that the Plan has to pay for the fluorescence in situ hybridization (FISH) testing provided on a 
urine sample on November 9, 2021. 
 
You asked the Plan to pay for the FISH testing. You say that this diagnosis was given by the treating provider. 
There is no regulation stating this cannot be paid with this diagnosis. The Plan denied your request. The Plan 
says that bladder tumor markers are not expected to be performed until other diagnostic studies fail to identify 
the etiology of the hematuria. 
 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for the FISH testing by a contract provider. The file does not show that the plan 
provided notice that the FISH testing would not be covered. There is no specific Medicare rule in the provider's 
jurisdiction which would indicate that this testing is noncovered for the enrollee's condition. Under Medicare 
rules, this means the FISH testing is considered approved by the plan. Therefore, we decided that the Plan has 
to pay for the fluorescence in situ hybridization (FISH) testing provided on a urine sample on November 9, 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance angiography (MRA). 
 
You asked the Plan to pre-approve an MRA. You say that an MRA is medically necessary. The Plan denied 
your request. The Plan says an MRA is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRAs must be reasonable and necessary for the 
diagnosis or treatment of the specific patient involved.  
 
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 an MRA. Our reviewer says that an 
MRA does not meet the Medicare coverage criteria. Our physician reviewer found that you have a history of 
epistaxis and a previous carotid endarterectomy. The record indicates that you underwent the requested service 
in May 2021. The provided record does not indicate that you satisfied the required criteria for a repeat study. 
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 a MRA have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a magnetic resonance angiography (MRA).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services (05650, 07140, 07310) provided October 
25, 2021, to October 28, 2021. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered. The Plan denied 
your request. The Plan says payment is not allowed for this claim because it was submitted with obsolete 
procedure codes. A corrected claim can be submitted to the Plan's Claims Department for reconsideration. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. In this case, the dental codes submitted are not valid. Based on this 
information, we decided that there is insufficient information in the record to determine if Medicare rules for 
coverage of the dental services (05650, 07140, 07310) provided October 25, 2021, to October 28, 2021 have 
been met. Therefore, we decided that the Plan does not have to pay for the dental services (05650, 07140, 
07310) provided October 25, 2021, to October 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on November 18, 2021. 
 
You asked the Plan to pay for dental code D0140. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says dental code D0140 is not covered under the 
Plan's supplemental dental benefit. 
 
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, dental code D0140 is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the limited oral 
evaluation (D0140) provided on November 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services provided on December 9, 2021. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the dental services were provided by a provider 
who has opted out of the Medicare program. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the dental 
services provided on December 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services provided from March 2, 2021, to March 4, 2021. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the provider has opted out of the Medicare 
program and services provided by a provider that has opted out of the Medicare program are not eligible for 
payment. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the dental 
services provided from March 2, 2021, to March 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for the fillings (D2332, D2335) provided 
on October 20, 2021, by the out of network dentist. 
 
You asked the Plan to pay an additional amount for the fillings. You say that dental is included in your 
coverage. The Plan denied your request. The Plan says no additional payment will be made for these services. 
 
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 and fillings are listed as covered, there 
is a 55% coinsurance when received out of network. Additionally, out of network providers may bill you for 
any amount greater than what the plan pays the provider. Therefore, we decided that the Plan does not have to pay an additional amount for the fillings (D2332, D2335) provided on October 20, 2021, by the out of network dentist.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Prolonged service in the inpatient or observation setting 
(99356) provided on April 15, 2021. 
 
You asked the Plan to pay for code 99356. 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 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 99356 is Prolonged service in the inpatient or observation 
setting, requiring unit/floor time beyond the usual service; first hour (List separately in addition to code for inpatient or observation Evaluation and Management service). 
 
We find that CPT code 99356 is not supported in the medical record. Specifically, the medical records 
submitted do not support a prolonged visit. Based on this information, we decided that Medicare rules for 
coverage of code 99356 have not been met. Therefore, we decided that the Plan does not have to pay for the 
Prolonged service in the inpatient or observation setting (99356) provided on April 15, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from April 8, 2022, forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from April 8, 2022, forward. You say that the 
services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue are 
not medically necessary. 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric care from April 8, 
2022, forward. Our reviewer says that you do not meet the criteria for acute inpatient mental health treatment 
beyond the date in question of April 8, 2022, forward. Our physician reviewer found you did not require 
inpatient mental health treatment beyond April 8, 2022, as you were not a danger to yourself or others and did 
not have any delusions, auditory or visual hallucinations. It did not appear that active treatment was taking 
place beyond the date in question. It did not appear that the services for the dates in question were reasonably 
expected or medically necessary to improve your condition or for the purpose of diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care from April 8, 2022, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from April 8, 2022, 
forward.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on 
November 30, 2021. 
 
You asked the Plan to pay for the comprehensive oral evaluation. You say that the first dentist's fax machine 
was not working correctly. You say that the documents had been faxed to this new dentist. You also say that 
they were unable to read them. The Plan denied your request. The Plan says comprehensive oral evaluation is 
covered once every 3 plan years. The Plan also says that the frequency limit has been exceeded. 
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 and comprehensive oral evaluation is 
covered once every 3 plan years, the frequency limit has been exceeded. The record shows that the Plan paid 
for a comprehensive oral evaluation that you received on September 7, 2021. Therefore, we decided that the 
Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on November 30, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services received from June 10, 
2021, to August 31, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says a licensed professional counselor is not eligible to bill Medicare for mental health services. 
 
The Plan must follow Medicare rules. Medicare rules say that services must be provided by providers who are 
enrolled in the Medicare program. 
 
The rendering licensed professional counselor is not eligible to bill Medicare for mental health services. 
The Plan did not pre-approve the services. We found no exception that would require the Plan to pay for these items/services. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for outpatient mental health services received from June 10, 2021, to August 31, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the mandibular partial denture (D5214) provided on 
October 13, 2021. 
 
You asked the Plan to pay more for the mandibular partial denture. You say that you would like this service to 
be covered. The Plan denied your request. The Plan says you reached your maximum benefit amount allowed 
for the 2021 calendar year. 
 
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 Plan offers a $3,000 annual dental 
benefit maximum. The contract says that after your annual maximum benefit maximum has been met, you are 
responsible for the full charges of any additional dental services. The record shows that you met the annual 
maximum benefit while processing this claim for the October 13, 2021 date of service and your annual 
maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay more for the 
mandibular partial denture (D5214) provided on October 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay the in network rate for the periapical x-rays (D0220, D0230), 
panoramic x-ray (D0330), and scaling and root planing (D4341 x 4) provided from September 10, 2021, to 
October 4, 2021. 
 
You asked the Plan to pay the in network rate for the periapical x-rays, panoramic x-ray, and scaling and root 
planing. You say that the dental office advised they accepted your insurance. You say that you thought it went 
through as you went twice for dental services. You also say that your dentist advised you should have a deep 
cleaning before surgery to ensure no infection was present. The Plan denied your request. The Plan says 
periapical x-ray, panoramic x-ray, and scaling and root planing are not listed as covered services.  
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the periapical x-ray, panoramic x-ray, 
and scaling and root planing are not among those covered under this benefit regardless of the provider's 
network status. Therefore, we decided that the Plan does not have to pay the in network rate for the periapical 
x-rays (D0220, D0230), panoramic x-ray (D0330), and scaling and root planing (D4341 x 4) provided from 
September 10, 2021, to October 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional intraoral periapical x-ray (D0230) provided on 
June 14, 2021. 
 
You asked the Plan to pay for the additional intraoral periapical x-ray. You say that you were not aware that an 
extra x-ray was taken or needed. You also say that you feel you should not be held responsible for the bill. The 
Plan denied your request. The Plan says your benefits for this service have been satisfied and the frequency 
limitation has been exceeded. 
 
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, intraoral x-rays are limited to one 
procedure per calendar year. The record shows that you received a first intraoral periapical x-ray (D0220) on 
June 14, 2021 and your intraoral x-rays benefit has been exhausted. Therefore, we decided that the Plan does 
not have to pay for the additional intraoral periapical x-ray (D0230) provided on June 14, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate and InQu Allograft for the 
enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that the clinical value and effectiveness of these services have not been 
demonstrated in the peer-reviewed literature. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Bone marrow 
aspirate and InQu Allograft are experimental. More research is needed to show safety and efficacy. Our 
physician reviewer found that the enrollee's condition does not meet criteria for coverage of these services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve bone marrow aspirate and InQu Allograft for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient hospital services for the enrollee. 
 
You asked the Plan to pre-approve inpatient hospital services. You say that these services are medically 
necessary. The Plan denied your request. The Plan says that there is no documentation provided to support the 
expectation the enrollee will require a greater than 2 midnight stay. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
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 inpatient hospital services. Our 
reviewer says that inpatient hospital services are not medically reasonable and necessary. The enrollee is 
medically stable and has been provided medical clearance to undergo this elective procedure. The planned 
procedures are not listed on the Inpatient Only List. The procedures are considered to be ambulatory. There is 
no documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay. 
Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of inpatient 
hospital 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 inpatient hospital services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve inpatient hospital services for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hereditary cardiovascular screening panel provided on 
May 27, 2021. 
 
You asked the Plan to pay for the testing services. You say that medical necessity has been signed off. The Plan 
denied your request. The Plan says the provider did not order cardiovascular genetic testing. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
We looked at the file and the rules. The file shows that the enrollee's treating physician did not order the testing 
services at issue. The medical records provided do not show that the testing would impact clinical management 
of a specific problem. 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 hereditary 
cardiovascular screening panel provided on May 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the 2 core build up (D2950), and 2 root canals (D3310) 
provided on November 2, 2021. 
You asked the Plan to pay for the 2 core build up and 2 root canals. You say that the services should be 
covered. The Plan denied your request. The Plan says core build up is not listed as a covered service. The Plan 
says that root canal is not listed as a covered service either. 
 
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 2 core build up and root canals are 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 2 
core build up (D2950), and 2 root canals (D3310) provided on November 2, 2021.