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

 
We decided that the Plan does not have to pay for 9 additional units of code 88341 provided on January 29, 
2021. 
 
You asked the Plan to pay for the additional units. The Plan denied your request. The Plan says the additional 
units are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
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 additional units Our reviewer says that 9 
additional units of code 88341 are not supported by the records provided. Our physician reviewer found that 
the laboratory report does not support an additional 9 units of service. The laboratory report describes 13 stains 
were completed. 
 
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 additional units have not been met. Therefore, we decided that the Plan does 
not have to pay for 9 additional units of code 88341 provided on January 29, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan, of the 
thorax, diagnostic; with contrast material(s) (71260) provided on February 16, 2022. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
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 
$50-$100 copayment for each Medicare-covered computed tomography (CT) scan. You must pay a $50 copay 
for services performed at a non-hospital facility and a $100 copay for services performed at a hospital facility.  
 
You have been asked to pay a $100 copayment for the CT scan provided at a hospital facility. 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 the computed tomography (CT) scan, of the 
thorax, diagnostic; with contrast material(s) (71260) provided on February 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implant placement (D6010) for tooth # 31. 
 
You asked the Plan to pre-approve the dental service. You say that a plan representative confirmed that the 
extractions and implant would be covered. You also say that this was confirmed 3 separate times. The Plan 
denied your request. The Plan says implant placement is not listed as a covered 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested implant placement is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an 
implant placement (D6010) for tooth # 31.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the 2D oral/facial photographic images obtained intra-orally 
or extra-orally (D0350) and the oral hygiene instructions (D1330) provided on April 5, 2022. 
 
You asked the Plan to pay for the services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services provided are not covered under 
your contractual policy. 
 
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 services provided in this case are 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
2D oral/facial photographic images obtained intra-orally or extra-orally (D0350) and the oral hygiene 
instructions (D1330) provided on April 5, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care provided on July 13, 2021. 
 
You asked the Plan to pay for initial hospital care. You say that the enrollee was not on hospice care for this 
service. The Plan denied your request. The Plan says original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for initial hospital care provided on July 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cone beam computed tomography (CT) capture (D0364) 
and pulp vitality test (D0460) provided on January 20, 2022. 
 
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 the dental services are not listed as covered. 
 
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 cone beam CT capture and pulp 
vitality test are not among those covered under this benefit. Therefore, we decided that the Plan does not have 
to pay for the cone beam computed tomography (CT) capture (D0364) and pulp vitality test (D0460) provided 
on January 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene panel testing provided on August 30, 2021. 
You asked the Plan to pay for the testing services. You say that you enable physicians to deliver personalized 
cancer care. The Plan denied your request. The Plan says the submission of claims using individual codes is 
considered incorrect coding. 
 
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. It is not appropriate to separately report CPT 81292 from the panel. 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 testing provided on August 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), bitewing x-rays (D0274), 
and prophylaxis (D1110) provided on October 18, 2021. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says the dental services were received from an out-of-network provider 
and are not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a periodic oral evaluation (D0120), bitewing x-rays (D0274), and prophylaxis (D1110) provided on 
October 18, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Synvisc (J7325) for the left knee. 
 
You asked the Plan to pre-approve Synvisc for the left knee. You say that the requested drug is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for coverage of 
the requested drug have 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 Synvisc for the left knee. Our reviewer 
says that the requested drug is not medically reasonable and necessary in this case. Our physician reviewer 
found that, based on the medical records provided and the Medicare-approved drug compendia, there is no 
documentation that the Synvisc at issue in this case meets Medicare criteria for medically reasonable and 
necessary. Provided records do not document radiologic imaging confirming the diagnosis of osteoarthritis of 
the left knee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Synvisc for the left knee have not been met. Therefore, we decided that the 
Plan does not have to pre-approve treatment with Synvisc (J7325) for the left knee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periapical x-ray (D0220) and protective restoration 
(D2940) provided on March 5, 2022. 
 
You asked the Plan to pay for the dental services. You say that your tooth cracked in half. You say that the x-
ray was necessary to see how far the crack went. You also say that you do not see why this would not be 
covered. The Plan denied your request. The Plan says the services you received are not listed as covered. 
 
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 and protective restoration are not among those covered under this benefit. Therefore, we decided that the Plan does not have 
to pay for the periapical x-ray (D0220) and protective restoration (D2940) provided on March 5, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home health (HH) physical therapy (PT) visits (CPT 
code G0151 x9). 
 
You asked the Plan to pre-approve the home health physical therapy visits. You say that the services are 
necessary. The Plan denied your request. The Plan says the medical record does not document a clearly evident 
need for the services of a skilled physical therapist. The Plan states the enrollee has already been educated on a 
home exercise program and there is no documentation of an active or acute on chronic condition that would 
necessitate a new program. 
 
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 the home health physical therapy visits. 
Our physician reviewer found the health plans denial should be upheld. The enrollee does not have 
documented, ongoing, HH PT needs. The enrollee is functioning at a level commiserate with a lower level of care (i.e., HEP, outpatient therapy). As such, the requested, ongoing, HH PT services are not medically 
necessary or reasonable. 
 
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 home health physical therapy visits have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the home health (HH) physical therapy (PT) visits (CPT 
code G0151 x9).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that you need these inserts because you are diabetic 
and the current ones you have are broken and hurt while walking. The Plan denied your request. The Plan says 
this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services (D1110, D0150, D0210) provided by an out-
of-network provider on April 28, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the charges. The Plan denied your request. The Plan says the dental services denied correctly as they were 
provided by a provider who is out-of-network with the plan. 
 
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 record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for dental services (D1110, D0150, D0210) provided by an out-of-network provider on April 28, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9128 billed for date of service January 12, 
2022. 
 
You asked the Plan to pay for procedure code S9128. You say that this service was medically necessary and 
should be paid. The Plan denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
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 code S9128 has a Status Indicator of I on the Physician Fee Schedule. This means that CPT 
code S9128 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for 
coverage of procedure code S9128 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code S9128 billed for date of service January 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance (dental code D4910) provided on 
March 30, 2022. 
 
You asked the Plan to pay for periodontal maintenance. You say that you would like for the Plan to pay for this 
service. The Plan denied your request. The Plan says the denial for this service is correct, because periodontal 
maintenance is only allowed when the enrollee has had a deep cleaning done in the past by the 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, periodontal maintenance is only 
covered after a deep cleaning has been performed. The documentation submitted does not support that a deep 
cleaning was performed prior to receiving periodontal maintenance. Therefore, we decided that the Plan does 
not have to pay for periodontal maintenance (dental code D4910) provided on March 30, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services provided on July 16, 2021. 
 
You asked the Plan to pay for anesthesia services. The Plan denied your request. The Plan says the enrollee was 
enrolled in hospice on July 16, 2021, passed away the same day, therefore, traditional Medicare is the primary 
payer. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for anesthesia services provided on July 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pontic (D6241) for tooth # 19, and retainer crowns 
(D6751) for teeth # 18 and 20. 
 
You asked the Plan to pre-approve the dental services. You say that the tooth area of 18 to 20 is a major 
function area. You also say that it is essential to replace with a bridge. The Plan denied your request. The Plan 
says the criteria have not been met. 
 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 dental 
services when the services are medically necessary and reasonable.  
 
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 dental services. Our reviewer says 
that the coverage criteria for the requested dental services have not been met. Our physician reviewer found the 
Plan criteria does not allow for bridgework where there are no missing anterior teeth and only posterior missing 
teeth. The reviewer found that the criteria would not be met as the allowance is limited to replacing two 
adjacent lower anterior teeth when there are no missing posterior teeth. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a pontic (D6241) for tooth # 19, and retainer crowns (D6751) for teeth # 18 and 20.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the first radiographic image (code D0220) and each 
additional film (code D0230) provided on March 31, 2022. 
 
  You asked the Plan to pay for the first radiographic image and each additional film. The Plan denied your 
request. The Plan says the intraoral x-rays are not a covered benefit 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, intraoral x-rays are not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for intraoral-periapical 
first radiographic image (code D0220) and intraoral-periapical each additional film (code D0230) provided on 
March 31, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care (99232) provided on July 28, 
2021. 
 
You asked the Plan to pay for the hospital care. You say that the claim should be paid. The Plan denied your 
request. The Plan says the enrollees claim would be covered under Original Medicare as it is responsible for 
coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is 
revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage before rendering 
services and to know proper billing procedures for a Medicare Advantage member on hospice. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on July 20, 2021. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for the subsequent hospital care 
(99232) provided on July 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (77001, 36580) provided on January 21, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are not 
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. In this case, we have confirmed that code 77001 
is an add-on code and has not been billed with an appropriate primary procedure code. Based on the claim 
submitted, Medicare billing criteria have not been met. 
 
Medicare rules also say that the Medicare approved amount for global surgery procedures includes payment for 
services related to the surgery when furnished by the physician who performs the surgery. Payment for the 
requested services (36580) provided on January 21, 2022, is included in the global surgical payment for the 
procedure (10160) provided on January 20, 2022. Procedure code 10160 has a global surgical period of 10 
days. Therefore, we decided that the Plan does not have to pay for the services (77001, 36580) provided on 
January 21, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the over-the-counter (OTC) COVID-19 test purchased on 
February 2, 2022. 
 
You asked the Plan to pay for the COVID-19 test. You say that you were unable to get the free test kits, and 
this was purchased before Medicare covered them. The Plan denied your request. The Plan says OTC COVID-
19 tests are not eligible for coverage through the Plan, they are only eligible for coverage through Original 
Medicare. 
 
  The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and the 
COVID-19 test is an OTC item. While Original Medicare started covering these tests on April 4, 2022, 
Medicare Advantage plans are able to elect to provide a supplemental benefit for this or elect not to do so. 
Therefore, we decided that the Plan does not have to pay for the over-the-counter (OTC) COVID-19 test 
purchased on February 2, 2022.