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

 
We decided that the Plan does not have to pay for lab services (80048, 82570, 80178, 82043) provided on 
December 22, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says there were network providers available. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the services at issue in this appeal. The Plan did not pre-approve the service 
at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided 
that the Plan does not have to pay for lab services (80048, 82570, 80178, 82043) provided on December 22, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an orthosis (L1686, L2624) provided November 23, 2021. 
 
You asked the Plan to pay for the orthosis. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed services. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
 The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. The record does not show that the provided discussed the need for this item with the enrollee. The 
record shows that the Plan made several attempts to obtain the necessary documentation without success. 
Therefore, we decided that the Plan does not have to pay for an orthosis (L1686, L2624) provided November 
23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency anesthesia services rendered on September 
27, 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 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. 
 
We find that CPT code 99140 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99140 is not separately payable. 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 pay for the 
emergency anesthesia services rendered on September 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140), and intraoral imaging 
(D0220 and D0230) provided by a participating provider on August 27, 2021. 
 
You asked the Plan to pay for a limited oral evaluation and intraoral imaging. You say that you would like the 
Plan to reimburse you. The Plan denied your request. The Plan says this claim has been processed correctly. 
 
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 a limited oral 
evaluation and intraoral imaging when the services are medically necessary and reasonable.  
 
We looked at the file and Medicare rules. These services have been processed correctly, applying a 50% 
coinsurance to the rendered dental services. Based on this information, we decided that the Plan's rules for 
coverage of a limited oral evaluation and intraoral imaging have been correctly applied. Therefore, we decided 
that the Plan does not have to pay for a limited oral evaluation (D0140), and intraoral imaging (D0220 and 
D0230) provided by an out-of-network provider on August 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an impacted tooth removal (D2740), deep sedation (D9222 
and D9223), a diagnostic consultation (D9310), and therapeutic parental drugs (D9612) provided by a 
participating provider on October 28, 2021. 
 
You asked the Plan to pay for an impacted tooth removal, deep sedation, a diagnostic consultation, and 
therapeutic parental drugs. You say that you were told that these services would be covered. The Plan denied 
your request. The Plan says this claim has been processed and denied 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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an impacted tooth removal (D2740), deep sedation (D9222 and D9223), a diagnostic consultation (D9310), and 
therapeutic parental drugs (D9612) provided by a participating provider on October 28, 2021.  
 
Tooth extractions (D7210) have been processed correctly with a 50% coinsurance of the allowed amount being 
applied.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vertical bitewing x-rays (D0277) provided on September 
28, 2021. 
 
You asked the Plan to pay for the dental service. You say that the basic regular x-ray cost should be applied to 
this service in the amount of $120. The Plan denied your request. The Plan says vertical bitewing x-rays are 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 vertical bitewing x-rays are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
vertical bitewing x-rays (D0277) provided on September 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital services provided to the enrollee on January 1, 2022. 
 
You asked the Plan to pay for the services. You say that  The Plan denied your request. The Plan says the claim 
is a duplicate. 
 
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 99217 is "Observation care discharge day management."  
We find that CPT code 99217 is not supported in the medical record. Specifically, the case file appears to show 
that this code was already paid for, and that the denied charge is indeed a duplicate. 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 hospital services provided to the enrollee on January 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient hospital observation provided 
from October 25, 2021, to October 27, 2021. 
 
You asked the Plan to waive the copayment for observation stay. You say that inpatient care was needed over 
observation level of care. The Plan denied your request. The Plan says the copayment amount you are being 
charged is correct. 
 
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 $200 
copayment for observation stay. The $200 copayment for observation is less than the $325 copayment for 
inpatient hospital care, resulting in a lower cost-share responsibility for you.   
You have been asked to pay $200 copayment for observation stay. Observation stay falls within the Outpatient 
Hospital Observation 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 outpatient 
hospital observation provided from October 25, 2021, to October 27, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (81479) provided August 9, 2021. 
 
You asked the Plan to pay for the genetic testing. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed services. 
 
The Plan must follow Medicare rules. Medicare rules say that GeneSight testing may only be ordered by 
licensed psychiatrists or neuropsychiatrists contemplating an alteration in neuropsychiatric medication for 
patients diagnosed with major depressive disorder (MDD). 
 
We looked at the file and Medicare rules. No clinical records from the ordering physician were provided to 
support a diagnosis of major depressive disorder. The records do not show this service was ordered by a 
licensed psychiatrist or neuropsychiatrist. Based on this information, we decided that Medicare rules for 
coverage of the genetic testing have not been met. 
 
 
 
 
  
 
 Therefore, we decided that the Plan does not have to pay for genetic testing (81479) provided August 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), complete series 
x-ray (D0210), prophylaxis (D1110) provided on September 20, 2021. 
 
You asked the Plan to pay for the dental services. You say that you were sent a list of dentists in your area. You 
also say that you chose this office because they were close to your home. The Plan denied your request. The 
Plan says the provider in this case was out of network on the date of service in this case. 
 
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 services received out of network 
are not among those covered under this benefit.  Additionally, the record does not indicate that the provider in this case is listed on the provider list. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), complete series x-ray (D0210), prophylaxis (D1110) provided on September 20, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve SNF admission. You say that SNF admission is medically necessary for the 
member. The Plan denied your request. The Plan says the member does not meet criteria for SNF admission. 
 
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 pre-approve SNF admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the member has stabilized medically and 
is ready for discharge from the hospital. The member does not require skilled nursing and/or skilled therapy 
services on a daily basis. She is medically stable and can receive further rehab services at a lower level of care. 
Although further rehab services would be appropriate to improve function, as a practical matter, the 
intermittent skilled services can be provided at a lower level of care than a skilled nursing facility. The member 
does not have any parental medication; complex wound care or nutrition given via a feeding tube. She is 
medically stable without any acute exacerbations of chronic medical problems.  Her physical function is at or 
near her baseline and she can receive services at a lower level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) admission.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Inpatient hospital care on September 7, 
2021 to September 15, 2021. 
 
You asked the Plan to waive the copayment for Inpatient hospital care. You say that you were informed that 
your fees would be covered. The Plan denied your request. The Plan says the copayment applied was correct. 
 
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 $150 
copayment per day, days 1-5; $0 per day, days 6-90; $0 copay for additional days for Inpatient hospital care. 
The total cost share amount is $750. 
 You have been asked to pay a $150 copayment per day, days 1-5; $0 per day, days 6-90; $0 copay for 
additional days. for Inpatient hospital care. Inpatient hospital care falls within the Inpatient hospital care 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 Inpatient hospital care on September 7, 2021 to 
September 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture services (97810, 97811, 99204) provided 
September 13, 2021 to October 25, 2021. 
 
You asked the Plan to pay for the acupuncture services. You say that the services were medically necessary and 
should be covered. The Plan denied your request. The Plan says the provider is not eligible for Medicare 
payment. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare.  
 
 However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. These treatments may be provided by a physician in accordance with state requirements, or 
by physician assistants, nurse practitioners/clinical nurse specialists, and auxiliary personnel if they meet 
certain licensure requirements. Auxiliary personnel furnishing acupuncture must be under the appropriate level 
of supervision of a physician, physician assistant, or nurse practitioner/clinical nurse specialist. 
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the rendering provider was not under the supervision 
of a physician, physician assistant, or nurse practitioner/clinical nurse specialist when services were provided. 
Therefore, we decided that the Plan does not have to pay for acupuncture services (97810, 97811, 99204) 
provided September 13, 2021 to October 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for problem focused oral exam (D0140) and resin-based 
composite, two surfaces, anterior (D2331) provided January 29, 2021. 
 
You asked the Plan to pay for the dental services. You say that you do not understand, even if you used an out 
of network doctor, why wasn't a portion of the bills paid, especially for the preventive care.  You request this issue be reviewed. You feel something should have been paid. The Plan denied your request. 
The Plan says enrollees must receive their dental services from an in-network provider. 
 
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. The requested provider in this case is not a network provider with the 
Plan. The Plan had network providers available who could have provided the items/services at issue in this 
appeal. The Plan did not pre-approve the item/service at issue.  Therefore, we decided that the Plan does not 
have to pay for problem focused oral exam (D0140) and resin-based composite, two surfaces, anterior (D2331) 
provided January 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on 
December 31, 2021. 
 
You asked the Plan to waive the copayment for the office visit. The Plan denied your request. The Plan says the 
claim processed correctly. 
 
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 $45 
copayment for Physician/Practitioner services, including doctor's office visits.  
 
You have been asked to pay a $45 copayment for the office visit. The office visit falls within the 
Physician/Practitioner services, including doctor's office visits 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 an office visit provided on December 31, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an out-of-network provider on 
October 6, 2020, and October 8, 2020. 
 
You asked the Plan to pay for dental services. You say that you would like a one-time reimbursement. The Plan 
denied your request. The Plan says services provided by an out-of-network provider are not covered. 
 
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 a limited 
number of dental services provided by participating provider. 
 
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 dental services have not been met. Therefore, we decided that the Plan does not 
have to pay for dental services provided by an out-of-network provider on October 6, 2020, and October 8, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Comprehensive Genomic Profile (CGP) testing provided to 
the enrollee on October 1, 2021. 
 
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. 
The Plan says this should be reported with only CPT 81479. 
 
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 81479. Based on this information, we decided that Medicare 
rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay 
for Comprehensive Genomic Profile (CGP) testing provided to the enrollee on October 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bitewing x-rays (D0272) provided on January 6, 2022. 
 
You asked the Plan to pay for the bitewing x-rays. You say that you did not have x-rays provided on the date in 
question. The Plan denied your request. The Plan says you had two intraoral x-rays (D0220, D0230) provided 
on the date in question along with the bitewing x-rays at issue. Your benefit covers 2 of these codes per 
calendar year. The intraoral x-rays have been paid for, but the bitewing x-rays have been denied as they exceed 
the frequency limitations of your 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. The Plan can cover 2 per 
calendar year of x-rays D0220, D0230, D0270, D0272, D0273 or D0274. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the x-rays are requested in a frequency 
that is not covered under this benefit. Documentation supports that the Plan has paid for intraoral x-rays 
(D0220 and D0230) provided on this same date. Therefore, we decided that the Plan does not have to pay for 
the bitewing x-rays (D0272) provided on January 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on December 
16, 2021. 
 
You asked the Plan to pay for the dental service. You say that it was determined you have mild periodontal 
disease. You say that this requires additional care to your cleaning your process. You say that you understand 
this service is not covered. You also say that you feel that payment for a regular cleaning should be applied to 
this service. The Plan denied your request. The Plan says periodontal maintenance is not 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the periodontal maintenance is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
periodontal maintenance (D4910) provided on December 16, 2021.