Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the office visit (99204), computed 
tomography, of the maxillofacial area; without contrast material (70486), and the unlisted maxillofacial 
prosthetic procedure (21089) rendered by the out-of-network (OON) provider on February 18, 2022 and 
February 25, 2022. 
 
You asked the Plan to issue reimbursement for these 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 at 
issue are not payable as they were rendered by an out-of-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.   
  
We looked at this case file and the Plans rules. Based on this information, we decided that the Plan's rules for 
coverage of these services have not been met. Specifically, the services in this case were rendered by an  
out-of-network dental provider. The Plan contract states that if you visit a dentist that is not in the dental 
network, you will be responsible for 100% of the costs. Therefore, we decided that the Plan does not have to 
issue reimbursement for the office visit (99204), computed tomography, of the maxillofacial area; without 
contrast material (70486), and the unlisted maxillofacial prosthetic procedure (21089) rendered by the out-of-
network (OON) provider on February 18, 2022 and February 25, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nutech (Organogenesis) NuCel 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 medical necessity for the denied procedure/services has not 
been established after clinical review and per the peer-reviewed medical 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. There is limited 
published, large-scale, long-term peer-reviewed literature that shows the NuCel to be an effective and/or safe 
treatment for the enrollee's pathology. 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 Nutech (Organogenesis) NuCel Allograft for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 81206, 81235, 81292, 81301, 
and 81321 provided on October 21, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 We find that CPT codes 81206, 81235, 81292, 81301, and 81321 are not supported in the medical record. 
Specifically, when a laboratory assays two or more genes in an enrollee in parallel, those two or more genes 
will be considered part of the same panel. A panel constitutes one single procedural service, so one code must 
be submitted for the panel. Review of the file does not support that only one code was submitted for the panel. 
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 laboratory services coded 81206, 
81235, 81292, 81301, and 81321 provided on October 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive this copayment  for a specialist visit on July 1, 2021. 
 
You asked the Plan to waive this copayment  for a specialist visit on July 1, 2021. You say that you don't feel 
you are responsible for this copayment. The Plan denied your request. The Plan says you must pay a $20 
copayment for each specialist visit. 
 
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 $20 
copayment for Physician/Practitioner Services, Including Doctor's Office Visits.  You have been asked to pay a 
$20 copayment for a specialist visit. Specialist visits fall 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 this copayment  for a specialist visit on July 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 81206, 81235, and 81321 
provided on October 15, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 81206, 81235, and 81321 are not supported in the medical record. Specifically, when a 
laboratory assays two or more genes in an enrollee in parallel, those two or more genes will be considered part 
of the same panel. A panel constitutes a single procedural service, so one code must be submitted for the panel. 
Review of the file does not support that only one code was billed for the panel provided. 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 laboratory services coded 81206, 81235, and 
81321 provided on October 15, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on September 30, 2021. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the billed 
services cannot be verified. 
 
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 87491 is infectious agent detection by nucleic acid (DNA 
or RNA); Chlamydia trachomatis, amplified probe technique. The CPT Code Manual definition of code 87591 
is infectious agent detection by nucleic acid (DNA or RNA); Neisseria gonorrhoeae, amplified probe 
technique. The CPT Code Manual definition of code 87661 infectious agent detection by nucleic acid (DNA or 
RNA); Trichomonas vaginalis, amplified probe technique. 
 
We find that the CPT codes are not supported in the medical record. Specifically, the records do not show that 
these tests were provided. 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 lab testing services 
provided on September 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic x-ray (D0330) provided on March 4, 2022. 
 
You asked the Plan to pay for an x-ray. You say that according to your records the last time you had this 
service done was on September 15, 2015. The Plan denied your request. The Plan says this service is covered 
by the Plan's dental benefit; however, your benefit for one full mouth x-ray series (D0210) or a panoramic x-
ray (D0330) every five years has been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers one full 
mouth x-ray series (D0210) or a panoramic x-ray (D0330) every five years. 
 
We looked at this case file, the Plan's rules, and Medicare rules. The record shows the Plan paid for a full 
mouth x-ray series provided on June 25, 2021; therefore, the benefit for one full mouth x-ray series or a 
panoramic x-ray has been exhausted. Therefore, we decided that the Plan does not have to pay for a panoramic 
x-ray (D0330) provided on March 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gingival irrigation - per quadrant (D4921) provided 
November 2, 2021. 
 
You asked the Plan to pay for the gingival irrigation. You say that you feel the wrong code was submitted for 
this service. The Plan denied your request. The Plan says this service is not covered under your benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
gingival irrigation - per quadrant (D4921) provided November 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction, erupted tooth requiring removal of bone 
and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210) provided 
January 19, 2022. 
 
You asked the Plan to pay for the surgical extraction. You say that you feel this is covered. The Plan denied 
your request. The Plan says this service is not covered under your benefits. A corrected claim has been 
requested from the 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. Therefore, we decided that the Plan does not have to pay for the 
extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of 
mucoperiosteal flap if indicated (D7210) provided January 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the osseous surgery, 4 or more contiguous teeth per quadrant 
(D4260), bone replacement graft (D4263), osseous surgery, 1 to 3 contiguous teeth per quadrant (D4261), 
collection and application of autologous blood concentrate product (D7921), and nitrous oxide (D9230) 
provided on February 16, 2022. 
 You asked the Plan to pay for the dental services. You say that you feel this should be covered under your 
medical coverage. You say that you were given gas, had an incision, and stitches. You also say this should be 
considered surgery. The Plan denied your request. The Plan says the dental 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 osseous surgery, bone replacement 
graft, collection and application of autologous blood concentrate product, and nitrous oxide are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the osseous 
surgery, 4 or more contiguous teeth per quadrant (D4260), bone replacement graft (D4263), osseous surgery, 1 
to 3 contiguous teeth per quadrant (D4261), collection and application of autologous blood concentrate product 
(D7921), and nitrous oxide (D9230) provided on February 16, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 12 additional physical therapy visits. 
 
You asked the Plan to pre-approve 12 additional physical therapy visits. You say that these services are 
medically necessary. The Plan denied your request. The Plan says that a home exercise program should help 
you reach your goals. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 12 additional physical therapy visits. 
Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent 
deterioration of the enrollee's condition. Our physician reviewer found that your condition does not meet 
criteria for coverage of 12 additional physical therapy visits. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 12 additional physical therapy visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 12 additional physical therapy visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional payment for the crown - full cast predominantly 
base metal (D2791) provided March 9, 2022. 
 
You asked the Plan to provide additional payment for the crown. You say that you were quoted a lower cost for 
the services than you are being asked to pay. The Plan denied your request. The Plan says the cost sharing has 
been applied correctly. The cost of dental services varies from office to office. 
 
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 crown 
with 50% coinsurance after the $50 deductible is met.  
 
We looked at the file and Medicare rules. You have been asked to pay your $50 deductible plus 50% of the 
contracted rate for the crown. This means you have been asked to pay the correct amount based on your 
contract with the Plan. Therefore, we decided that the Plan does not have to provide additional payment for the 
crown - full cast predominantly base metal (D2791) provided March 9, 2022.   
Your complaint about differences between contracted rates and potentially being provided inaccurate 
information when requesting an estimated quote for services is not a valid appeal for medical coverage. This 
part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for acute inpatient hospital services provided to the enrollee from May 30, 
2021, to June 4, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this was medically necessary. The 
Plan denied your request. The Plan says that the enrollee was stable from the emergency room. 
 
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 pay for acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the enrollee presented for evaluation of hip pain after a fall on 5/30/21. An x-ray revealed a 
fracture, and he was admitted for surgical stabilization and pain management. He was discharged on 6/4/21. 
The record does show that at the time of inpatient admission, the admitting physician reasonably expected that 
the enrollee's necessary hospital care (including earlier emergency department and/or observation care) would 
span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for acute inpatient hospital services provided to the enrollee from May 30, 2021, to June 4, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve arthrodesis, posterior or posterolateral technique, single 
interspace; lumbar (with lateral transverse technique, when performed) (22612). 
 
You asked the Plan to pre-approve spinal fusion. You say that the requested procedure is medically necessary. 
 The Plan denied your request. The Plan says the requested procedure does not meet criteria. 
 
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 spinal fusion. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the request is for the use of the device as a stand-alone procedure, not as part of a spine surgery. 
The North American Spine Society says, no literature supports the use of interspinous fixation without 
performing an open decortication and fusion of the posterior bony elements or interbody fusion. This is 
considered experimental/ investigational. 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of spinal fusion have not been met. Therefore, we decided that the Plan does not 
have to pre-approve arthrodesis, posterior or posterolateral technique, single interspace; lumbar (with lateral 
transverse technique, when performed) (22612).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on March 31, 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 March 31, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the office visit provided on February 21, 2022.

You asked the Plan to waive the deductible for the office visit. You say that you paid the $10 specialist copay and can't understand why you are being charged more. The Plan denied your request. The Plan says the deductible amount was applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan clearly says that there is $500 deductible which applies to office visits. 

The item or service you asked the Plan to waive the deductible for falls within the benefit category "Physician/Practitioner Services, Including Doctor's Office Visits." The Plan has followed Medicare rules by clearly disclosing in the contract that the $500 deductible applies to office visits. This cost sharing is a contractual obligation that had not been met at the time the office visit was received on February 21, 2022. Therefore, we decided that the Plan does not have to waive the deductible for the office visit provided on February 21, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from January 
11, 2022, to February 5, 2022. 
 
You asked the Plan to pay for the SNF care provided from January 11, 2022, to February 5, 2022. You say that 
the services are coverable under the Medicare Act. The Plan denied your request. The Plan says the SNF care 
was not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the SNF care provided from January 7, 
2022, to January 10, 2022. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. 
Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy 
needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the SNF care provided from January 7, 2022, to January 10, 2022 have not been 
met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) care 
provided from January 11, 2022, to February 5, 2022.