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

 
We decided that the Plan does not have to pay for trimming of dystrophic nails, any number (G0127) provided 
December 13, 2021. 
 
You asked the Plan to pay for the podiatry services. You say that this service was performed due to the 
enrollee's medical conditions, and it is a covered procedure as per the plan. The Plan denied your request. The 
Plan says the claim was not submitted with the appropriate modifier 
 
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 G0127 Q8 is trimming of dystrophic nails, any number. 
HCPCS Modifier Q8 is used to report two class B findings as they pertain to routine foot care.  
 
We asked our coder 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 podiatry services. Our reviewer says that the Medicare 
criteria for coverage was not met. Our reviewer found the provider reported Q8 to indicate that the enrollee has 
two class B findings that qualify for coverage under Medicare. In this case, HCPCS G0127 would be supported 
by documentation submitted, however an appropriate modifier should be appended for services that are not 
normally reported together but are appropriate under the circumstances. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the podiatry services have not been met. Therefore, we decided that the Plan 
does not have to pay for trimming of dystrophic nails, any number (G0127) provided December 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the validity testing provided on February 28, 2022. 
 
You asked the Plan to pay for the testing services. You say that the lab tests for prescribed drugs and drugs of 
abuse. The Plan denied your request. The Plan says the code cannot be separately reimbursed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 We looked at the file and Medicare rules. We find that the testing described by billed code 83789 is considered 
specimen validity testing which is not separately payable. 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 validity testing provided on February 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on February 9, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says no modifiers are 
allowed with this code pair. 
 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 82465 is a column II code to column I code 80061 with a modifier 
indicator of 0. The column II code is therefore not payable. Based on the claim submitted, Medicare billing 
criteria have not been met. Therefore, we decided that the Plan does not have to pay for the lab services 
provided on February 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the blood smear services coded 85060 provided on March 
25, 2022. 
 
You asked the Plan to pay for the blood smear services. You say that you disagree with the Plan's 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 code 85060 is not supported in the medical record. Specifically, this code has a professional 
component/technical component of 8. This code was billed with a place of service 22 (on campus-outpatient 
hospital). Professional component/technical component indicator 8 identifies the professional component of 
clinical laboratory codes for which separate payment may be made only if the physician interprets an abnormal 
smear for hospital inpatient. No payment is recognized for this code furnished to hospital outpatients or non-
hospital patients. Based on this information, we decided that Medicare rules for coverage of the blood smear 
services have not been met. Therefore, we decided that the Plan does not have to pay for the blood smear 
services coded 85060 provided on March 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99204) provided on April 13, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not covered under your 
contractual policy or by Medicare. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit (99204) provided on April 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a reline complete lower denture (D5751) provided on April 
21, 2022. 
 
You asked the Plan to pay for the dental services. You say that that you were told both relines would be 
covered. The Plan denied your request. The Plan says your benefit for the requested item or service has already 
been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service April 21, 2022. You 
received the upper reline and since only one procedure code is covered per calendar year, the lower reline is 
denied. Therefore, we decided that the Plan does not have to pay for a reline complete lower denture (D5751) 
provided on April 21, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 77002 billed for date of service March 25, 2022. 
 
You asked the Plan to pay for procedure code 77002. You say that these services are supported in the medical 
records. The Plan denied your request. The Plan says they have agreed to pay for the other services; however, 
the provided documentation does not support the billing of code 77002. 
 
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 77002 is fluoroscopic guidance for needle placement (e.g., biopsy, aspiration, injection, localization 
device) (List separately in addition to code for primary procedure). 
 
We asked our coder 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 procedure code 77002. Our reviewer says that this service is 
not supported in the medical records provided. Our reviewer found that although an injection procedure was 
documented, the procedure report does not include documentation of fluoroscopic guidance and therefore this 
service cannot be confirmed as performed.  
 We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 77002 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 77002 billed for date of service March 25, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found documentation does not support the medical necessity due to lack of medical 
complexity and nursing needs, and slow progress for admission to an IRF. While you would benefit from physical and occupational therapy, your rehabilitation needs can be safely provided in an alternate and low 
intensity setting such as in an skilled nursing facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chemotherapy services (J9155, 96402) provided December 
15, 2021 . 
 
You asked the Plan to pay for the chemotherapy services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the claim cannot be paid 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 J9155, & 96402 are not supported in the medical record. Specifically, the claim was 
not submitted with a valid diagnosis code for the procedure (96402). Code J9155 cannot be paid without an 
approved procedure. Based on this information, we decided that Medicare rules for coverage of the 
chemotherapy services have not been met. Therefore, we decided that the Plan does not have to pay for 
chemotherapy services (J9155, 96402) provided December 15, 2021 .
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for endoscopy on May 31, 2022. 
 
You asked the Plan to waive the copayment for endoscopy. You say that you a colonoscopy which is a similar 
service and that was covered in full so this service should be as well. You say that the procedure was done in 
the provider's office, and you were unaware that they were going to charge an outpatient copay. The Plan 
denied your request. The Plan says the cost sharing 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 a $250 
copayment per visit for outpatient surgery. If you are having surgery in a hospital facility, you should check 
with your provider about whether you will be an inpatient or outpatient. Unless the provider writes an order to 
admit you as an inpatient to the hospital, you are an outpatient and pay the cost sharing amounts for outpatient 
surgery. Even if you stay in the hospital overnight, you might still be considered an outpatient.  
 
 
 
 You have been asked to pay a $250 copayment for endoscopy. Endoscopy falls within the Outpatient surgery, 
including services provided at hospital outpatient facilities and ambulatory surgical centers 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 endoscopy on May 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction, erupted tooth or exposed root (elevation 
and/or forceps removal) (D7140) and extraction, erupted tooth requiring removal of bone and/or sectioning of 
tooth, and including elevation of mucoperiosteal flap if indicated (D7210) provided April 25, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the dental services. You say that you had difficulty finding an in-network 
provider on the Plan's website. 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 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 the extraction, erupted tooth or exposed root (elevation and/or forceps removal) (D7140) and 
extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of 
mucoperiosteal flap if indicated (D7210) provided April 25, 2022, by an out-of-network (OON) provider.  
 
Your complaint about having difficulty finding network providers on the Plan's website 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (88120) provided January 12, 2022 . 
 
You asked the Plan to pay for the genetic testing. You say that this service was medically necessary. The Plan 
denied your request. The Plan says this service was for screening purposes and non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that bladder tumor marker fluorescence in situ 
hybridization (FISH) testing services are covered for diagnosis codes that support medical necessity. 
 
We looked at the file and Medicare rules. Diagnosis code N39.0 is not listed as a covered diagnosis code for 
this service. 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 (88120) provided 
January 12, 2022 .
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance (D4910) provided on March 14, 
2022, by an out-of-network provider. 
 
You asked the Plan to pay for the dental services. You say that the provider was out-of-network last year and is 
no different this year. 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 periodontal maintenance (D4910) provided on March 14, 2022, by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for an intraoral x-ray provided on November 19, 2021. 
 
You asked the Plan to pay more for the dental services. You say that you needed the implant so that you can 
chew food properly. The Plan denied your request. The Plan says your combined allowance for supplemental 
preventive and comprehensive dental services have been met. 
 
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, certain limitations apply. The record 
shows your $2,000 allowance was exhausted on date of service November 19, 2021. Therefore, we decided that 
the Plan does not have to pay more for an intraoral x-ray provided on November 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4341). 
 
You asked the Plan to pre-approve periodontal scaling and root planing. You say that the enrollee needs these 
services. The Plan denied your request. The Plan says these services 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 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 pre-approve 
periodontal scaling and root planing (D4341).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for genetic testing (0239U) provided February 26, 2021. 
 
You asked the Plan to pay for the genetic testing. You say that this service was medically necessary. The Plan 
denied your request. The Plan says that the plan was unable to review the appeal in the allotted timeframe. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The plan's denial letter did not clearly articulate the reason for the denial. The 
plan states they were unable to review the appeal within the allowed 60-day timeframe. The plan requested 
clinical records to support this service and the record shows that medical records were submitted by the 
provider for review. Therefore, we decided that the Plan has to pay for genetic testing (0239U) provided 
February 26, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided by a participating 
provider on April 25, 2022. 
 
You asked the Plan to pay for the dental services. You say that you cannot afford this. You say that you would 
like help paying for this. The Plan denied your request. The Plan says your benefit for the requested item or 
service has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service April 19, 2022. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided by a 
participating provider on April 25, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on December 22, 2021. 
 
You asked the Plan to pay for ambulance services. The Plan denied your request. The Plan says Original 
Medicare would be responsible for payment of all Medicare covered services related or unrelated to the 
members terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all 
hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-
for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until 
the first day of the month following the month in which hospice was revoked or discharged. 
 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 ambulance services provided on December 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on July 21, 2021. 
You asked the Plan to pay for the office visit. The Plan denied your request. The Plan says non-emergent, non-
urgent services with out-of-network providers require prior authorization. 
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 did not pre-approve the 
services 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 an office visit provided on July 21, 2021.