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

 
We decided that the Plan does not have to pay for the gene panel testing provided on October 24, 2021. 
 
You asked the Plan to pay for the testing services. You say that the gene panel will establish specific mutations. 
The Plan denied your request. The Plan says the testing is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or 
provider must corroborate the documentation in the beneficiary's medical documentation. 
 
 
 We looked at the file and Medicare rules. In this case, there are no medical records from the enrollees treating 
physician to show how testing of the 648 genes will impact clinical management. There are no records to show 
that the testing was needed for the treatment of a specific medical problem. Therefore, we decided that the Plan 
does not have to pay for the gene panel testing provided on October 24, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from June 25, 2022, forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from June 25, 2022, forward. You say that the 
requested services are medically necessary. The Plan denied your request. The Plan says the services at issue 
are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of inpatient psychiatric care from June 
25, 2022, forward have been met. No medical records were submitted for beyond June 24, 2022, as such, we 
cannot confirm whether criteria are met for these dates. Requests for coverage of these dates should be 
submitted to the Plan directly. Therefore, we decided that the Plan does not have to pre-approve inpatient 
psychiatric care from June 25, 2022, forward.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implant services on tooth #'s 7 and 10 (D6057, D6059). 
 
You asked the Plan to pre-approve implants. You say that you disagree with the denial for implant services. 
The Plan denied your request. The Plan says implant services (D6057, D6059) are not covered by your dental 
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. 
 
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 
implant services on tooth #'s 7 and 10 (D6057, D6059).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the imaging services provided on April 5, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the imaging services. You say that you would like the claim reviewed and 
reprocessed for payment. The Plan denied your request. The Plan says the rendering and referring providers are 
both OON providers and there was no approved authorization. Also, the service rendered was not urgent or 
emergent. 
 
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 items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the imaging services provided on April 5, 2022, by 
an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a prefabricated post and core (D2954) and a crown (D2740), 
provided by an out-of-network provider on January 24, 2022. 
 
You asked the Plan to pay for a prefabricated post and core and a crown. You say that you thought that you 
would be covered at 50%. The Plan denied your request. The Plan says the rendered dental services are not 
covered 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 a 
prefabricated post and core (D2954) and a crown (D2740), provided by an out-of-network provider on January 
24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown on tooth #29 (D2740). 
 
You asked the Plan to pre-approve a crown. You say that you would like the Plan to approve a second crown 
this year since you did not get one last year due to COVID-19. The Plan denied your request. The Plan says this 
service is covered by the Plan's benefits; however, your benefit for one crown per year 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 Plans coverage rules apply in this case. The Plan covers one crown per 
year. 
 
We looked at this case file, the Plans rules, and Medicare rules. The record shows the Plan pre-approved 
coverage for a crown on tooth #4; therefore, the benefit for a crown has been exhausted. Therefore, we decided 
that the Plan does not have to pre-approve a crown on tooth #29 (D2740).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Group 3 power wheelchair (PWC), adjustable angle 
footplate, and cushion rendered on July 28, 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 there is no valid proof of delivery. 
 
The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that all DMEPOS 
suppliers are required to maintain proof of delivery. 
 
We looked at the file and Medicare rules. There is no valid proof of delivery in the documentation. 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 Group 3 power wheelchair (PWC), adjustable angle 
footplate, and cushion rendered on July 28, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the blood bank physician services coded 86077 provided on 
February 11, 2022.  
You asked the Plan to pay for the blood bank physician services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the number of units billed are not payable. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 86077 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the blood 
bank physician services have not been met. Therefore, we decided that the Plan does not have to pay for the 
blood bank physician services coded 86077 provided on February 11, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for needle electromyography, each extremity (95885) provided 
on October 11, 2021. 
 
You asked the Plan to pay for needle electromyography. You say that this code was billed appropriately and is 
supported in the record. The Plan denied your request. The Plan says this is an add-on code which was billed 
without an appropriate primary procedure. 
 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 95885 
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. Therefore, we decided that the Plan does not have to 
pay for needle electromyography, each extremity (95885) provided on October 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on January 31, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you submitted documentation for review. The Plan 
denied your request. The Plan says the rendering provider is an OON provider and there was no referral from 
an in-network provider or an approved authorization. Also, the service rendered was not urgent or emergent. 
  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 items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the office visit provided on January 31, 2022, by 
an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay for the comprehensive oral exam (D0150). We decided that the Plan does 
not have to pay for the complete x-ray series (D0210), the 3-D photo image (D0351), the core build-up, 
including pins (D2950 x2), the interim crown (D2799 x 2), and the porcelain fused to metal crown (D2751).  
 
You asked the Plan to pay for the comprehensive oral exam (D0150), the complete x-ray series (D0210), the 3-
D photo image (D0351), the core build-up, including pins (D2950 x2), the interim crown (D2799 x 2), and the 
porcelain fused to metal crown (D2751). You say that you were told that the crowns were covered. The Plan 
says that the services are not covered benefits. 
 
We decided that the Plan has to pay for the comprehensive oral exam (D0150).  
 
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 stated that the comprehensive oral exam (D0150) denied because the 
service exceeded the maximum allowable amount. However, the Plan did not submit records for the previous 
comprehensive oral exams. This means we cannot determine if the Plan had paid for two comprehensive oral 
exams in 2021. Therefore, we decided that the Plan has to pay for the comprehensive oral exam (D0150).  
 
We also decided that the Plan does not have to pay for the complete x-ray series (D0210), the 3-D photo 
image (D0351), the core build-up, including pins (D2950 x2), the interim crown (D2799 x 2), and the 
porcelain fused to metal crown (D2751). 
 
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 complete x-ray series (D0210), the 
3-D photo image (D0351), the core build-up, including pins (D2950 x2), the interim crown (D2799 x 2), and 
the porcelain fused to metal crown (D2751) are not among those covered under this benefit. Therefore, we 
decided that the Plan does not have to pay for the complete x-ray series (D0210), the 3-D photo image 
(D0351), the core build-up, including pins (D2950 x2), the interim crown (D2799 x 2), and the porcelain fused 
to metal crown (D2751). 
 
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 pay for the anesthesia services coded 99100 provided on June 18, 2021. 
 
You asked the Plan to pay for the anesthesia services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services billed are not separately 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, the CPT Code Manual definition of code 99100 is anesthesia for patient of extreme age, younger 
than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure). 
 
We find that CPT code 99100 is not supported in the medical record. Specifically, this code has a status 
indicator of "B". This means payment for this service is bundled into payment for other services not specified, 
and no separate payment can be made. Based on this information, we decided that Medicare rules for coverage 
of the anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for the 
anesthesia services coded 99100 provided on June 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bone replacement graft (D7953) provided on March 9, 2022. 
 
You asked the Plan to pay for a bone replacement graft (D7953). You say that this extraction procedure does 
not seem to be a standard medical benefit. The Plan denied your request. The Plan says an oral surgery 
procedure is regarded as a medical benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, 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 a bone 
replacement graft (D7953) provided on March 9, 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 based on the medical records provided there is no documentation that the enrollee requires the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. Records do 
not clarify that treatment at the skilled nursing facility level is not appropriate in this case. 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) of the thorax (71250). 
 
You asked the Plan to pre-approve a CT of the thorax. The Plan denied your request. The Plan says the enrollee 
had a CT scan in April of this year. The Plan also says that it did not show concerning changes, and it is not 
clear why a repeat scan is needed now. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically 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 a CT of the thorax. Our reviewer says 
that the health plans denial should be upheld at the present time. Our physician reviewer found there appears 
to be some confusion as to the timing of this requested CT scan. While the scan was ordered on April 26, 2022, 
the expected date of completion appears to be April 26, 2023. Our reviewer found that ongoing surveillance of 
the enrollees nodules is medically necessary and reasonable, but it is unclear and confusing for an order to be 
in place a year ahead of time. There is no evidence that imaging is currently, acutely, medically necessary. Our 
physician reviewer also found that the provider should order the desired, surveillance, CT scan closer to its 
actual due date. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a CT of the thorax have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a computed tomography (CT) of the thorax (71250).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 69990 and 76000 billed for date of service 
December 9, 2021. 
 
You asked the Plan to pay for procedure codes 69990 and 76000. You say that the records support payment of 
these codes. The Plan denied your request. The Plan says payment for codes 69990 and 76000 is bundled into 
payment for code 63047. 
 
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 69990 
is a column II code to column I code 63047 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 for code 69990.  
 
In addition, we have confirmed that code 76000 is a column II code to column I code 63047. This claim has not 
been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing 
criteria have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 69990 
and 76000 billed for date of service December 9, 2021.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the MRI provided on August 6, 2021. 
 
You asked the Plan to pay for the MRI. You say that you are disputing the claim for redetermination. The Plan 
denied your request. The Plan says that all diagnostic radiology services require a prior authorization. 
 
The Plan must follow Medicare rules. The rules say that plans may choose the networks of providers available 
to enrollees and may require enrollees to obtain authorization before receiving services. 
 
The Plan says prior authorization is required for diagnostic radiology according to Chapter 4 of the Evidence of 
Coverage. Chapter 4 says prior authorization is only required for in-network diagnostic radiology services. 
Chapter 3 of the Evidence of Coverage clearly states that prior authorization is not required for out-of-network 
services. Therefore, we decided that the Plan has to pay for the MRI provided on August 6, 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 pre-approve osseous surgery (D4260). 
 
You asked the Plan to pre-approve osseous surgery. You say that these services are medically necessary. The 
Plan denied your request. The Plan says osseous surgery (D4260) is not covered by your routine dental 
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. 
 
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 
osseous surgery (D4260).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the compression stockings identified with code A6549 that 
were issued on December 16, 2021. 
 
You asked the Plan to pay for the compression stockings. You say that you are requesting a reconsideration of 
the Plan's denial for payment. The Plan denied your request. The Plan says this item is not a covered benefit 
under your contractual policy or by Medicare. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the compression 
stockings identified with code A6549 that were issued on December 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gingival irrigation (D4921) to be provided by a network 
provider. 
 
You asked the Plan to pay for the gingival irrigation (D4921). You say that you are appealing this denial of the 
claim. The Plan denied your request. The Plan says the service is 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 gingival irrigation (D4921) is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
gingival irrigation (D4921) to be provided by a network provider.