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

 
We decided that the Plan does not have to pay for the Tempus gene panel testing (81206, 81292) provided 
September 27, 2021. 
 
You asked the Plan to pay for the molecular pathology testing. You say that please review attached 
information. The Plan denied your request. The Plan says the records do not meet the billed service 
 
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 find that CPT codes 81206 and 81292 is not supported in the medical record. Specifically, 
Medicare denies coverage when a laboratory assays two or more genes in a patient in parallel. Those two or 
more genes will be considered part of the same panel. A panel constitutes a single procedural service, so one 
CPT code must be submitted for the panel. Based on this information, we decided that Medicare rules for 
coverage of the molecular pathology testing have not been met. Therefore, we decided that the Plan does not 
have to pay for the Tempus gene panel testing (81206, 81292) provided September 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the mandibular partial denture (D5214) provided on 
December 30, 2021. 
 
You asked the Plan to pay more for the mandibular partial denture. You say that you were told that this denture 
was approved. You also say that you did not want a new bottom denture. The Plan denied your request. The 
Plan says your annual out-of-pocket maximum of $3,000 was met on December 30, 2021. 
 
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 Plan offers a $3,000 annual limit. 
The record shows that you met the annual maximum benefit while processing this claim for the December 30, 
2021 date of service and your annual maximum benefit has been exhausted. Therefore, we decided that the 
Plan does not have to pay more for the mandibular partial denture (D5214) provided on December 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional payment for the periodic oral evaluation - 
established patient (D0120) and prophylaxis - adult (D1110) provided January 17, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to provide additional payment for the periodic oral exam and dental cleaning. You say that 
you would have to travel further to a network provider. The Plan denied your request. The Plan says these 
claims have processed correctly according to your OON 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 Plan rules states that if 
you choose to go to a dentist that does not participate in the Plans dental vendors network, you may pay more. 
The dentist can bill you for additional costs if what they charge is more than the maximum payable benefit 
amount for preventative services covered by the Plan. 
 
We looked at the file, and Medicare rules. The Plan provided documentation showing that they paid the 
maximum payable benefit amount approved by the Plan. You have been asked to pay the difference between 
the maximum payable benefit amount and the amount the OON provider billed the Plan. This means that 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 periodic oral evaluation - established patient (D0120) 
and prophylaxis - adult (D1110) provided January 17, 2022, by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for physical therapy (PT) services provided 
from December 8, 2021, to December 30, 2021 
 
You asked the Plan to waive the copayments for the PT services. You say that you were informed by the 
provider that there would be no copayments for physical therapy. The Plan denied your request. The Plan says 
you have been charged the correct cost sharing amount. 
 
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 $30 
copayment for each physical therapy visit.  
 You have been asked to pay a $30 copayment for each of the 6 PT services provided from December 8, 2021, 
to December 30, 2021. The total for all visits is $180 ($30 copayment x 6 visits = $180). The PT services fall 
within the Outpatient Rehabilitation Services 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 copayments 
for physical therapy (PT) services provided from December 8, 2021, to December 30, 2021
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CxBladder testing provided on November 11, 2021. 
 You asked the Plan to pay for the testing services. You say that the test replaces the need for other urine-based 
tests. The Plan denied your request. The Plan says the testing is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or 
provider must corroborate the documentation in the 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 the results of the testing will be used as part of a specific treatment strategy. Medicare 
does not cover this testing for screening purposes. 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 CxBladder testing provided on November 11, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray services provided on October 23, 2021.

You asked the Plan to pay for the services provided. You say that the records show the procedure was performed. The Plan denied your request. The Plan says two separate procedures were not performed.

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 71045 is not supported. The file show that CPT code 71045 was previously billed and paid by the Plan for the same date of service at issue. The records do not show that more than 1 chest x-ray was performed by the provider on this date of service. 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 the chest x-ray services provided on October 23, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for magnetic resonance imaging (MRI) (74183) 
provided on January 5, 2022. 
 
You asked the Plan to waive the deductible for the MRI. You say that the services should be covered as you 
disagree with the charges. The Plan denied your request. The Plan says the deductible applied correctly based 
on the services provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $300 deductible which applies to diagnostic radiology.  
 
 
  The item or service you asked the Plan to waive the deductible for falls within the benefit category diagnostic 
radiology. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $300 
deductible which applies to diagnostic radiology. This cost sharing is a contractual obligation that had not been 
met at the time the MRI was received on January 5, 2022. Therefore, we decided that the Plan does not have to 
waive the deductible for magnetic resonance imaging (MRI) (74183) provided on January 5, 2022.  
 
Since the $300 deductible was met, you have also been asked to pay a $50 copayment. 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.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the technical component (TC) of the surgical pathology 
services provided on October 30, 2020. 
 
You asked the Plan to pay for the TC of the surgical pathology services. You say that you would like the Plan 
to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered 
as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that payment is not made under the physician fee 
schedule for TC services furnished in institutional settings where the TC service is bundled into the facility 
payment, e.g., hospital inpatient and outpatient settings. 
 
We looked at the file and Medicare rules. The global code for 88305 was billed which includes both the professional and TC. Only the professional component is payable since the services were provided to a hospital 
outpatient. Therefore, we decided that the Plan does not have to pay for the technical component (TC) of the 
surgical pathology services provided on October 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Prolonged evaluation and management service before 
and/or after direct patient care (99358) provided on December 15, 2021. 
 
You asked the Plan to pay for code 99358. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not supported. 
 
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 99358 is Prolonged evaluation and management service 
before and/or after direct patient care; first hour.  
We find that CPT code 99358 is not supported in the medical record. Specifically, code 99358 is a time-based 
code. The records provided did not indicate prolonged evaluation and management services before and/or after 
direct patient care for the first hour was performed. Based on this information, we decided that Medicare rules 
for coverage of code 99358 have not been met. Therefore, we decided that the Plan does not have to pay for the 
Prolonged evaluation and management service before and/or after direct patient care (99358) provided on 
December 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown (D2740) on tooth #20 provided on August 16, 2021. 
 
You asked the Plan to pay for the crown. You say that you were told the provider would do a prior 
authorization to see what your balance was for these crowns. You also say that you cannot afford to pay the 
$867.00 you are being charged. The Plan denied your request. The Plan says your benefits for this service have 
been satisfied and the frequency limitation has been exceeded. 
 
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, crowns are limited to two procedure 
codes per calendar year. The record shows that you received crowns (D2740) on tooth #'s 18 and 19 on August 
16, 2021 and your crowns benefit has been exhausted. Therefore, we decided that the Plan does not have to pay 
for the crown (D2740) on tooth #20 provided on August 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a microprocessor knee. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a microprocessor knee is covered when specific 
criteria are met. 
 
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 services are not medically necessary. Our physician reviewer found the requested microprocessor knee 
appears to exceed your medical needs. You have multiple comorbidities. The microprocessor knee is heavier 
than a mechanical knee. The documentation from your treating provider does not show that you are unable to 
use a mechanical K3 knee over a microprocessor knee. The services are therefore not reasonable or medically 
necessary. 
 
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 a microprocessor knee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive genomic profile testing provided on June 3, 2021. 
 
You asked the Plan to pay for comprehensive genomic profile testing. You say that you were compliant with 
Medicare regulations for billing. The Plan denied your request. The Plan says the denial of payment for these 
test codes is correct, because there is a more appropriate code to describe this service. 
 
The Plan must follow Medicare rules. Medicare rules say that comprehensive genomic profile testing should be 
billed with code 81479 for date of service June 3, 2021.   
We looked at the file and Medicare rules. This test was not billed with the appropriate coding. Based on this 
information, we decided that Medicare rules for coverage of comprehensive genomic profile testing have not 
been met. Therefore, we decided that the Plan does not have to pay for comprehensive genomic profile testing 
provided on June 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established 
patient (D0150) provided January 19, 2022. 
 
You asked the Plan to pay for the comprehensive oral exam. You say that you should be covered for an exam 
every six months. The Plan denied your request. The Plan says you have exceeded the frequency limit for the 
service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the 
comprehensive oral exam once every three plan years. 
 
We looked at the file and Medicare rules. The Plan provided documentation showing that a comprehensive 
exam was previously covered on December 18, 2020.  Based on this information, we decided that the Plan's frequency limit for coverage of the comprehensive oral exam has been exceeded. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established patient (D0150) provided January 19, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the periodic oral evaluation (D0120), panoramic x-ray (D0330), two 
endodontic therapies (D3310 x2), complete maxillary denture (D5110), and immediate mandibular denture 
(D5140) provided on September 1, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the periodic oral evaluation, panoramic x-ray, endodontic therapies, complete 
maxillary denture, and immediate mandibular denture. You say that you contacted the Plan who advised that 
this treating provider was in-network. You also say that you would like this claim to be reviewed because you 
were misinformed about how to proceed. The Plan denied your request. The Plan says that non-emergency 
services provided by an OON provider are not available with your dental plan. 
 
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 did not provide a copy of the applicable call records for this case. You 
say that you contacted the Plan and were advised that this treating provider was in-network. Without the call 
records of your conversation with the Plan, we cannot determine that the Plan has substantiated their denial of 
payment in this case. Therefore, we decided that the Plan has to pay for the periodic oral evaluation (D0120), 
panoramic x-ray (D0330), two endodontic therapies (D3310 x2), complete maxillary denture (D5110), and 
immediate mandibular denture (D5140) provided on September 1, 2021 by an out-of-network (OON) provider.  
 
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), a core build-up (D2950), 
pontic (D6245), a retainer crown (D6740), surgical erupted tooth removal (D7210), and a bone replacement 
graft (D7953) provided by a participating provider on November 24, 2021. 
 
You asked the Plan to pay for a limited oral evaluation, a core build-up, pontic (D6245), a retainer crown 
(D6740), surgical erupted tooth removal (D7210), and a bone replacement graft. You say that you would like 
reimbursement for these services. The Plan denied your request. The Plan says the services that were rendered 
are not covered 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 pay for a limited 
oral evaluation (D0140), a core build-up (D2950), pontic (D6245), a retainer crown (D6740), surgical erupted 
tooth removal (D7210), and a bone replacement graft (D7953) provided by a participating provider on 
November 24, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 81238, 81220, 81225, 
81230, 81227, 81355, 81241, 81291, and 81240) provided on June 9, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not covered 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. 
 
The denial remains upheld as non-covered as Medicare denies coverage when a laboratory assays two or more 
genes in a patient in parallel. Those two or more genes will be considered part of the same panel. A panel 
constitutes a single procedural service, so one CPT code must be submitted for the panel. Therefore, we 
decided that the Plan does not have to pay for the laboratory services (CPT code(s): 81238, 81220, 81225, 
81230, 81227, 81355, 81241, 81291, and 81240) provided on June 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infusion supplies rendered on December 9, 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 claim is a duplicate. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. 
 
We looked at the file and Medicare rules. The file shows that the services at issue were previously paid by the 
Plan on a separate claim for the same date of service. 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 infusion supplies rendered on December 9, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on February 5, 2021. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the tests are not 
benefits for the diagnoses listed on the claim form. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The file shows that lab testing for iron, iron binding capacity, and ferritin were provided. The records provided 
do not indicate an iron deficiency. The testing was not ordered to treat a specific problem. It appears that the 
testing services were requested for screening purposes. Medicare does not cover this testing for screening 
purposes. Therefore, we decided that the Plan does not have to pay for the lab testing services provided on 
February 5, 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), panoramic x-ray (D0330), and scaling in presence of moderate to severe gingival inflammation 
(D4346) provided on October 20, 2021. 
 
You asked the Plan to pay for the dental services. You say that you were given information on the cleanings 
and an endodontist. You say that you were not told anything about having to pay 20%. You say that you were 
given a list of providers. You say that this provider is in network. You also say that you should not be 
responsible for this bill. The Plan denied your request. The Plan says the claim 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, dental services performed by a 
specialist are not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pay for the comprehensive oral evaluation (D0150), complete series x-ray (D0210), panoramic x-ray (D0330), 
and scaling in presence of moderate to severe gingival inflammation (D4346) provided on October 20, 2021.