Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the oxygen concentrator and portable 
accessory provided on March 3, 2022. 
 
You asked the Plan to waive the cost share for the oxygen concentrator and portable accessory. You say that 
they are billing you for an oxygen concentrator you do not have. 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 20% 
coinsurance for per item for DME.  
 
You have been asked to pay a 20% coinsurance for per item for the oxygen concentrator and portable accessory 
for a total of $31.54. The oxygen concentrator and portable accessory falls within the Durable Medical 
Equipment (DME) and Related Supplies 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 cost share 
for the oxygen concentrator and portable accessory provided on March 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81161 billed for date of service January 21, 
2022. 
 
You asked the Plan to pay for procedure code 81161. You say that the services were medically necessary. The 
Plan denied your request. The Plan says payment for code 81161 is bundled into payment for code 81413. 
 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 81161 
is a column II code to column I code 81413. 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 code 81161 billed for date of service January 21, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 82435 billed for date of service December 
31, 2021. 
 You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says an 
appropriate modifier was not 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.  
 
In this case, we have confirmed that code 82435 is a column II code to column I code 80051, code 84132 is a 
column II code to column I code 80051, and code 84295 is a column II code to column I code 80051. The 
codes at issue were not 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 code 82435 billed for date of service December 31, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 6, 2022, billed with 
codes 81206, 81210, 81235, 81272, 81275, 81276, 81301, 81311, 81191, 81321. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says this claim has not been billed as required 
by Medicare billing regulations. 
 The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
February 6, 2022, billed with codes 81206, 81210, 81235, 81272, 81275, 81276, 81301, 81311, 81191, 81321.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2750) for tooth # 7. 
 
You asked the Plan to pre-approve the dental service. You say that your crown has fallen out. You say that it is 
hard for you to chew and eat food. You say there is a hole in your tooth. You also say that you have a medical 
condition, and any little thing can affect you. 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 January 11, 2020. 
Therefore, we decided that the Plan does not have to pre-approve a crown (D2750) for tooth # 7.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda (J9271). 
 
You asked the Plan to pre-approve the Keytruda. You say that Keytruda is medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 the Keytruda. Our reviewer says that 
Keytruda is not medically necessary. Our physician reviewer found use of this drug in this clinical situation is 
not supported in the Medicare-approved compendia or in the CMS-approved peer-reviewed literature. 
 
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 Keytruda have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Keytruda (J9271).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for deep sedation/general anesthesia 
(D9222, D9223) provided on November 4, 2021. 
 
You asked the Plan to pay an additional amount for deep sedation/general anesthesia. You say that the services 
were necessary, and you want the Plan to pay for them. The Plan denied your request. The Plan says the cost 
share was applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 50% 
coinsurance for deep sedation/general anesthesia.  
 
You have been asked to pay a 50% coinsurance for deep sedation/general anesthesia. Deep sedation/general 
anesthesia fall within the deep sedation/general anesthesia 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 pay an additional amount for deep sedation/general anesthesia (D9222, D9223) provided on November 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 28, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says that it isn't your responsibility to obtain 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 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 an office visit provided on March 28, 2022, by an 
out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for complete denture (D5110) and periodontal 
scaling (D4341) provided on January 8, 2022, and January 18, 2022. 
  You asked the Plan to waive the copayments for complete denture and periodontal scaling. You say that you 
are appealing the denied services. The Plan denied your request. The Plan says the proper copayments were 
applied for the covered services. 
 
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 
among those covered under this benefit with the proper copayments applied. Therefore, we decided that the 
Plan does not have to waive the copayments for complete denture (D5110) and periodontal scaling (D4341) 
provided on January 8, 2022, and January 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene panel testing provided on November 1, 2021. 
 
You asked the Plan to pay for the testing services. You say that the testing enables personalized cancer care. 
The Plan denied your request. The Plan says the submission of claims using individual gene codes is 
considered incorrect coding. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the panel testing was not billed with a single code as required. 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 gene panel testing provided on November 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services billed with codes 00560, 36556, and 36620 
provided on December 28, 2021. 
 
You asked the Plan to pay for codes 00560, 36556, and 36620. 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 codes 00560, 36556, and 36620 are not supported in the medical record. Specifically, the 
documentation shows that the enrollee was enrolled in a clinical research program. This means the valid 
modifiers (Q0 or Q1) were not billed with these services. Based on this information, we decided that Medicare 
rules for coverage of codes 00560, 36556, and 36620 have not been met. Therefore, we decided that the Plan 
does not have to pay for the services billed with codes 00560, 36556, and 36620 provided on December 28, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (G0483, 80307) provided January 28, 2022. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the records do not support the billed services. 
 
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 codes G0483, & 80307 is Drug Testing, 22 or more drug 
classes. 
 
We find that CPT codes G0483, & 80307 are not supported in the medical record. Specifically, the records do 
not show that 22 or more drug classes were tested. Based on this information, we decided that Medicare rules 
for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for 
lab services (G0483, 80307) provided January 28, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prosthodontic services (D9222, D9223, D0150, D0001) 
provided September 9, 2021 to November 9, 2021. 
 
You asked the Plan to pay for the prosthodontic services. You say that this service should be considered a 
medical service and eligible for coverage. The Plan denied your request. The Plan says the procedure 
performed is dental in nature and is non-covered under the medical benefit. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for prosthodontic services (D9222, 
D9223, D0150, D0001) provided September 9, 2021 to November 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for carpal tunnel surgery provided on November 2, 2021. 
 
You asked the Plan to pay for . You say that  The Plan denied your request. The Plan says  
 
We are remanding this issue back to the Plan. Medicare rules say that a non-contract provider can make an 
appeal request only when it has agreed to waive its right to payment from the enrollee. The rules further say 
that if a non-contract provider files a request for reconsideration of a denied claim without a waiver of liability 
form, the Plan must make and document reasonable efforts to obtain the waiver of liability form. You can find 
this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Parts C & D Enrollee 
Grievances, Organization/Coverage Determinations, and Appeals Grievance Manual, Section 50.9.   
 
In this case, the record does not show that the Plan made any attempts to obtain a waiver of liability document. 
Therefore, we are dismissing the case and referring this issue back to the Plan. The Plan should provide the 
appellant with a waiver of liability form and instructions for completion. Once a valid waiver is received, the 
plan should complete the plan level review. If the Plan decides it will not pay for the services provided, the 
Plan will send the case back to us as a new appeal. A new case number will be assigned.  Therefore, we 
decided that the Plan does not have to pay for carpal tunnel surgery provided on November 2, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF 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 Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF 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 you require the 
services on an inpatient basis, only in a skilled nursing facility setting. Records do not document that services 
in the home with home health care or in a long-term care facility on a part time basis are 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on April 7, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to appeal the denial of the claim. The 
Plan denied your request. The Plan says the provider is out-of-network, and it was determined these services 
can be received in-network. 
 
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 an office visit provided on April 7, 2022, by an 
out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (81479) provided July 7, 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 coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that SelectMDx is covered for males with a previous 
negative prostate biopsy who are being considered for a repeat biopsy. 
 
We looked at the file and Medicare rules. There is no record of a prior prostate biopsy. Based on this 
information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, 
we decided that the Plan does not have to pay for genetic testing (81479) provided July 7, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mass spectrometry and tandem mass spectrometry coded 
83789 provided on March 1, 2022. 
 
You asked the Plan to pay for the mass spectrometry and tandem mass spectrometry. You say that you disagree 
with the Plan's denial. The Plan denied your request. The Plan says the services billed are not supported by the 
documentation. 
 
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 83789 is mass spectrometry and tandem mass 
spectrometry (eg, MS, MS/MS, MALDI, MS-TOF, QTOF), non-drug analyte(s) not elsewhere specified, 
qualitative or quantitative, each specimen. 
 We find that CPT code 83789 is not supported in the medical record. Specifically, this code is not separately 
reimbursable when billed for specimen validity testing on urine specimens utilized for drug testing. Based on 
this information, we decided that Medicare rules for coverage of the mass spectrometry and tandem mass 
spectrometry have not been met. Therefore, we decided that the Plan does not have to pay for the mass 
spectrometry and tandem mass spectrometry coded 83789 provided on March 1, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve HBA1/HBA2 (alpha globin 1 and alpha globin 2), gene analysis; duplication/deletion variants (81269).

You asked the Plan to pre-approve genetic testing. You say that the enrollee has microcytic anemia, and you highly suspect the enrollee has alpha thalassemia. Beta thalassemia is virtually eliminated as a cause as the enrollee's laboratory tests were negative. The Plan denied your request. The Plan says this test can only be approved when results are needed to diagnose or treat a condition. The records they received do not show that this applies.

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 genetic testing. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the provider indicated alpha thalassemia is the probable cause of microcytic anemia, it does not appear that the results of the HBA1/HBA2 (alpha globin1 and alpha globin2) gene analysis; duplication/deletion variants testing will alter management. The Medicare LCA noted above states CPT 81269 is unlikely to impact therapeutic decision making in the clinical management of the enrollee and will be denied automatically as not 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 genetic testing have not been met. Therefore, we decided that the Plan does not have to pre-approve HBA1/HBA2 (alpha globin 1 and alpha globin 2), gene analysis; duplication/deletion variants (81269).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core build up on tooth #14 (D2950) and a crown on tooth 
#14 (D2740) provided on March 8, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
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, 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 core 
build up on tooth #14 (D2950) and a crown on tooth #14 (D2740) provided on March 8, 2022.