Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the special anesthesia service (99100) provided on January 
14, 2022. 
 
You asked the Plan to pay for the special anesthesia service (99100). You say that the anesthesia records detail 
the need for the services provided and full payment is due to be paid. The Plan denied your request. The Plan 
says procedure code 00752 has been overturned and procedure code 99100 remains denied as bundled services 
are not eligible for separate payment. 
 
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 99100 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99100 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of the special anesthesia service (99100) have not been met. Therefore, we decided that the Plan does not have 
to pay for the special anesthesia service (99100) provided on January 14, 2022.
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 March 15, 2022. 
 
You asked the Plan to pay for a limited oral evaluation. You say that this should be covered. The Plan denied 
your request. The Plan says the annual dental allowance maximum has already been met and 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 up to a $2,000 
allowance for all covered dental services. 
 
We looked at the file and Medicare rules. The annual allowance amount of $2,000 has already been met and 
exhausted. Based on this information, we decided that the Plan's rules for coverage of a limited oral evaluation 
have not been met. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation 
(D0140) provided by a participating provider on March 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services coded as 81404 and 81479 provided on July 26, 2021 
 
You asked the Plan to pay for the lab services. You say that please reprocess the claim using the Plan and CMS 
guidelines for independent laboratories. The Plan denied your request. The Plan says you billed with an 
incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services coded as 81404 and 81479 provided on July 26, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the topical application of fluoride varnish (D1206) provided 
April 14, 2022. 
 
You asked the Plan to pay for the fluoride varnish. You say that you were told the services provided would be 
free. The Plan denied your request. The Plan says this service is not covered under your benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
topical application of fluoride varnish (D1206) provided April 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950), 
pontic - porcelain fused to high noble metal (D6240), retainer crown - porcelain fused to high noble metal 
(D6750) provided September 23, 2021. 
 
You asked the Plan to pay for the core buildup, pontic and retainer crown. You say that you would like these 
services covered. The Plan denied your request. The Plan says you have exceeded your dental maximum for 
2022. 
 
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 core 
buildup, pontic and retainer crown up to a $1,000 annual maximum.  
 We looked at the file and Medicare rules. The Plan provided documentation showing that at the time these 
claims were processed you had exhausted your annual maximum.  Therefore, we decided that the Plan does not 
have to pay for the core buildup, including any pins when required (D2950), pontic - porcelain fused to high 
noble metal (D6240), retainer crown - porcelain fused to high noble metal (D6750) provided September 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 81220, 81225, 81226, 81227, 
81230, 81238, 81240, 81241, 81291, 81335, and 81355 provided on September 1, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 We find that CPT codes 81220, 81225, 81226, 81227, 81230, 81238, 81240, 81241, 81291, 81335, and 81355 
are not supported in the medical record. Specifically, when a laboratory assays two or more genes in an 
enrollee in parallel, those two or more genes will be considered part of the same panel. A panel constitutes a 
single procedural service, so one code must be submitted for the panel. Review of the file does not support that 
only one code was submitted for the panel provided. Based on this information, we decided that Medicare rules 
for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to 
pay for the laboratory services coded 81220, 81225, 81226, 81227, 81230, 81238, 81240, 81241, 81291, 
81335, and 81355 provided on September 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share amount for the crowns (D2740 x 3) provided 
from October 28, 2021, to November 11, 2021. 
 
You asked the Plan to waive the cost share amount for the dental services. You say that you feel you should not 
be responsible for the cost share based on the crown material and other dental issues. The Plan denied your 
request. The Plan says there is a 50% coinsurance for crowns. The Plan also says that the cost share was 
applied correctly. 
 
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 and crowns are listed as covered, there 
is a 50% coinsurance that applies to these services. This is a contractual obligation you agreed to when you 
enrolled in the Plan's dental coverage. Therefore, we decided that the Plan does not have to waive the cost 
share amount for the crowns (D2740 x 3) provided from October 28, 2021, to November 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the white glass with metal crown for tooth #10 (D2751) 
to be provided by a network provider. 
 
You asked the Plan to pre-approve the white glass with metal crown for tooth #10 (D2751). You say that tooth 
#10 needs a crown. The Plan denied your request. The Plan says the service exceeded the frequency limitation 
in the benefit plan. 
 
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 Plan also has a maximum benefit 
of crowns once per 60 months. The requested services are not covered because the Plan paid for a white glass 
with metal crown for tooth #10 (D2751) on October 8, 2020, which exhausted your benefit. Therefore, 
we decided that the Plan does not have to pre-approve the white glass with metal crown for tooth 
#10 (D2751) to be provided by a network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transit system for a wheelchair. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says optional 
attachments for travel are not covered. 
 The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The file shows that a transit system was requested for the wheelchair to be secured during transport. The item 
at issue does not serve a purpose that is primarily medical in nature. Therefore, we decided that the Plan does 
not have to pre-approve a transit system for a wheelchair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown on tooth #18 (D2740) and core build up on tooth 
#18 (D2950) provided on April 4, 2022. 
 
You asked the Plan to pay for a crown and core build up. You say that  The Plan denied your request. The Plan 
says a crown (D2740) and core build up (D2950) 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 pay for a crown 
on tooth #18 (D2740) and core build up on tooth #18 (D2950) provided on April 4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on July 27, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the laboratory services are not supported in the medical record. Specifically, when a laboratory 
assays two or more genes in an enrollee in parallel, those two or more genes will be considered part of the same 
panel. A panel constitutes a single procedural service so one code must be submitted for the panel. Review of 
the file does not support that only one code was billed for the panel provided. Based on this information, we 
decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided 
that the Plan does not have to pay for the laboratory services provided on July 27, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on February 8, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says there is insufficient documentation to 
corroborate the services as billed. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Medicare rules say that specimen validity testing is not covered separately. 
 
The services at issue in this case are for the purpose of specimen validity testing. Based on this information, we 
decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided 
that the Plan does not have to pay for the laboratory services provided on February 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pulpal debridement, primary and permanent teeth 
(D3221) provided November 24, 2021, and the unspecified endodontic procedure, by report (D3999), and 
limited oral evaluation - problem focused (D0140) provided December 8, 2021. 
 
You asked the Plan to pay for the pulpal debridement, unspecified endodontic procedure and limited oral exam. 
You say that these services were necessary for a covered root canal. The Plan denied your request. The Plan 
says the pulpal debridement and unspecified endodontic procedure are not covered under your benefits. You 
have exceeded the frequency limit for the limited oral exam. 
 
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 limited 
oral exam per plan year.   
We looked at the file and Medicare rules. The Plan provided documentation showing that a limited oral exam 
was previously covered on November 24, 2021. Based on this information, we decided that the Plan's 
frequency limit for coverage of the limited oral exam has been exceeded. Though the Plan offers dental 
benefits in excess of Medicare coverage, the pulpal debridement and unspecified endodontic procedure are not 
among those covered services. Therefore, we decided that the Plan does not have to pay for the pulpal 
debridement, primary and permanent teeth (D3221) provided November 24, 2021, and the unspecified 
endodontic procedure, by report (D3999), and limited oral evaluation - problem focused (D0140) provided 
December 8, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the drug testing provided on April 27, 2017. 
 
You asked the Plan to pay for the drug testing. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says that the documentation submitted does not 
support the service 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, the CPT Code Manual definition of 
code G0482 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs 
and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to 
gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, 
eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other 
universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and 
variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control 
material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all 
sources, includes specimen validity testing, per day; 15-21 drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0482 is supported in the medical record. Specifically, the lab report clearly shows that 
15-21 drug classes were tested in this case. Please note, we counted the classes based on the separately billable 
tests from the CPT Handbook. Additionally, the Plan has not forwarded any evidence to support why CPT code 
80307 is not eligible for payment. It is the burden of the Health Plan to substantiate their denial with evidence. 
In this case, the Plan's denial has not been substantiated so we must find in your favor. Also, the record 
indicates that this provider was directed by the Plan to not obtain records. With this direction, it is inappropriate 
for the Plan to deny these services based on the physician signature. Based on this information, we decided that 
Medicare rules for coverage of the drug testing have been met. Therefore, we decided that the Plan has to pay 
for the drug testing provided on April 27, 2017.  
 
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: Lab
Decision: Favorable

 
We decided that the Plan has to pay for drug testing provided on July 3, 2018. 
 
You asked the Plan to pay for the drug testing. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says that the documentation submitted does not 
support the service 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, the CPT Code Manual definition of 
code G0482 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs 
and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to 
gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, 
eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other 
universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and 
variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control 
material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all 
sources, includes specimen validity testing, per day; 15-21 drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0482 is supported in the medical record. Specifically, the lab report clearly shows that 
15-21 drug classes were tested in this case. Please note, we counted the classes based on the separately billable 
tests from the CPT Handbook. Also, the record indicates that this provider was directed by the Plan to not 
obtain records. With this direction, it is inappropriate for the Plan to deny these services based on the physician 
signature. Based on this information, we decided that Medicare rules for coverage of the drug testing have been 
met. Therefore, we decided that the Plan has to pay for drug testing provided on July 3, 2018.  
 
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 dental services provided on March 4, 2021. 
 
You asked the Plan to pay for dental services. You say that you were told that your dental surgery would be 
covered under your medical coverage. The Plan denied your request. The Plan says dental services are only 
covered for surgery of the jaw or related structures, setting fractures of the jaw or facial bones, extraction of 
teeth to prepare the jaw for radiation treatment or neoplastic disease. There is no active dental coverage for 
what member is requesting. 
 
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 dental services provided on 
March 4, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cardiac risk assessment genetic screening testing provided to 
the enrollee on June 8, 2021. 
 
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. 
The Plan says Medicare Part B covers cardiovascular disease screening tests when ordered by the physician 
who is treating the beneficiary for the purpose of early detection of cardiovascular disease in individuals 
without apparent signs or symptoms of cardiovascular disease. 
 
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 pay for the testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the record indicates that the enrollee has a history of hypertension and hyperlipidemia. The enrollee has no cardiac symptoms. The record does not indicate how the results of the requested test will alter the 
enrollee's clinical management. The record provided does not support the medical necessity of the requested 
service. The record provided does not establish the medical necessity and reasonableness, as defined by 
Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for cardiac risk assessment genetic screening testing provided to the enrollee on June 8, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from 
November 1, 2021, to November 30, 2021. 
 
You asked the Plan to pay for home health services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says the claim has not been billed in accordance 
with Medicare billing regulations. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. The rules say for continuous home health care 
periods, the through date must be 29 days after the From date for a 30-day period of care. 
 We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, this claim 
was not billed with a through date that is 29 days after the from date. Therefore, we decided that the Plan does 
not have to pay for the home health services provided to the enrollee from November 1, 2021, to November 30, 
2021.