Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for polarization, any lens material, per lens (code V2762) and 
lens, polycarbonate (V2784) provided on August 5, 2022. 
 
You asked the Plan to pay for polarization, any lens material and polycarbonate. The Plan denied your request. 
The Plan says polarization, any lens material and polycarbonate are non-covered lens enhancements. 
 
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear 
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  
 
We looked at the file and the Plan's rules. The file shows that the only lens enhancements that are covered are 
for progressive lenses. Based on this information, we decided that the Plan's rules for coverage of polarization, any lens material and polycarbonate have not been met. Therefore, we decided that the Plan does not have to 
pay for polarization, any lens material, per lens (code V2762) and lens, polycarbonate (V2784) provided on 
August 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve block services. 
 
You asked the Plan to pre-approve genicular nerve block services. You say that this procedure is medically 
necessary for the enrollee's condition. The Plan denied your request. The Plan says there is not enough 
evidence to show that this procedure is safe and that it works well for knee pain. 
 
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 genicular nerve block services. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee is a 77-year-old diagnosed with chronic right knee pain from 
osteoarthritis. In this case, the role of genicular nerve blocks and of radiofrequency ablation in the treatment of 
osteoarthritis of the knee is under active clinical investigation and is the subject of several ongoing clinical 
trials. Therefore, the request is deemed, at this point, not medically reasonable and 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 genicular nerve block services have not been met. Therefore, we decided that 
the Plan does not have to pre-approve genicular nerve block services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on January 31, 2022, billed with 
codes 81225, 81227, 81230, 81231, 81232, 81291, 81306, 81328, 81355, 81335, 0031U, 0032U, and 0033U. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like this claim reprocessed 
based on the medical records. The Plan denied your request. The Plan says panel testing should be billed using 
one CPT code on the claim. 
 
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 
January 31, 2022, billed with codes 81225, 81227, 81230, 81231, 81232, 81291, 81306, 81328, 81355, 81335, 
0031U, 0032U, and 0033U.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ambulance ride provided on May 17, 
2022. 
 
You asked the Plan to waive the copayment for an ambulance ride. You say that you should not have this 
copayment. The Plan denied your request. The Plan says this cost sharing was charged 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 $295 
copayment for ambulance services. 
 
You have been asked to pay a $295 copayment for an ambulance ride. This item/service falls within the 
ambulance 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 copayment for an ambulance ride 
provided on May 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 1, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that this was medically necessary, and you are appealing 
with supporting records. The Plan denied your request. The Plan says the enrollee must receive care from a 
network provider. 
 
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 this item/service. Therefore, we 
decided that the Plan does not have to pay for an office visit provided on June 1, 2022, by an out-of-network 
(OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on March 
11, 2022. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you should not be 
responsible to pay this. The Plan denied your request. The Plan says this cost sharing was charged 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 $10 
copayment for a specialist office visit.  
 
 
 
 
 
 
 
 You have been asked to pay $10 for a specialist office visit. This item/service falls within the specialist visit 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for an office visit provided on 
March 11, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for strapping; thorax provided to the enrollee on January 28, 
2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says this was denied as a duplicate to the referring claim for the same date of 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, the CPT Code Manual definition of code 29200 is "Strapping; thorax." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that this denial is inacurrate, as the 
Medically Unlikely Edits (MUE) for this code is 1. The documentation does not support two units. 
 We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for strapping; thorax provided to the enrollee on January 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an endosteal implant (21249), a bone graft (21210), 
formation of direct or tubed pedicle (15574), and alveoloplasty (41874). 
 
You asked the Plan to pre-approve the dental services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says endosteal implant (21249), bone graft (21210), formation of direct or 
tubed pedicle (15574), and alveoloplasty (41874) are not covered by the enrollee's 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 an 
endosteal implant (21249), a bone graft (21210), formation of direct or tubed pedicle (15574), and 
alveoloplasty (41874).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 8, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that the ability of an anesthesiologist to perform and bill 
for this type of service, where it is separate and apart from the pre-anesthesia assessment, is long established. 
The Plan denied your request. The Plan says this provider is not a network provider in advance. The Plan also 
says that these services were not approved in advance. 
 
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 June 8, 2022, by an 
out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the comprehensive oral exam (D0150), intraoral - 
periapical first radiographic image (D0220), intraoral - periapical each additional radiographic image (D0230), 
bitewings - four radiographic images (D0274) and re-cement or re-bond crown (D2920) provided on July 27, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay more for the dental services. You say that you were not given a 2022 provider 
directory. The Plan denied your request. The Plan says you are responsible for any charged amount above the 
Plans cost-sharing amount when your services are received from an out-of-network provider. 
 
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. 
 You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Additionally, thought he Plan offers dental benefits in excess of Medicare coverage, the re-cement or re-bond 
crown is not among those covered services. Therefore, we decided that the Plan does not have to pay more for 
the comprehensive oral exam (D0150), intraoral - periapical first radiographic image (D0220), intraoral - 
periapical each additional radiographic image (D0230), bitewings - four radiographic images (D0274) and re-
cement or re-bond crown (D2920) provided on July 27, 2022, by an out-of-network (OON) provider.  
 
Your complaint about potentially not being provided current network provider information is not a valid appeal 
for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare 
does not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown on tooth #2 and 30 (D2740), core build up on tooth 
#2 and 30 (D2950), prophylaxis (D1110), fluoride (D1206), oral hygiene instructions (D1330), and an 
adjunctive pre-diagnostic test (D0431) provided on June 27, 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 your annual dental benefit has been exhausted. The Plan also says 
that oral hygiene instructions (D1330) and an adjunctive pre-diagnostic test (D0431) are not covered by your 
dental benefits. 
 
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 this benefit includes 
coverage up to $1,000 for covered dental services. 
 
The record shows your annual dental benefit limit has been exhausted. You have been asked to pay a total of 
$3,233 for the dental services received on June 27, 2022. This item/service falls within the dental 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.  
 
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, oral hygiene instructions and an 
adjunctive pre-diagnostic test are not among those covered under this benefit. Therefore, we decided that the 
Plan does not have to pay for a crown on tooth #2 and 30 (D2740), core build up on tooth #2 and 30 (D2950), 
prophylaxis (D1110), fluoride (D1206), oral hygiene instructions (D1330), and an adjunctive pre-diagnostic 
test (D0431) provided on June 27, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 
You asked the Plan to pre-approve the services. You say that this needs to be at home as your legs have so 
much pain you can't even walk to leave home. The Plan denied your request. The Plan says this does not meet 
the criteria, and further medical justification was not provided. 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found that you have 
documented home health physical therapy (PT) needs. It is unclear whether you are truly homebound, as you 
have attended medical appointments. There is no evidence of an acute illness or injury for which physical 
therapy might be necessary. As such, the requested services are not shown to be medically necessary or 
reasonable. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve home health services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (G2023 and U0003) provided on 
March 24, 2022. 
 
You asked the Plan to pay for procedure codes G2023 and U0003. 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 all services billed by the SNF (including those 
furnished under arrangements with an outside supplier) for a resident of a SNF in a covered Part A stay are 
included in the SNF's Part A bill. 
 
We looked at the file and Medicare rules. The file shows the billed services for March 24, 2022, are not listed 
as excluded from consolidated billing. The enrollee was inpatient at a participating SNF on this date of service. 
The billed services should be included in the SNFs bill. Therefore, we decided that the Plan does not have to 
pay for the laboratory services (G2023 and U0003) provided on March 24, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan. 
 
You asked the Plan to pre-approve PET scan. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says this test is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that PET 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 PET scan. Our reviewer says that the 
enrollee does not meet the Medicare criteria for the requested PET scan. Our physician reviewer found the 
enrollee had a PET scan in August 2022 and it did not demonstrate abnormality. The record does not indicate 
that the enrollee is receiving active treatment or had a clinical change. Therefore, this test is not recommended 
at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PET scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a positron emission tomography (PET) scan.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the SelectMdx testing provided on December 2, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not medically 
necessary. 
 
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 literature indicates that two clinical studies were identified for SelectMDx, which detail the 
results of a total of three studies describing the development and initial clinical validation of SelectMDx.One of 
the studies detailed the process with which the genetic markers utilized in the test were discovered, and the 
second study described the development of a risk score that incorporates the genetic markers with traditional risk factors, and the subsequent clinical validation of the risk score. Though the initial results are encouraging, 
there is an overall paucity of sufficient evidence currently available in the peer-reviewed literature to evaluate 
the clinical utility of this test. Only two studies have been published to date regarding the performance of 
SelectMDx. Of the three cohorts studied among the two publications, the first two were utilized to establish 
analytical validity, and the third was utilized for clinical validity. Furthermore, studies were conducted in the 
Netherlands; thus the results are not generalizable to men living in other countries, including the United 
States.Given that most of the results were focused on test validation, SelectMDx needs to be tested in larger 
and heterogeneous populations in diverse clinical settings to further assess the clinical validity and clinical 
utility of this test. As such, the requested SelectMdx testing at issue in this case is not medically reasonable or 
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 the testing have not been met. Therefore, we decided that the Plan does not have 
to pay for the SelectMdx testing provided on December 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an out-of-network referral for a power wheelchair. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says medically necessary care is available 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an out-of-network referral for a power wheelchair.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the respiratory virus testing coded as 87631 provided on 
February 9, 2022. 
 
You asked the Plan to pay for the respiratory virus testing. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says payment cannot be made for this 
service with the billed diagnosis code. 
 
The Plan must follow Medicare rules. Medicare rules say that the ICD-10-CM code R07.0, defined as pain in 
throat, is not among those codes listed that supports the medical necessity of respiratory virus testing coded as 
87631. Based on this information, we decided that Medicare rules for coverage of the respiratory virus testing 
have not been met. Therefore, we decided that the Plan does not have to pay for the respiratory virus testing 
coded as 87631 provided on February 9, 2022.