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

 
We decided that the Plan does not have to pay more for a limited oral evaluation (D0140), periapical 
radiographic imaging (D0220), a crown (D2740), a core build-up (D2950), and prophylaxis (D1110) provided 
February 14, 2023, to March 21, 2023. 
 
You asked the Plan to pay more for the dental services. You say that these charges should all be covered. 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. D2950 
is not a covered benefit. Therefore, we decided that the Plan does not have to pay more for a limited oral 
evaluation (D0140), periapical radiographic imaging (D0220), a crown (D2740), a core build-up (D2950), and 
prophylaxis (D1110) provided February 14, 2023, to March 21, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on January 4, 2023. 
 
You asked the Plan to pay for the lab services. You say that this was a Medicare-covered lab service, so this 
claim should be paid. 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, for 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 provided on January 4, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 18, 2023, billed with 
codes  81225, 81226, 81227, 81231, 81232, 81238, 81240, 81241, 81291, 81306, 81238, and 81335. 
 
You asked the Plan to pay for the genetic testing billed. You say that this service was medically necessary. 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 
March 18, 2023, billed with codes  81225, 81226, 81227, 81231, 81232, 81238, 81240, 81241, 81291, 81306, 
81238, and 81335.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services rendered from January 
1, 2022, to January 17, 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 not reported correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We asked our 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 services. Our reviewer says that the services at issue 
in this case were not supported by the medical records. Our reviewer found that there is no evidence that the 
enrollee had or was treated for ulcerative colitis, Crohns disease, or inflammatory bowel syndrome while in 
the SNF. The enrollee did have nausea and vomiting after breaking her arm. The billing is not supported. 
 
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 skilled nursing facility (SNF) services rendered from January 1, 2022, to January 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (procedure code 99222) rendered on May 
2, 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 the documents do not support this level of care. 
 
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 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 while the history talks about the 
enrollees accident, few details are provided regarding the enrollees hand injury, which is what the consultant 
was asked to advise on. Additionally, the review of systems is not comprehensive. As such, the history is not comprehensive and the billing of CPT 99222 is not supported. 
 
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 initial hospital care (procedure code 99222) rendered on May 2, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided September 7, 2022, 
to September 8, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this admission was medically 
necessary. The Plan denied your request. The Plan says this admission was not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found on admission the enrollee was afebrile without leukocytosis and was 
hemodynamically stable. There was no expectation that the enrollee would require hospital services that would 
likely cross two midnights.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided September 7, 2022, to September 8, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for extractions and anesthesia provided April 7, 2023. 
 
You asked the Plan to pay for extractions and anesthesia. You say that these services should be covered. The 
Plan denied your request. The Plan says these services have been processed 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, anesthesia is not among those covered 
under this benefit. The correct deductible and coinsurance amount have been applied to the extractions 
provided. Therefore, we decided that the Plan does not have to pay for extractions and anesthesia provided 
April 7, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 1 standard power operated vehicle with a 
patient weight capacity up to and including 300 pounds (K0800).  
 
You asked the Plan to pre-approve the durable medical equipment (DME). You say that you really need the 
chair.  The Plan denied your request. The Plan says this request is not medically necessary.  
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 durable medical equipment (DME). 
Our physician reviewer found the documentation available for review does not support that you require a 
power mobility device to accomplish mobility related self-care tasks in the home. There is no indication they are unable to use an alternative assistive device. 
 
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 durable medical equipment (DME) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a group 1 standard power operated vehicle with a patient 
weight capacity up to and including 300 pounds (K0800).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the fifteen (15) lymphedema decongestive treatment 
therapy (97110 x15). 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the services are not 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 the services. Our physician reviewer 
found the decongestive therapy is expected to be temporary - up to 3 weeks. The enrollee does respond to 
decongestive therapy and there are no barriers identified which prevent the enrollee from continuing to manage 
the lymphedema themselves. 
 
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 the fifteen (15) lymphedema decongestive treatment therapy (97110 x15).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 57 additional routine transportation trips (A0120). 
 
You asked the Plan to pre-approve the additional trips. You say that you have stage 5 kidney disease and this 
requires 3 dialysis treatments a week. You also say that any less than 3 treatments a week could be fatal to you. 
The Plan denied your request. The Plan says you have zero trips remaining and any additional routine 
transportation trips will not be covered.  
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 trips per year.  
 
We looked at your request, the records in the case file, and the rules. You asked the Plan to pre-approve 57 
additional routine transportation trips for your dialysis appointments. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve 57 additional routine transportation trips (A0120).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (0018U, 0245U, 88381) provided on March 2, 
2023. 
 
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 documentation does 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. 
 
We find that CPT codes 0018U, 0245U, and 88381 are not supported in the medical record. Specifically, the 
date of service indicated in the records is February 15, 2023. This does not match the date of service billed. 
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 (0018U, 0245U, 88381) provided on 
March 2, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medication assisted treatment provided on February 13, 
2023, by an OON provider.  You asked the Plan to pay for the medication assisted treatment. You say that the Plan must pay this claim per 
Medicare guidelines. The Plan denied your request. The Plan says the services were not authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the medication assisted treatment provided on 
February 13, 2023, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on January 24, 2023. 
 
You asked the Plan to pay for the office visit. You say that the services were medically necessary. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the office visit provided 
on January 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for the drug injection provided on March 22, 
2023. 
 
You asked the Plan to reduce the coinsurance for the drug injection. You say that the price for this procedure is 
much higher than in the past. 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 20% 
coinsurance for in-network Medicare Part B drugs. 
 
You have been asked to pay 20% coinsurance for the drug injection. This item/service falls within the in-
network Medicare Part B drugs 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 reduce the coinsurance for 
the drug injection provided on March 22, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 83789 rendered on March 27, 2023. 
 
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 Current Procedure Terminology (CPT) code 83789-59 (1 Unit) remains not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the services have not been met. Specifically, we find that the testing described by the billed code is 
considered specimen validity testing which is not separately payable. Therefore, we decided that the Plan does 
not have to pay for procedure code 83789 rendered on March 27, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a chest x-ray provided on April 18, 2023. 
 
You asked the Plan to pay for a chest x-ray. You say that this is supported in the records. The Plan denied your 
request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a chest x-ray provided 
on April 18, 2023.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for an implant supported porcelain/ceramic crown (D6065) and a custom 
fabricated abutment (D6057) provided on October 5, 2022. 
 
You asked the Plan to pay for an implant supported porcelain/ceramic crown (D6065) and a custom fabricated 
abutment (D6057). You say that this claim was only approved and you were reimbursed $800. You also say 
you do not agree with the amount. The Plan denied your request. The Plan says that the services were 
previously paid according to fee schedule. 
 
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 an implant 
supported porcelain/ceramic crown (D6065) and a custom fabricated abutment (D6057) when the services are 
medically necessary and reasonable. 
 
We looked at the file, the Plan rules and Medicare rules. The Plan rules say that the Plan does not allow 
providers to add additional separate charges, called balance billing. The Plan contract also says that this 
protection (that you never pay more than your cost-sharing amount) applies even if we pay the provider less 
than the provider charges for a service and even if there is a dispute and we dont pay certain provider charges. 
The Plan contract also says that if you receive the covered services from an out-of-network provider who 
participates with Medicare, you pay the coinsurance percentage multiplied by the Medicare payment rate for 
participating providers. Specifically, there is no indication in the EOC that this does not apply to supplemental 
benefits. The EOC says when you get services covered by our plan. The record shows that these services are 
covered by the Plan, and therefore, fall under the balance billing protection. Based on this information, we 
decided that the Plan's rules for coverage of an implant supported porcelain/ceramic crown (D6065) and a 
custom fabricated abutment (D6057) have been met. Therefore, we decided that the Plan has to pay for an 
implant supported porcelain/ceramic crown (D6065) and a custom fabricated abutment (D6057) provided on 
October 5, 2022.  
 
  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: Unfavorable

 
We decided that the Plan does not have to pay for the DecisionDx-SCC test (0315U) provided on February 20, 
2023. 
 
You asked the Plan to pay for the DecisionDx-SCC test. You say that this testing is medically necessary. The 
Plan denied your request. The Plan says this testing is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. 
 
We looked at the file and Medicare rules. This test is listed in the DEX database as not covered. Based on this information, we decided that Medicare rules for coverage of the DecisionDx-SCC test have not been met. 
Therefore, we decided that the Plan does not have to pay for the DecisionDx-SCC test (0315U) provided on 
February 20, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pathology services provided on March 01, 2023. 
 
You asked the Plan to pay for the pathology services. You say that this was a necessary part of the procedure. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the pathology services 
provided on March 01, 2023.