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

 
We decided that the Plan does not have to pay for lab services provided on May 31, 2023. 
 
You asked the Plan to pay for the lab services. You say that a DEX code has been assigned to this testing. The 
Plan denied your request. The Plan says the claim for this molecular pathology testing did not include the 
required unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Please note that although you contend that a DEX code has been assigned for this testing, no such 
code was included on the claim you submitted. 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 provided on May 31, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation-problem focused (D0140), 
intraoral-periapical first radiographic image (D0220), and the intraoral-periapical additional radiographic image 
(D0230) provided on July 24, 2023. 
 
You asked the Plan to pay for the dental services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says your benefit for the services provided 
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 services provided has been exhausted. Specifically, the Plans contract states that 
one intraoral x-ray is covered per calendar year. You previously received this service on April 26, 2023, less 
than one year prior, which was paid for by the Plan. Additionally, the Plans contract states that one limited 
oral evaluation is covered per calendar year. You previously received this service on May 12, 2023, less than 
one year prior, which was paid for by the Plan. Therefore, you have exhausted the allowable benefit for these 
services. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation-problem 
focused (D0140), intraoral-periapical first radiographic image (D0220), and the intraoral-periapical additional 
radiographic image (D0230) provided on July 24, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 6, 2023. 
 
You asked the Plan to pay for the lab services. You say that as a lab, you do not have access to medical records 
beyond your lab report. 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 June 6, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for a retainer crown for teeth #5 and #8, core 
buildup for teeth #5 and #8, pontic for teeth #6 and #7, and unspecified adjunctive procedure (D6740, D2950, 
D6245, D9999) provided on March 31, 2022, to April 19, 2022. 
 
You asked the Plan to waive the copayments for the dental services. You say that the services should be 
covered as you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied 
correctly based on the services provided. Additionally, the unspecified adjunctive procedure denied correctly as 
they do not fall within 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. 
 
You have been asked to pay a $2,180 copayment for retainer crowns, pontics, and core buildup services. 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. Additionally, the unspecified adjunctive procedure denied correctly as they 
do not fall within your dental benefits. Therefore, we decided that the Plan does not have to waive the 
copayments for a retainer crown for teeth #5 and #8, core buildup for teeth #5 and #8, pontic for teeth #6 and 
#7, and unspecified adjunctive procedure (D6740, D2950, D6245, D9999) provided on March 31, 2022, to 
April 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the compression stockings (A6537) 
purchased on August 2, 2023. 
 
You asked the Plan to issue reimbursement for this item. You say that you are requesting a reconsideration of 
the Plan's denial for payment. The Plan denied your request. The Plan says this item is not a covered benefit.  
  
 
 
 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6537 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to issue reimbursement for the 
compression stockings (A6537) purchased on August 2, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76642 billed for date of service January 3, 
2023.  
 You asked the Plan to pay for procedure code 76642. You say that CPT code 76642 26 50 was billed correctly 
and should be paid. The Plan denied your request. The Plan says the number of units billed exceeds the 
maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 76642 26 50 is 1 unit. The MAI value for this code is 2. You billed 2 units 
of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 76642 26 50 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 76642 billed for date of service January 3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on April 25, 2023. 
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration for the denied 
claim. 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 an office visit provided 
on April 25, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultraviolet light therapy system (E0691) provided May 9, 
2023. 
 
You asked the Plan to pay for the ultraviolet light therapy system. You say that please see the attached medical 
records. The Plan denied your request. The Plan says the records do not show that the enrollee meets the 
criteria. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. There is no skin examination, and the record does not show a 
diagnosis of psoriasis. There is also no indication that intractable psoriasis, as there is no indication the enrollee 
has failed other treatments for psoriasis. There are also no other factors described that would justify treatment 
at home rather than alternative sites, like a clinic or the hospital. Based on this information, we decided that 
Medicare rules for coverage of the ultraviolet light therapy system have not been met. Therefore, we decided 
that the Plan does not have to pay for the ultraviolet light therapy system (E0691) provided May 9, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service April 4, 
2023. 
 You asked the Plan to pay for procedure code 99100. You say that you are requesting the claim be reviewed 
and reprocessed for payment. The Plan denied your request. The Plan says procedure code 99100 is considered 
bundled and not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service April 4, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for remote monitoring of physiologic parameter provided on 
June 13, 2023. 
 
You asked the Plan to pay for remote monitoring of physiologic parameter. You say that you are requesting 
reconsideration for the denied claim. 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 remote monitoring of 
physiologic parameter provided on June 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on August 8, 
2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. 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 April 6, 2023. Therefore, 
we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on August 8, 
2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant Reveal diagnostic testing (81479) provided on 
June 3, 2023. 
 
You asked the Plan to pay for the Guardant Reveal diagnostic testing. You say that this testing was medically 
necessary. The Plan denied your request. The Plan says this test is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests such as the 
Guardant Reveal are subject to the MolDX application, assessment, and approval process. 
 We looked at the file and Medicare rules. We find that the Guardant Reveal test has not been approved for 
coverage based on information in the DEX Diagnostic Exchange. Based on this information, we decided that 
Medicare rules for coverage of the Guardant Reveal diagnostic testing have not been met. Therefore, we 
decided that the Plan does not have to pay for the Guardant Reveal diagnostic testing (81479) provided on June 
3, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the ontruzant injections provided on May 
16, 2023, to August 16, 2023. 
 
You asked the Plan to waive the coinsurance for the ontruzant injections. You say that you were unaware of the 
coinsurance. 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 Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for the ontruzant injections. This item/service falls within the 
Medicare Part B prescription 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 waive the coinsurance for 
the ontruzant injections provided on May 16, 2023, to August 16, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urinary tract infection (UTI) panel provided on January 3, 
2023, and billed with codes 87640, 87481, 87798, 87653, 81003, and 87086. 
 
You asked the Plan to pay for the UTI panel. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this testing should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a single panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the UTI panel have not been met. 
Therefore, we decided that the Plan does not have to pay for the urinary tract infection (UTI) panel provided on 
January 3, 2023, and billed with codes 87640, 87481, 87798, 87653, 81003, and 87086.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inactivated tick-borne encephalitis vaccine provided on July 
12, 2023. 
 
You asked the Plan to pay for inactivated tick-borne encephalitis vaccine. You say that vaccines and injections 
are covered. The Plan denied your request. The Plan says this requested service is not covered by the Plan 
under any circumstances. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide inactivated tick-
borne encephalitis vaccine. The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to inactivated tick-
borne encephalitis vaccine. Therefore, we decided that the Plan does not have to pay for inactivated tick-borne 
encephalitis vaccine provided on July 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office services provided on June 10, 2023. 
 
You asked the Plan to pay for office services. You say that you are requesting reconsideration for the denied 
claim. 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 office services provided 
on June 10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the out-of-area hotel accommodations provided 
from August 4, 2022, to August 14, 2022. 
 
You asked the Plan to reimburse you for the hotel accommodations. You say that the government of the 
country you were visiting required a quarantine upon coming into the country. You say that it was urgent that 
you attend to a family dispute requiring your presence. You also say that you feel this should be covered under 
emergency care. The Plan denied your request. The Plan says this is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the hotel accommodations have not been met. Specifically, the hotel accommodations were not medically necessary for the diagnosis and treatment of an illness or injury, nor were they needed to improve the 
functioning of a malformed body member. Therefore, we decided that the Plan does not have to reimburse you 
for the out-of-area hotel accommodations provided from August 4, 2022, to August 14, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure (64628, 64629). 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says the requested service 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 pre-approve this service. Our reviewer says that the 
requested service is not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there is no magnetic resonance imaging (MRI) showing only modic changes without facet joint 
degenerative disease or stenosis. The cause of pain is not clear.   
  
 
 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Intracept procedure (64628, 64629).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for take-home supply of methadone provided on May 29, 2023. 
 
You asked the Plan to pay for take-home supply of methadone. You say that you are requesting reconsideration 
for the denied claim. 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 take-home supply of 
methadone provided on May 29, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on May 18, 2023. 
 
You asked the Plan to pay for the psychotherapy. You say that the services were medically necessary. The Plan 
denied your request. The Plan says a Mental Health Counselor is on the list of individuals who are not eligible 
to enroll in Medicare.  
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for psychotherapy provided on 
May 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service June 18, 
2023, to July 15, 2023. 
 
You asked the Plan to pay for procedure code S9328. You say that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says the billed code is invalid for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service June 18, 2023, to July 15, 2023.