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

 
We decided that the Plan does not have to pay for a fungal infection polymerase chain reaction (PCR) panel 
provided on May 3, 2023. 
 
You asked the Plan to pay for a fungal infection PCR panel. You say that this testing was medically necessary. 
The Plan denied your request. The Plan says the guidelines state that fungal infection of the nail (tinea unguium 
or onychomycosis) can be verified by direct microscopic examination with potassium hydroxide, fungal culture 
of desquamated subungual material, or fungal stain of a nail clippings fixed in formalin. 
 
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 a fungal infection PCR panel. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the longstanding standard of care for the evaluation of fungus in toenails is the 
performance of both KOH and fungal culture on a toenail specimen. These laboratory tests are inexpensive, 
sensitive, and specific. It is unclear as to why this enrollee's toenail required PCR testing as compared to KOH 
and fungal culture. Therefore, the PCR testing of this enrollee's right hallux toenail was 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 a fungal infection PCR panel have not been met. Therefore, we decided that the 
Plan does not have to pay for a fungal infection polymerase chain reaction (PCR) panel provided on May 3, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation and additional intraoral x-
rays (D0230, D0150) provided on June 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 May 11, 2022 (D0150) 
and June 8, 2023 (D0230). Therefore, we decided that the Plan does not have to pay for a comprehensive oral 
evaluation and additional intraoral x-rays (D0230, D0150) provided on June 8, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), the intraoral radiographic 
images (D0220 and D0230), the bitewings (D0274), and a cleaning (D1110) provided on May 31, 2023. 
 
You asked the Plan to pay for the dental services. You say that you are entitled to the dental services that were 
rendered and you request the Plan to pay the provider. The Plan denied your request. The Plan says your annual 
dental maximum benefit for the year 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 the Plan paid $1,500 for dental services on January 3, 2023; therefore, your annual dental maximum 
benefit for the year of 2023 was exhausted on the date of service of January 3, 2023. Therefore, we decided that 
the Plan does not have to pay for a periodic oral evaluation (D0120), the intraoral radiographic images (D0220 
and D0230), the bitewings (D0274), and a cleaning (D1110) provided on May 31, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for maxillary/mandibular partial dentures (D5213, D5214) 
provided on May 4, 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 January 20, 2021. 
Therefore, we decided that the Plan does not have to pay for maxillary/mandibular partial dentures (D5213, 
D5214) provided on May 4, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an out-of-network acute inpatient stay 
provided from December 28, 2022, to January 6, 2023. 
 
You asked the Plan to waive the copayment for an out-of-network acute inpatient stay. You say that you were 
out of the area at the time of this stay. 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 $500 
copayment per admission for hospital inpatient care.  
 
You have been asked to pay a $500 copayment per admission for an out-of-network acute inpatient stay. This 
item/service falls within the hospital inpatient care 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 out-of-network acute inpatient stay provided from 
December 28, 2022, to January 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SIJ denervation RFA. 
 
You asked the Plan to pre-approve SIJ denervation RFA. You say that the requested procedure is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet the required LCD criteria for 
the requested procedure to be approved. 
 
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 SIJ denervation RFA. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this is considered experimental therapy because of the wide variation in efficacy 
reported in the peer reviewed literature. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SIJ denervation RFA have not been met. Therefore, we decided that the Plan 
does not have to pre-approve SIJ denervation RFA.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral- periapical first radiographic image (D0220) and a 
limited oral evaluation (D0140) provided on June 14, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. 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 February 6, 2023. 
Therefore, we decided that the Plan does not have to pay for intraoral- periapical first radiographic image (D0220) and a limited oral evaluation (D0140) provided on June 14, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 11103 provided on May 3, 2023. 
 
You asked the Plan to pay for procedure code 11103. 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 that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 11103 is an add-on code and has not been billed with an appropriate primary procedure code. Based on the claim 
submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code 11103 provided on May 3, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6545. 
 
You asked the Plan to pre-approve the compression stockings. You say that the requested compression 
stockings are necessary because your ankles are swollen on the inside. The Plan denied your request. The Plan 
says the denial of authorization for the requested compression stockings is correct, because the Medicare 
guidelines were not met. 
 
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6545 
are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that 
compression bandages and gradient compression wraps are covered only when they are used as dressings over 
a qualifying wound. 
 
The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you 
do not have a medical condition for which compression stockings can be covered or paid for by Medicare. 
Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code 
A6545.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the osseous surgery (D4260) and the sedation (D9248) 
provided on May 17, 2023. 
 You asked the Plan to pay for the dental services. You say that you are appealing the denied dental services. 
The Plan denied your request. The Plan says the denial of payment for these services is correct, because the 
osseous surgery and the sedation are not covered by 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, 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 
osseous surgery (D4260) and the sedation (D9248) provided on May 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prostate specific antigen (PSA) test provided April 29, 
2023, while out of the country. 
 
You asked the Plan to pay for the PSA test provided while out of the country. You say that you were traveling 
and required this necessary service. The Plan denied your request. The Plan says this service is not covered 
when provided outside of the United States. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services furnished outside the United 
States are excluded from coverage except for certain services described in the rules section of this letter. The 
Plan provides a worldwide coverage benefit that exceeds Medicare coverage. The Plan covers services 
provided outside of the country only under emergent or urgent circumstances. 
 
We looked at the file and Medicare rules. In this case, based on the documentation provided, the outpatient 
services at issue do not appear to have been urgent or emergent. Based on this information, we decided that 
Medicare rules for coverage of the PSA test provided while out of the country have not been met. Therefore, 
we decided that the Plan does not have to pay for the prostate specific antigen (PSA) test provided April 29, 
2023, while out of the country.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an in-network visit and laboratory testing provided on March 
2, 2023. 
 
You asked the Plan to pay for an in-network visit and laboratory testing. You say that the plan needs to pay for 
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. Your 
contract with the Plan says that there is a $625 deductible which applies to Physician/Practitioner services, 
including doctor's office visits. You have been asked to pay $123.57 towards this $625 deductible. 
 
The item or service you asked the Plan to pay for falls within the Physician/Practitioner services, including 
doctor's office visits benefit category. The Plan has followed Medicare rules by clearly disclosing in the 
contract that there is a $625 deductible which applies to Physician/Practitioner services, including doctor's 
office visits. This cost sharing is a contractual obligation that had not been met at the time an in-network visit 
and laboratory testing was received on March 2, 2023. Therefore, we decided that the Plan does not have to pay 
for an in-network visit and laboratory testing provided on March 2, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 12, 2023, billed with 
codes 87481, 87491, 87563, 87640, 87653, 87798, 87641, and 87500. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's denial. 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 
June 12, 2023, billed with codes 87481, 87491, 87563, 87640, 87653, 87798, 87641, and 87500.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87506 for date of service August 24, 2022. 
 
You asked the Plan to pay for procedure code 87506. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are not supported. 
 
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 87506 is infectious agent detection by nucleic acid (DNA 
or RNA); gastrointestinal pathogen (eg, Clostridium difficile, E. coli, Salmonella, Shigella, norovirus, Giardia), 
includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple 
types or subtypes, 6-11 targets. 
 
 
 We find that CPT code 87506 is not supported in the medical record. Specifically, the documentation indicates 
that more than 11 targets were tested. Based on this information, we decided that Medicare rules for coverage 
of procedure code 87506 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 87506 for date of service August 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on July 05, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for an office visit. You say that you are asking for the medical records to be 
reviewed. The Plan denied your request. The Plan says the enrollee must receive their care from a network 
provider (for more information about this, see Section 2 of Chapter 3). In most cases, care the enrollee receives 
from an out-of-network provider (a provider who is not part of the plans network) will not be 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 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 July 05, 2023, by an 
out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the core buildup (D2950) for tooth #29 to be provided 
by an out-of-network provider. 
 
You asked the Plan to pre-approve the dental service. You say that there is no in-network providers that can 
provide the requested dental service with anesthesia. The Plan denied your request. The Plan says 
comprehensive dental services from an out-of-network provider are not covered by your supplemental benefits. 
Also, there are multiple in-network providers in your service area that can provide you with comprehensive 
dental services. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 You are requesting a comprehensive dental service from an out-of-network provider. Though the Plan offers a 
dental benefit in excess of Medicare coverage, the requested item or service is not covered under this benefit 
when received from an out-of-network provider. Therefore, we decided that the Plan does not have to pre-
approve the core buildup (D2950) for tooth #29 to be provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the telehealth visit provided on June 15, 2023, by an OON 
provider.  
 
You asked the Plan to pay for the telehealth visit. You say that you are requesting reconsideration of the denied 
claim. The Plan denied your request. The Plan says this service is not covered when received by an out-of-
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 a POS benefit to allow the enrollee to access certain services from non-network 
providers. The Plan contract also says that an in-network provider must be used for the out-of-network 
telehealth services benefit. 
 
The requested provider in this case is not a network provider with the Plan. 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 telehealth visit provided on June 15, 2023, by 
an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99204 billed for date of service April 13, 
2023. 
 
You asked the Plan to pay for procedure code 99204. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says the provided records do 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 99204 is: Office or other outpatient visit for the 
evaluation and management of a new patient, which requires a medically appropriate history and/or 
examination and moderate level of medical decision making. When using time for code selection, 45-59 
minutes of total time is spent on the date of the encounter. 
 
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 procedure code 99204. Our reviewer says that procedure 
code 99204 does not meet criteria for payment. Our reviewer found that the provided documentation does not 
support medical decision making of moderate level. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99204 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99204 billed for date of service April 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cleaning and periodic oral evaluation provided on January 
4, 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 the services denied correctly as the claim was 
submitted untimely. 
 
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 records 
provided show that the claim for payment was submitted on June 29, 2023. This is more than 120 days from 
January 4, 2023. Therefore, the rules for coverage have not been met and the Plan does not have to pay for the 
dental services provided on January 4, 2023.