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

 
We decided that the Plan does not have to pay for procedure code 81456 billed for date of service January 31, 
2023.  
 
You asked the Plan to pay for procedure code 81456. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment for code 81456 is bundled into 
payment for code 81455. 
 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 81456 
is a column II code to column I code 81455 with a modifier indicator of 0. The column II code is therefore not 
payable. 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 81456 billed for date of service January 31, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services with an out-of-network provider. 
 
You asked the Plan to pre-approve the dental services with an out-of-network provider. You say that the 
enrollee wants to see this provider. The Plan denied your request. The Plan says dental services from an out-of-
network provider are not covered by your supplemental 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 are requesting dental services from an out-of-network provider. Though the Plan offers a dental benefit in 
excess of Medicare coverage, the requested items or services are 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 dental 
services with an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed (E0265). 
 
You asked the Plan to pre-approve a total electric hospital bed. You say that this item should be covered. The 
Plan denied your request. The Plan says this is not a covered item. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed (E0265).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Evenity. You asked the Plan to pre-approve Evenity. 
You say that the enrollee has a diagnosis of gastroesophageal reflux disease (GERD), therefore is unable to 
take the preferred drug Forteo. The Plan denied your request.  The Plan says there is no record that shows the enrollee has tried the preferred drug Forteo and it hasn't worked 
or that the enrollee has medical reasons that prevent them from using it.  
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Evenity. Our reviewer says the 
requested drug is not medically necessary. Our physician reviewer found that the Plan requires a trial of the 
drug Forteo before they will approve the requested drug. In this case, the enrollee has not tried and failed the 
required drug. There is no documentation provided indicating that the Plans required drug would likely be less 
effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Evenity have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Evenity.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 84436, 84479, and 84480 billed for date of 
service March 16, 2023.   

You asked the Plan to pay for procedure codes 84436, 84479, and 84480. You say that you would like the Plan 
to reconsider their denial of payment. The Plan denied your request. The Plan says payment for code 84480 is 
bundled into payment for code 84481. Payment for code 84479 is bundled into payment for code 84439. 
Payment for code 84436 is bundled into payment for code 84439. 
 
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 84480 
is a column II code to column I code 84481 with a modifier indicator of 0, code 84479 s a column II code to 
column I code 84439 with a modifier indicator of 0, and code 84436 is a column II code to column I code 
84439 with a modifier indicator of 0. The column II codes are therefore not payable. 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 codes 84436, 84479, and 84480 billed for date of service March 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a prefabricated abutment and overdenture (D5863, D6056) 
provided on April 26, 2022. 
 
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 March 15, 2022. 
Therefore, we decided that the Plan does not have to pay for a prefabricated abutment and overdenture (D5863, 
D6056) provided on April 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care provided on June 1, 2023, by an 
OON provider.  
 
You asked the Plan to pay for the nursing facility care. You say that you are requesting this claim be 
reprocessed as in-network. The Plan denied your request. The Plan says the service was 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 nursing facility care provided on June 1, 2023, 
by an OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 24, 2023, billed with 
codes 87798, 87481, 87653, 87640, and 87641. 
 
You asked the Plan to pay for the genetic testing billed. 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. We find that the panel testing was not billed with a single 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 24, 2023, billed with codes 87798, 87481, 87653, 87640, and 87641.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computer-assisted surgical navigational procedure 
(20985). 
 
You asked the Plan to pre-approve a computer-assisted surgical navigational procedure. You say that this is 
medically necessary. 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 pre-approve a computer-assisted surgical 
navigational procedure. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found computer-assisted shoulder surgery has 
not been shown to be better than open surgery in clinical outcomes. 
 
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 computer-assisted surgical navigational procedure have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a computer-assisted surgical navigational 
procedure (20985).
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pre-approve a home health aide (G0156 x28). 
 
You asked the Plan to pre-approve the aide services. You say that this is medically necessary. The Plan denied 
your request. The Plan says that the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
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 aide services. Our reviewer says 
that the services are medically reasonable and necessary. Our physician reviewer found the enrollee is noted to 
spinal cord injury with quadriplegia and neurogenic bowel and bladder. He is unable to perform a routine 
bowel program and does not have access to caregiver assistance to accomplish this. This is a medical need and 
not assistance related to daily activities, such as dressing or bathing. 
 
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 aide services have been met. Therefore, we decided that the Plan has to pre-
approve a home health aide (G0156 x28).  
 
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 procedure code 81456 billed for date of service March 21, 
2023.  
 
You asked the Plan to pay for procedure code 81456. You say that the NCCI has agreed to change the NCCI 
indicator to 1, which would allow payment for these two codes together. The Plan denied your request. The 
Plan says payment for code 81456 is bundled into payment for code 81455. 
 
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 81456 is a column II code to column I code 81455 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Please note that the NCCI 
indicator change that you reference was not officially implemented until October 1, 2023. This date is well 
after your date of appeal. As a result, the Plan cannot be obligated to bypass this edit. You have the right to 
submit the claim again for additional consideration based on the rule change. Therefore, we decided that the 
Plan does not have to pay for procedure code 81456 billed for date of service March 21, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pulp vitality tests, surgical procedure for isolation,  and 
therapeutic parenteral drug (D9610, D0460, D3910) provided on April 12, 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 17, 2023. 
Therefore, we decided that the Plan does not have to pay for a pulp vitality tests, surgical procedure for 
isolation, and therapeutic parenteral drug (D9610, D0460, D3910) provided on April 12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a cleaning, intraoral x-ray, and comprehensive oral 
evaluation (D0150, D1110, D0210) provided on June 19, 2023. 
 
You asked the Plan to pay more 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 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. 
Therefore, we decided that the Plan does not have to pay more for a cleaning, intraoral x-ray, and 
comprehensive oral evaluation (D0150, D1110, D0210) provided on June 19, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81456 billed for date of service February 13, 
2023.  
 
You asked the Plan to pay for procedure code 81456. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 81456 is bundled into payment for code 81455. 
 
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 81456 is a column II code to column I code 81455 with a modifier indicator of 0. The column II code is therefore not 
payable. 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 81456 billed for date of service February 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation and periodontal maintenance 
(D4910, D0120) provided on July 12, 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 31, 2023 and 
March 8, 2023. Therefore, we decided that the Plan does not have to pay for a periodic oral evaluation and 
periodontal maintenance (D4910, D0120) provided on July 12, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the chiropractic manipulative treatment (98941) provided on  
September 27, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says that the service is not payable as the claim 
was submitted untimely.  
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for this service was submitted electronically on October 5, 2021. This means that 
the claim was submitted timely within one calendar year after the date of service. Therefore, we decided that 
the Plan has to pay for the chiropractic manipulative treatment (98941) provided on September 27, 2021.  
 
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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ER services provided on May 23, 2023. 
 
You asked the Plan to waive the copayment for ER services. You say that this should be covered. 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 $125 
copayment for emergency room services.  
 
You have been asked to pay $125 copayment for ER services. This item/service falls within the emergency 
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 ER services provided on May 
23, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit provided by an in-network 
provider on June 2, 2023. 
 
You asked the Plan to waive the copayment for the office visit. You say that you refuse to pay the bill. 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 $20 
copayment for each in-network Medicare-covered individual or group therapy visit. 
 
 
 You have been asked to pay a $20 copayment for the office visit. This item/service falls within the outpatient 
mental health 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 the office visit 
provided by an in-network provider on June 2, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral x-ray and comprehensive oral evaluation 
(D0210, D0150) provided on May 3, 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 November 3, 2022. 
Therefore, we decided that the Plan does not have to pay for an intraoral x-ray and comprehensive oral 
evaluation (D0210, D0150) provided on May 3, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87481 billed for date of service June 20, 
2022. 
 
You asked the Plan to pay for the billed services. You say that the enrollee was symptomatic and at higher risk 
for complications. The Plan denied your request. The Plan says the coding is 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 87481 is infectious agent detection by nucleic acid (DNA 
or RNA); Candida species, amplified probe technique. 

We find that the billed 5 units of CPT code 87481 is not supported in the medical record. Specifically, the lab 
results to not show that 5 Candida species were tested. Based on this information, we decided that Medicare 
rules for coverage of the billed services have not been met. Therefore, we decided that the Plan does not have 
to pay for procedure code 87481 billed for date of service June 20, 2022.