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

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel provided on 
June 6, 2023, and billed with codes 87798 and 87481. 
 
You asked the Plan to pay for the urine PCR 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 urine PCR panel have not been met. 
Therefore, we decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel 
provided on June 6, 2023, and billed with codes 87798 and 87481.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder test (0013M) provided on May 5, 2023. 
 
You asked the Plan to pay for the Cxbladder test. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for Cxbladder are non-
covered. 
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the Cxbladder test have not been met. Therefore, we decided that 
the Plan does not have to pay for the Cxbladder test (0013M) provided on May 5, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a mandibular denture (D5214) provided 
on May 11, 2023. 
 
You asked the Plan to waive the coinsurance for D5214. You say that your secondary insurance should 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 50% 
coinsurance for dental services/major services.  
 
You have been asked to pay $261, which is less than a 50% coinsurance of the allowed amount for D5214. The 
total allowed amount is $769. The total 50% coinsurance is $384.50 ($769 x 50% - $384.50). This item/service 
falls within the dental services/major services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance 
for a mandibular denture (D5214) provided on May 11, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve twenty (20) additional occupational therapy visits. 
 
You asked the Plan to pre-approve the therapy services. You say that the additional occupational therapy visits 
are medically necessary for the enrollee. The Plan denied your request. The Plan says the request for the 
additional occupational therapy visits are not medically necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the record provides no support for additional therapy based on 
response to previous therapy. No prior range of motion or strength data is presented in the re-evaluation or 
evidence continued therapy will impact outcomes beyond what can be achieved with a home exercise program 
for an enrollee with intact strength. 
 
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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve twenty (20) additional occupational therapy visits.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for computed tomography cerebral perfusion analysis (CTP) 
provided on April 27, 2023. 
 
You asked the Plan to pay for the CTP. You say that the CTP was medically necessary. The Plan denied your 
request. The Plan says the CTP does not meet the Medicare LCD coverage criteria.  
 
The Plan follows Medicare rules.  
 
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 CTP. Our reviewer says that the requested 
CTP is not considered medically reasonable and necessary in this case. Our physician reviewer found criteria 
require a demonstration of a large vessel occlusion or blockage which would be amenable to intervention. The 
report describes correlation with a CTA of the head and neck earlier in the day, the report of which is not 
enclosed for review. Absent such a report the medical necessity of the CT perfusion study and compliance can't 
be assessed as required by the Medicare LCD criteria 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CTP have not been met. Therefore, we decided that the Plan does not have to 
pay for CTP provided on April 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services provided on June 15, 2023. 
 
You asked the Plan to pay for the dental services. You say that your dentist retired, and you did not know the 
dentist who replaced him was not in-network. The Plan denied your request. The Plan says the dental services 
were received from an out-of-network provider and 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. 
 
The record shows you received the requested 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 pay for the dental services provided on June 15, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) and water 
circulating heat pad with pump (E0217) provided March 4, 2023, to March 3, 2023. 
 
You asked the Plan to pay for a pneumatic compression device and water circulating heat pad with pump. You 
say that pleas review the medical records and process the claim for payment. The Plan denied your request. The Plan says pneumatic compression device is not covered by Medicare to prevent deep vein thrombosis during 
and/or following surgery and a water circulating heating pad system is not medically necessary. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675) and water circulating heat pad with pump (E0217) provided 
March 4, 2023, to March 3, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a non-covered item or service (A9270 x3), foot, arch support, 
removable, premolded, metatarsal, each (L3050 x3) and sales tax (S9999) provided May 5, 2023. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the services are not payable as billed.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
For code L3050 the records show that you do not suffer from diabetic foot disease, and you do not wear a leg 
brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of 
orthotics for your condition. 
 
We find that procedure code A9270 has a Status Indicator of N on the Physician Fee Schedule. This means that 
procedure code A9270 is not covered by Medicare of the Health Plan. 
 
We find that procedure code S9999 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9999 is not valid for Medicare purposes. Furthermore, state sales tax is not covered or 
reimbursable by the Health Plan.  Therefore, we decided that the Plan does not have to pay for a non-covered 
item or service (A9270 x3), foot, arch support, removable, premolded, metatarsal, each (L3050 x3) and sales 
tax (S9999) provided May 5, 2023.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to hold you harmless for oral hygiene instructions (D1330) and nutritional 
counseling (D1310) billed for date of service May 15, 2023. 
 
You asked the Plan to hold you harmless for oral hygiene instructions and nutritional counseling. You say that 
you have never seen this provider and did not receive dental services. The Plan denied your request. The Plan 
says that these services are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan has not addressed your statement that the services did not occur and 
has not provided any documentation to support that the services took place. Therefore, we decided that the Plan 
has to hold you harmless for oral hygiene instructions (D1330) and nutritional counseling (D1310) billed for 
date of service May 15, 2023.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary for your 
recovery period, and you feel that you would not get proper care at a skilled nursing facility. The Plan denied 
your request. The Plan says you do not meet the criteria for admission to an IRF.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not require treatment by multiple therapies. While the medical record 
supports a need for physical or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided in a different level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care provided on February 23, 2023, to 
March 30, 2023. 
 
You asked the Plan to pay for the nursing facility care. You say that you are requesting reconsideration of 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 the nursing facility care 
provided on February 23, 2023, to March 30, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder test (0013M) provided on March 11, 2023. 
 
You asked the Plan to pay for the Cxbladder test. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for Cxbladder are non-
covered. 
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the Cxbladder test have not been met. Therefore, we decided that 
the Plan does not have to pay for the Cxbladder test (0013M) provided on March 11, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0480 billed for date of service September 
15, 2022.  
 
You asked the Plan to pay for procedure code G0480. You say that the claim should be paid. The Plan denied 
your request. The Plan says payment for code G0480 is bundled into payment for code G0481. 
 
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 G0480 is a column II code to column I code G0481 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 G0480 billed for date of service September 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DecisionDx-SCC test (0315U) provided on May 2, 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 
May 2, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vabysmo. 
 You asked the Plan to pre-approve Vabysmo. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
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 Vabysmo. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has a diagnosis/diagnoses of wet age-related macular degeneration and active choroidal 
neovascularization. The documentation does not support that the enrollee has tried and failed Avastin and 
Byooviz. The documentation does not support that Avastin and Byooviz would likely be less effective and/or 
likely have adverse effects for the enrollee. Therefore, the enrollee does not meet criteria for the requested 
drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vabysmo have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Vabysmo.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 6, 2023, billed with 
codes 81201, 81292, 81295, 81298, 81307, 81317, 81321, 81351, 81209, and 81334. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing 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 
May 6, 2023, billed with codes 81201, 81292, 81295, 81298, 81307, 81317, 81321, 81351, 81209, and 81334.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing (G0482) provided December 20, 2022.  
You asked the Plan to pay for the drug testing. You say that the claim should be paid. The Plan denied your 
request. The Plan says medical records submitted do not include an order that specifically list what tests are to 
be performed in the custom panel 
 
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 G0482 is drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 15-21 
drug class(es), including metabolite(s) if performed. 
 
Review of the file shows that the medical records submitted do not include an order that specifically list what 
tests are to be performed in the custom panel. Based on this information, we decided that Medicare rules for 
coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for 
the drug testing (G0482) provided December 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation, endosteal implants, a 
prefabricated abutment, custom fabricated abutment, bone graft, unspecified implant procedure, or 
alveoloplasty (D0150, D6010, D6056, D6057, D6104, D6199, D7310) provided from March 2, 2023, to April 
27, 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 they do not fall 
within your dental benefits. 
 Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. The Plan contract directs the enrollee to pursue dental coverage through their current dental 
plan, which is offered separately through the enrollees plan sponsor. You may contact the Plan directly if you 
have questions regarding this separate insurer and how to request coverage through them. Therefore, we 
decided that the Plan does not have to pay for the comprehensive oral evaluation, endosteal implants, a 
prefabricated abutment, custom fabricated abutment, bone graft, unspecified implant procedure, or 
alveoloplasty (D0150, D6010, D6056, D6057, D6104, D6199, D7310) provided from March 2, 2023, to April 
27, 2023 .
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2740) provided on June 8, 2023. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for this. 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 31, 2023. Therefore, 
we decided that the Plan does not have to pay for a crown (D2740) provided on June 8, 2023.