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

 
We decided that the Plan does not have to pre-approve the Invitae MLH1 gene analysis testing (81294, 81292). 
 
You asked the Plan to pre-approve the genetic testing. You say that please see attached medical records to 
support this appeal. The Plan denied your request. The Plan says under Medicare guidelines, this request is not 
medically necessary because the genetic test requested is not approved by MolDX Technical Assessment. 
 
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 the diagnostic program, MolDX Technical Assessment, the 
requested tests, the Invitae MLH1 testing are not approved tests as they have not completed the registration and 
technical assessment process to meet Medicares reasonable and necessary criteria for coverage. Based on this 
information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, 
we decided that the Plan does not have to pre-approve the Invitae MLH1 gene analysis testing (81294, 81292).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the internal root repair of perforation defects (D3333). 
 
You asked the Plan to pre-approve the internal root repair of perforation defects. The Plan denied your request. 
The Plan says this service is not covered under the benefit 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 service is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the internal 
root repair of perforation defects (D3333).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services provided by an out-of-network provider 
on July 14, 2023. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says the services were not authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for drug testing services provided by an out-of-
network provider on July 14, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve unspecified restorative procedure (D2999). 
 
You asked the Plan to pre-approve unspecified restorative procedure. You say that this should be covered. The 
Plan denied your request. The Plan says this is not a covered service. 
 
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 pre-approve 
unspecified restorative procedure (D2999).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two core buildups, including any pins when required 
(D2950 x2) provided on August 17, 2023. 
 
You asked the Plan to pay for the core buildups. You say that you were told this service had to be done. You 
also say that you thought it should have been covered because the Plan agent who signed you up explained that 
you had $2,000 to spend toward dental work. The Plan denied your request. The Plan says this service is not a 
covered expense under the Plan. The Plan also says that you did not contact the Plan prior to the date 
of service to verify benefits and provider eligibility. 
 
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 two 
core buildups, including any pins when required (D2950 x2) provided on August 17, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on August 10, 
2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on August 10, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Guardant Reveal testing (81479). 
 
You asked the Plan to pre-approve the Guardant Reveal testing. You say that this service is medically 
necessary. The Plan denied your request. The Plan says rules for coverage are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that Next Generation Sequencing (NGS) is covered 
when the patient has not been previously tested with the same test using NGS for the same cancer genetic 
content. 
 
We looked at the file and Medicare rules. The records provided show the same Guardant Reveal test was 
previously performed. Based on this information, we decided that Medicare rules for coverage of the Guardant 
Reveal testing have not been met. Therefore, we decided that the Plan does not have to pre-approve Guardant 
Reveal testing (81479).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic casts and the surgical removal of an implant body 
(D6100, D0470) provided on August 14, 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. 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 diagnostic 
casts and the surgical removal of an implant body (D6100, D0470) provided on August 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99232 billed for date of service July 20, 
2023, to July 23, 2023.  
 
You asked the Plan to pay for procedure code 99232. You say that the claim is 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 submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 99232 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 99232 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 99232 billed for date of service July 20, 2023, to July 23, 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 September 
10, 2023, to September 23, 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 September 10, 2023, to September 23, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G7 sensor and receiver. 
 
You asked the Plan to pre-approve the Dexcom G7 sensor and receiver. The Plan denied your request. The Plan 
says only the preferred brand products listed in the EOC are covered.  
 The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including 
non-preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in 
clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for the Dexcom G7 receiver. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G7 
sensor and receiver.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on August 21, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that the claim is billed correctly and should be paid. 
The Plan denied your request. The Plan says this is a non-covered service 
 The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services provided on August 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit (99205) to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve an office visit. You say that the service at issue is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says rules for coverage for OON services have not been 
met. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit (99205) to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services rendered on August 25, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says 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. Based on this information, we decided that Medicare rules for coverage of the services have not 
been met. Therefore, we decided that the Plan does not have to pay for laboratory services rendered on August 
25, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral x-rays (D0220) provided on August 22, 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 Plan's 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 July 13, 2023. Therefore, 
we decided that the Plan does not have to pay for intraoral x-rays (D0220) provided on August 22, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical placement of implant body (D6010), guided tissue 
regeneration (D4266), extraction of erupted tooth (D7210), collection and application of autologous blood 
concentrate product (D7921), bone replacement graft for ridge preservation (D7953), deep sedation/general 
anesthesia (D9223) and therapeutic parenteral drug (D9610) provided on March 1, 2023. 
 
  You asked the Plan to pay for surgical placement of implant body, guided tissue regeneration, extraction of 
erupted tooth, collection and application of autologous blood concentrate product, bone replacement graft for 
ridge preservation, deep sedation/general anesthesia, and therapeutic parenteral drug. You say that this was 
medically necessary. The Plan denied your request. The Plan says these services are not a covered expense 
under your dental 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 surgical 
placement of implant body (D6010), guided tissue regeneration (D4266), extraction of erupted tooth (D7210), 
collection and application of autologous blood concentrate product (D7921), bone replacement graft for ridge 
preservation (D7953), deep sedation/general anesthesia (D9223) and therapeutic parenteral drug (D9610) 
provided on March 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound therapy provided by a chiropractor on August 
18, 2023. 
 
You asked the Plan to pay for the ultrasound therapy. You say that before you began treatment your provider 
contacted the Plan and they advised them that your coverage included therapy. The Plan denied your request. 
The Plan says that the only covered chiropractic service is manual manipulation of the spine. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the ultrasound therapy provided by a chiropractor on August 18, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor (CGM), supplies and 
accessories provided on July 23, 2023. 
 
You asked the Plan to pay for the CGM, supplies and accessories. You say that you have submitted proof of 
delivery along with other supporting documentation, but the claim keeps denying for missing this information. 
The Plan denied your request. The Plan says the provider is not a plan contract provider and is not enrolled in 
Medicare as a durable medical equipment supplier. 
 
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 the continuous glucose monitor (CGM), 
supplies and accessories provided on July 23, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the unlisted multianalyte assay with algorithmic 
analysis, BluePrint test (81599). 
 
You asked the Plan to pre-approve the BluePrint test. You say that the medical records provided support the 
necessity of the requested service The Plan denied your request. The Plan says the requested genetic testing, 
BluePrint, is not an approved test. 
 
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 BluePrint genetic testing have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the unlisted multianalyte assay with algorithmic analysis, BluePrint test (81599).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the removal of benign odontogenic cyst or tumor (D7451) 
provided on September 13, 2023. 
 
You asked the Plan to pay for the dental service. You say that you were referred to a specialist and the dental 
issue was a great concern and could have caused future damage to healthy teeth. The Plan denied your request. 
The Plan says the denial of payment for this service is correct, because the removal of benign odontogenic cyst 
or tumor is 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 item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
removal of benign odontogenic cyst or tumor (D7451) provided on September 13, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor (CGM), supplies and 
accessories provided on July 4, 2023. 
 
You asked the Plan to pay for the CGM, supplies and accessories. You say that you have submitted proof of 
delivery along with other supporting documentation, but the claim keeps denying for missing this information. 
The Plan denied your request. The Plan says the provider is not a plan contract provider and is not enrolled in 
Medicare as a durable medical equipment supplier. 
 
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 the continuous glucose monitor (CGM), 
supplies and accessories provided on July 4, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for over-the-counter COVID-19 test kits provided on 
September 11, 2023. 
 
You asked the Plan to reimburse for over-the-counter COVID-19 test kits. You say that you were under the 
impression that over-the-counter COVID-19 tests were covered. The Plan denied your request. The Plan says 
this is not a covered benefit. 
 
  The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and over-the-
counter COVID-19 test kits is an OTC item. The Plan does not offer coverage for OTC items, which includes 
COVID-19 test kits.  Therefore, we decided that the Plan does not have to reimburse for over-the-counter 
COVID-19 test kits provided on September 11, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on 
September 22, 2023. 
 
You asked the Plan to pay for the ED services. You say that your claim got denied because you were not 
eligible to bill Medicare. The Plan denied your request. The Plan says Medicare payment cannot be made to 
this type of provider. 
 
The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare and 
cannot receive payment for services.  
 
  We looked at the file and Medicare rules. We find that the provider at issue is not affiliated with a hospital and 
cannot receive Medicare payment. Therefore, we decided that the Plan does not have to pay for the emergency 
department (ED) services provided on September 22, 2023.