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

 
We decided that the Plan does not have to pay for the laboratory services provided on June 27, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that these services are not covered when 
provided OON. 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 laboratory services 
provided on June 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on June 27, 2023. 
 
You asked the Plan to pay for the office visit. You say that you say that the service was medically necessary. 
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 office visit provided 
on June 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the surgical removal of erupted tooth (D7210) for tooth 
#24 and #25. 
 
You asked the Plan to pre-approve the dental services. You say that dental code D7140 is not the appropriate 
code to care for the enrollee's teeth. The Plan denied your request. The Plan says the denial of authorization for 
surgical removal of erupted tooth is correct because the teeth do not show severe bone loss. Also, an extraction 
has been approved for tooth #24 and #25. 
 
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 Plan covers the dental 
services when the services are medically necessary and reasonable.  
 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 dental services. Our reviewer says 
that the surgical removal of erupted tooth for tooth #24 and #25 is not medically necessary. Our physician 
reviewer found that the letter asked for reconsideration of teeth #20, #21, #22, #28, and #29 to reverse the 
downgraded code from D7210 to D7140. The letter did not mention teeth #24 or #25. There was a treatment 
plan included which shows the recommended treatment proposed by the provider. There were 3 periapical x-
rays included that shows teeth #20, #21, #27, #28, #29, and a partial view of tooth #22. There were no x-rays 
included of teeth #24 and #25. Without an x-ray of these teeth in question, I am unable to make a determination 
whether D7210 is medically reasonable or necessary for teeth #24 and #25. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the surgical removal of erupted tooth (D7210) for tooth #24 and #25.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ultrasound image-guided radiation therapy (IGRT). 
 
You asked the Plan to pre-approve IGRT. 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 IGRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found using ultrasound on a daily basis is not unreasonable to offer but is not necessary. The device 
itself is Food & Drug Administration (FDA) approved for use with ultrasound, though that in and of itself does 
not mean that daily imaging is necessary. Daily IGRT would not be furnished in accordance with accepted 
standards of medical practice.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IGRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve ultrasound image-guided radiation therapy (IGRT).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on May 30, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services 
cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient information in the record to determine if Medicare rules for coverage of the services have been met. The 
documentation submitted does not contain medical records from the non-contract provider to verify the billed 
services. Therefore, we decided that the Plan does not have to pay for the drug testing services provided on 
May 30, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve MLH1 (mutL homolog 1, colon cancer, nonpolyposis 
type 2) (e.g., hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; promoter 
methylation analysis (81288). 
 
You asked the Plan to pre-approve the genetic testing. You say that you are submitting medical notes to support 
medical necessity for the enrollee. The Plan denied your request. The Plan says this test is not reasonable and 
necessary because it is not likely to directly impact decision making for treatment. 
 
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. This test is listed under Tier 2 non-covered codes. 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 MLH1 (mutL homolog 1, colon cancer, nonpolyposis 
type 2) (e.g., hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; promoter 
methylation analysis (81288).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 billed for date of service May 23, 
2023. 
 You asked the Plan to pay for procedure code 99285. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 99285 is bundled into payment for code 99152. 
 
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 99285 
is a column II code to column I code 99152. This claim has not been billed with an appropriate modifier to 
bypass the edit. 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 99285 billed for date of service May 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided with procedure code 99219. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says the claim was billed with an inappropriate place or 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that the place of service (POS) code is generally used 
to reflect the actual setting where the beneficiary receives the face-to-face service. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the practitioner services provided have not been met. We find that the claim was inappropriately 
billed with POS 21 as documentation shows that the enrollee was in outpatient observation on the date of 
service in question. Therefore, we decided that the Plan does not have to pay for practitioner services provided 
with procedure code 99219.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies.  
 
You asked the Plan to pre-approve incontinence supplies. You say that after your surgery you have to 
constantly wear Depends. This is a necessity for quality of life. The Plan denied your request. The Plan says 
this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on June 1, 2023. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says you billed with an 
incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for the lab services provided on June 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on July 3, 2023, billed with 
procedure code 99221. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99221 is not supported in the medical record. Specifically, the documentation provided 
does not contain notes for services rendered on the date of service in question. Based on this information, we 
decided that Medicare rules for coverage of the practitioner services provided have not been met. Therefore, we 
decided that the Plan does not have to pay for practitioner services provided on July 3, 2023, billed with 
procedure code 99221.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation (A0120). 
 
You asked the Plan to pre-approve the additional trips. You say that you need the additional trips for medical 
visits. You also say that you have no one to take you and the bus isn't an option. The Plan denied your request. 
The Plan says the trip report received shows that you have used all 72 trips for 2023. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 72 trips per year.  
 
We looked at your request, the records in the case file, and the rules. You asked the Plan to pre-approve the 
additional trips for your medical appointments. Based on this information, we decided that you have exhausted 
the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not 
have to pre-approve additional routine transportation (A0120).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics.  
 
You asked the Plan to pre-approve foot orthotics. You say that you need these orthotics because your calves 
and feet hurt. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
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. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
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 
December 31, 2022, and billed with codes 87640, 87481, 87798, 87653, 87086, and 87186. 
 
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 December 31, 2022, and billed with codes 87640, 87481, 87798, 87653, 87086, and 87186.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve evaluation and management services to be provided by 
an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve evaluation and management services. You say that you are requesting 
reconsideration for the denied claim. The Plan denied your request. The Plan says this provider is out-of-
network, and the services could be performed in-network. 
 
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 
evaluation and management services 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 procedure code 80048 billed for February 16, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 80048 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 80048 is basic metabolic panel (Calcium, total) This 
panel must include the following: Calcium, total (82310) Carbon dioxide (bicarbonate) (82374) Chloride 
(82435) Creatinine (82565) Glucose (82947) Potassium (84132) Sodium (84295) Urea nitrogen (BUN) 
(84520). 
 
We find that CPT code 80048 is not supported in the medical record. Specifically, the records have a different specimen collection date than the billed date of service. Based on this information, we decided that Medicare 
rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code 80048 billed for February 16, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Genomic Unity Whole Genome Singleton Analysis 
(81425) to be provided by an out-of-network (OON) provider.  
 You asked the Plan to pre-approve the genetic testing. You say that the medical records provided will show 
proof of medical necessity. The Plan denied your request. The Plan says enrollees must receive their medical 
services from an in-network provider with the exception being urgent or emergent services. Non-emergent 
services with non-contracted providers require prior authorization before services being rendered. 
 
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. Also, this test is considered experimental or 
investigational as there are not enough studies to show this test will make a difference in the enrollee's 
treatment. 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 the Genomic Unity Whole Genome Singleton Analysis 
(81425) to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance imaging (MRI) 
provided on July 07, 2023. 
 
You asked the Plan to waive the copayment for a magnetic resonance imaging (MRI). You say that you 
disagree with the cost share applied. 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 $350 
copayment for outpatient diagnostic tests. 
 
You have been asked to pay a $350 copayment for a magnetic resonance imaging (MRI). This item/service 
falls within the outpatient diagnostic tests 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. You have been asked to pay $264.53, which is less than the standard 
copayment for an MRI. Therefore, we decided that the Plan does not have to waive the copayment for a 
magnetic resonance imaging (MRI) provided on July 07, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implant placement (D6010), a custom abutment 
(D6057), and abutment supported crown (D6059). 
 
You asked the Plan to pre-approve D6010, D6057, and D6059. You say that you need this dental work. The 
Plan denied your request. The Plan says the requested dental services are not covered 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 pre-approve 
implant placement (D6010), a custom abutment (D6057), and abutment supported crown (D6059).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visits (99205, 99215) with a vascular surgeon to 
be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve office visits. You say that you disagree with the denial. The Plan denied 
your request. The Plan says you must use network providers to get your medical care and services. 
 
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 
office visits (99205, 99215) with a vascular surgeon to be provided by an out-of-network (OON) provider.