Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on 
September 22, 2023. 
 
You asked the Plan to pay for the dental services. You say that you never had an exam. You say you are aware 
that you had an exam in June of 2023 and knew the frequency was every six months. You say you would not 
have gotten an exam if it was going to be denied. 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 June 13, 2023. Therefore, 
we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on 
September 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for home testing for the heart provided from 
July 7, 2021, to July 6, 2022. 
 
You asked the Plan to waive the copayments for at home heart testing. You say that you do your testing at 
home and should not be charged more. 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 $10 
copayment for physician/practitioner services, including doctors office visits.  
You have a $10 copayment per service, with 14 tests sent ($10 per service x 14 tests = $140 total). 
 You have been asked to pay a $140 total copayment for at home heart testing. This item/service falls within the 
physician/practitioner services, including doctors office visits 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 copayments for home testing for the heart provided from July 7, 2021, to July 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve peripheral nerve stimulation (PNS). 
 
You asked the Plan to pre-approve PNS. You say that you are requesting reconsideration for the denied claim. 
The Plan denied your request. The Plan says it is not reasonable and 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 PNS. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this device is considered experimental/investigational for chronic low back pain. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of PNS have not been met. Therefore, we decided that the Plan does not have to 
pre-approve peripheral nerve stimulation (PNS).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the office visit on August 15, 2023. 
 
You asked the Plan to waive the deductible for the office visit. You say that you want to appeal the amount 
being charged. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $390 deductible which applies to physician/practitioner services, 
including doctor's office visits.  
 
The item or service you asked the Plan to waive the deductible for falls within the physician/practitioner 
services, including doctor's office visits benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $390 deductible which applies to physician/practitioner services, 
including doctor's office visits. This cost sharing is a contractual obligation that had not been met at the time 
the office visit was received on August 15, 2023. Therefore, we decided that the Plan does not have to waive 
the deductible for the office visit on August 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic injection provided on March 28, 2023. 
 
You asked the Plan to pay for the therapeutic injection. You say that you are appealing the denial with 
supporting documentation. 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 therapeutic injection 
provided on March 28, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye refraction provided on August 11, 2023. 
 
You asked the Plan to pay for the eye refraction. You say that you did not know that this would not be covered, 
and you would be billed for it. The Plan denied your request. The Plan says this request exceeds the benefit 
limit. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers up to 1 routine eye exam including contact lens fitting every calendar year. 
 
 
 
 
 
 We looked at the file and the Plan's rules. Specifically, the record shows that you received a routine eye exam 
with a refraction on February 28, 2023, and this benefit has been exhausted. Based on this information, we 
decided that the Plan's rules for coverage of the eye refraction have not been met. Therefore, we decided that 
the Plan does not have to pay for the eye refraction provided on August 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve catheter placement in coronary artery(s) for coronary 
angiography; with left heart catheterization including intraprocedural injection(s) for left ventriculography 
(93458) to be provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve left heart artery/ventricle angiography to be provided by an OON provider. 
You say that the services are necessary. The Plan denied your request. The Plan says there are in-network 
providers that are able to provide these services. Therefore, coverage criteria 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 
catheter placement in coronary artery(s) for coronary angiography; with left heart catheterization including 
intraprocedural injection(s) for left ventriculography (93458) to be provided by an out-of-network (OON) 
provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the acupuncture treatments (97810, 97811) 
provided on July 25, 2023. 
 
You asked the Plan to issue reimbursement for these services. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services are 
not payable as they were not rendered on the basis of a covered condition.  
 
 
 
  
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the acupuncture services in this case were not 
rendered on the basis of a diagnosis for chronic low back pain. Therefore, we decided that the Plan does not 
have to issue reimbursement for the acupuncture treatments (97810, 97811) provided on July 25, 2023.
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 July 27, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says this is not a 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 July 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on February 2, 2023, to July 11, 
2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says your $1,500 annual maximum 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 $1,500 annual maximum was exhausted. Therefore, we decided that the Plan does not have to pay 
for dental services provided on February 2, 2023, to July 11, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 19, 2023. 
 
You asked the Plan to pay for the lab services. You say that the claim should be paid. 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 lab services provided on May 19, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing (G0483) provided April 20, 2023. 
 You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the service is not supported by the records. 
 
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 G0483 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; 22 or 
more drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0483 is not supported in the medical record. The submitted medical records do not 
contain sufficient detail to support the billed charges. Of note, the medical records submitted do not include a 
signed physician order or lab requisition that specifically list 22 or more drugs what tests are to be performed as 
outlined in CMS guidelines. Based on this information, we decided that Medicare rules for coverage of the 
service have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing 
(G0483) provided April 20, 2023.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to reduce the cost share for the comprehensive hearing test (92557) provided on 
April 13, 2023. 
 
You asked the Plan to reduce the cost share for the comprehensive hearing test. You say that for this 
appointment your benefit says you should owe a $25 copay, and you would like this claim to be reviewed for 
the amount charged. The Plan denied your request. The Plan says that this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that enrollees must pay a $25 copay for Medicare-covered services from a specialist 
under the hearing services benefit category.  
 
The Plan says you must pay 50% coinsurance for the comprehensive hearing test. Based on the Plan contract, 
however, you cannot be asked to pay more than a $25 copay for the comprehensive hearing test. The hearing 
services section of the 2023 EOC also does not specify that the $25 copayment for Medicare-covered services 
from a specialist is limited to certain locations where a service is provided. Therefore, we decided that the Plan 
has to reduce the cost share for the comprehensive hearing test (92557) provided on April 13, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 CDx testing (81479) provided on July 16, 
2023. 
 
You asked the Plan to pay for the Guardant360 CDx testing (81479). You say that you would like the Plan to 
reconsider their denial of payment. 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 a valid unique identifier was 
reported. The unique identifier, Z031D, is not a valid code for the provided Guardant360 CDx testing. Based 
on this information, we decided that Medicare rules for coverage of the Guardant360 CDx testing (81479) have 
not been met. Therefore, we decided that the Plan does not have to pay for the Guardant360 CDx testing 
(81479) provided on July 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the porcelain/ceramic crown (D2740) and the core buildup, 
including any pins when required (D2950) provided on July 20, 2023. 
 
You asked the Plan to pay for the dental items. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the dental items were received from an out-of-
network provider and are not covered by your supplemental benefits. Additionally, the core buildup provided in 
this case is not a covered benefit under the supplemental dental policy.  
 
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 dental items from an out-of-network provider. Though the Plan offers a 
dental benefit in excess of Medicare coverage, dental items/services are not covered under this benefit when 
received from an out-of-network provider. Additionally, the core buildup provided in this case is not a covered 
benefit. Therefore, we decided that the Plan does not have to pay for the porcelain/ceramic crown (D2740) and 
the core buildup, including any pins when required (D2950) provided on July 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intracept procedure and genicular nerve block. 
 
You asked the Plan to pre-approve intracept procedure and genicular nerve block. You say that you are 
requesting reconsideration for the denied claim. The Plan denied your request. The Plan says the requested 
services do not meet the standard of care. 
 
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 intracept procedure and genicular nerve 
block. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found that genicular nerve block is experimental for knee pain. 
There is no clinical indication for intracept. There is no magnetic-resonance imaging (MRI) with only modic 
changes without facet degenerative joint disease (DJD) or stenosis. The cause of back pain is unclear. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of intracept procedure and genicular nerve block have not been met. Therefore, we 
decided that the Plan does not have to pre-approve intracept procedure and genicular nerve block.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen therapy (HBOT). 
 
You asked the Plan to pre-approve hyperbaric oxygen therapy. You say that you are requesting reconsideration 
for the denied claim. The Plan denied your request. The Plan says long COVID is not a covered indication for 
hyperbaric oxygen therapy. 
 
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 hyperbaric oxygen therapy. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the Food and Drug Administration (FDA) has not cleared or authorized the 
use of any HBOT device to treat Covid-19 or any conditions. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of hyperbaric oxygen therapy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve hyperbaric oxygen therapy (HBOT).
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve revascularization (37231, 37230, 37229, 37228, 37227, 
37226, 37225, 37224). 
 
You asked the Plan to pre-approve revascularization. You say that the services are necessary. The Plan denied 
your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that PTA is covered when used under certain conditions. 
 
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 revascularization. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found there is insufficient documentation 
to support the medical necessity for peripheral revascularization in this enrollee's clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of revascularization have not been met. Therefore, we decided that the Plan does 
not have to pre-approve revascularization (37231, 37230, 37229, 37228, 37227, 37226, 37225, 37224).