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

 
We decided that the Plan does not have to pre-approve CT scan of the heart for the enrollee. 
 
You asked the Plan to pre-approve this is medically necessary.. You say that this is medically necessary. The 
Plan denied your request. The Plan says the records do not show any signs or symptoms of heart disease. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
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 this is medically necessary. Our 
reviewer says that the requested scan is not medically reasonable or necessary. Our physician reviewer found 
the enrollee has increased coronary risk but no evidence of coronary disease. In this circumstance guidelines 
for the management of cardiac risk and dyslipidemia have been established, are periodically updated by expert 
committees and are endorsed by several national organizations. These guidelines currently do not recommend 
routine performance of specialized tests in the context of assessing coronary risk including coronary CT 
scanning and calcium scoring.  Treatment change or addition based on the results of screening with coronary 
CT scanning has not been shown to improve cardiac outcome incremental to that achievable by treatment based 
on a combination of standard risk factor profiling and basic lipid analysis. This testing is not likely to be more 
beneficial than available standard therapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this is medically necessary. have not been met. Therefore, we decided that the 
Plan does not have to pre-approve CT scan of the heart for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the compression stockings identified with code A6549 that 
were issued on September 30, 2019. 
 
You asked the Plan to pay for the compression stockings. You say that you were told the stockings would be 
covered. The Plan denied your request. The Plan says the compression stockings are not covered as they are not 
covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the compression 
stockings identified with code A6549 that were issued on September 30, 2019.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospice long term care services (code T2046) provided 
from July 1, 2019 to July 19, 2019. 
 
You asked the Plan to pay for the long term care services. You say that the Plan should pay for room and 
board, regardless if prior authorization was obtained. The Plan denied your request. The Plan says the denial of 
payment for these services is correct, because the billed code is not valid for Medicare purposes and is not 
covered. 
 
The Plan must follow Medicare rules. Medicare rules say that procedure code T2046 is not valid for Medicare 
purposes and is not payable.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the long term care services have not been met. Therefore, we decided that the Plan does not have to 
pay for the hospice long term care services (code T2046) provided from July 1, 2019 to July 19, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture (D5225). 
 
You asked the Plan to pre-approve the maxillary partial denture. You say that your partial is a medical need. 
You also say that the previous dentures did not fit correctly. The Plan denied your request. The Plan says this 
service exceeds the maximum count allowed per period. 
 
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, maxillary partial denture (D5225) is 
limited to one procedure every five plan years. The record shows that you received a maxillary partial denture 
on November 6, 2018 and your maxillary partial denture benefit has been exhausted. Therefore, we decided 
that the Plan does not have to pre-approve a maxillary partial denture (D5225).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost-sharing for radiology services received on February 
28, 2020. 
 
You asked the Plan to waive the cost-sharing for the services. You say that The Plan denied your request. The 
Plan says no adjustments will be made to either claim in question. 
 
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 $35 
copayment for outpatient diagnostic tests.  
 
You have been asked to pay a $35 copayment for the spinal x-ray and 20% coinsurance for the radiologic 
exam. The services fall within the outpatient diagnostic tests and outpatient hospital 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 cost-sharing for radiology services received on February 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6549. 
 
You asked the Plan to pre-approve the compression stockings. You say that you require the compression 
stockings. The Plan denied your request. The Plan says the compression stockings are noncovered. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6549.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a guided tissue regeneration (D4266) and an incisional 
biopsy of oral tissue (D7286). 
 
You asked the Plan to pre-approve the guided tissue regeneration and incisional biopsy of oral tissue. You say 
that you are in pain, and the biopsy is needed before you can receive further treatment. The Plan denied your 
request. The Plan says these services are not covered under your benefit package. 
 
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, 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 a 
guided tissue regeneration (D4266) and an incisional biopsy of oral tissue (D7286).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on January 22, 2020. 
 
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 the procedure codes were not billed correctly. 
 
The plan must follow Medicare rules. The rules say that anatomical modifiers are required for procedures 
performed on different anatomical sites. 
 
We looked at the file and Medicare rules. The file shows that the procedure codes were billed with modifier -
T6. This is an anatomical modifier that is not relevant for laboratory codes. The claim is not payable as billed. 
Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on January 22, 
2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the MRI scan coded 70553 and the duplex scan of 
extracranial arteries coded 93880 provided on January 18, 2020. 
 
You asked the Plan to pay for the MRI scan and the duplex scan of extracranial arteries. You say that you 
would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were 
billed incorrectly. 
 
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 codes 70553 and 93880 are not supported in the medical record. Specifically, the claim was 
not billed with the correct ICDE codes for the date of service. Based on this information, we decided that 
Medicare rules for coverage of the MRI scan and the duplex scan of extracranial arteries have not been met. 
Therefore, we decided that the Plan does not have to pay for the MRI scan coded 70553 and the duplex scan of 
extracranial arteries coded 93880 provided on January 18, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing coded G0482 provided on March 12, 2019. 
 
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the services billed are not supported by the documentation. 
 
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 G0482 is not supported in the medical record. Specifically, the documentation as to 
why 15-31 drug classes and other miscellaneous codes are needed to manage the enrollee's care. 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 coded G0482 provided on March 12, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a core buildup, including any pins when required 
(D2950) for tooth #10, gingival irrigation (D4921) of the upper left quadrant, alveoloplasty in conjunction with 
extractions (D7311) of the upper left quadrant, and a crown (D2750) for tooth #10. 
 
You asked the Plan to pre-approve the core buildup, gingival irrigation, alveoloplasty, and crown. You say that 
you believe there was an error in denying this case. The Plan denied your request. The Plan says core buildup, 
gingival irrigation, and alveoloplasty are not covered benefits. The Plan also says that the x-rays do not show 
evidence of pathologic destruction of the tooth/implant beneath the current crown warranting a replacement 
crown. 
 
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. The Plan covers crowns 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 core buildup, gingival irrigation, 
alveoloplasty, and crown. Our reviewer says that the crown (D2750) for tooth #10 is not medically necessary. 
Our physician reviewer found the documentation presented indicates that a replacement crown (D2750) for 
tooth #10 implant does not meet the criteria for coverage. Our reviewer also found that the crown in place 
appears adequate. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, core buildup, gingival irrigation, and 
alveoloplasty are not among those covered under this benefit. 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 crown have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a core buildup, including any pins 
when required (D2950) for tooth #10, gingival irrigation (D4921) of the upper left quadrant, alveoloplasty in 
conjunction with extractions (D7311) of the upper left quadrant, and a crown (D2750) for tooth #10.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a periodontal scaling and root planing (D4341) of the 
lower left quadrant. 
 
You asked the Plan to pre-approve the scaling and planing. You say that the enrollee has several dental issues. 
The Plan denied your request. The Plan says the documentation does not demonstrate evidence of significant 
bone loss and/or radiographic root surface calculus on four or more teeth per quadrant. 
 
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. The Plan covers the scaling 
and planing 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 scaling and planing. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found due to the lack of adequate 
documentation (periodontal charting and diagnostic radiographs) the need for the service could not be 
determined. 
 
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 scaling and planing have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a periodontal scaling and root planing (D4341) of the lower left quadrant.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (CPT 27818, CPT 99152) provided on 
September 4, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed codes cannot 
be verified. 
 
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 27818 is "Closed treatment of trimalleolar ankle fracture; 
with manipulation". The CPT Code Manual Definition of code 99152 is "Moderate sedation services provided 
by the same physician or other qualified health care professional performing the diagnostic or therapeutic 
service that the sedation supports, requiring the presence of an independent trained observer to assist in the 
monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice 
time, patient age 5 years or older". 
 
We asked our coding 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 the services. Our reviewer says that the use 
of CPT codes 27818 and 99152 is not supported by the records provided. Our coding reviewer found that the 
documentation did not include "closed treatment of trimalleolar ankle fracture; with manipulation", and 
"Moderate Sedation" for date of service September 4, 2019. 
 
We looked at this coder?s review, the file, and Medicare rules. 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 the services (CPT 27818, CPT 99152) provided on September 4, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Pedialyte. 
 
You asked the Plan to pre-approve Pedialyte. You say that this is medically necessary for you. The Plan denied 
your request. The Plan says that this not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. 
 
The items you asked the Plan to pre-approve are nutritional supplements. Therefore, we decided that the Plan 
does not have to pre-approve Pedialyte.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for transitional care management services (99496) provided on 
January 9, 2020. 
 
You asked the Plan to pay for the transitional care management services. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says procedure code 
99496 has been incorrectly billed with place of service 31. 
 
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 99496 is transitional Care Management Services with the 
following required elements: Communication (direct contact, telephone, electronic) with the patient and/or 
caregiver within 2 business days of discharge Medical decision making of high complexity during the service 
period Face-to-face visit, within 7 calendar days of discharge. 
 
We find that CPT code 99496 is not supported in the record. Specifically, transition care management services 
involve the transition from certain inpatient settings to the member's community. This claim was billed with 
place of service code 31 for Skilled Nursing Facility. It is inappropriate to bill transition of care codes in a 
Skilled Nursing Facility. Based on this information, we decided that Medicare rules for coverage of the 
transitional care management services have not been met. Therefore, we decided that the Plan does not have to 
pay for transitional care management services (99496) provided on January 9, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services. 
 
You asked the Plan to pay for the ambulance services. You say that you are appealing the Plan's decision 
because you already paid the ambulance company that transported you. You say that the other responding 
ambulance must have been dispatched in error and they did not transport you. You asked the Plan to reconsider 
their decision. The Plan denied your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on December 27, 2019. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (CPT 99152) provided on December 10, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code cannot 
be verified. 
 
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 99152 is "Moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older". 
 
We asked our coding 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 the services. Our reviewer says that the use 
of CPT code 99152 is not supported by the records provided. Our coding reviewer found that the operative 
report does not include documentation of "moderate sedation, time of sedation services or trained observer to 
assist in the monitoring of patient's level of consciousness and physiological status", therefore, CPT code 
99152 cannot be verified. 
 
We looked at this coder?s review, the file, and Medicare rules. 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 the services (CPT 99152) provided on December 10, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a surgical extraction. 
 
You asked the Plan to pre-approve the extraction. You say that you need to have two molars extracted because 
they are impeding with your root canal. The Plan denied your request. The Plan says this service is not covered. 
 
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, the requested items or services are not 
among those covered under this benefit. The only extractions that are covered by the Plan are simple 
extractions performed by a general dentist. Surgical extractions are not covered. Therefore, we decided that the 
Plan does not have to pre-approve a surgical extraction.