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

 
We decided that the Plan does not have to pay for the 2 retainer crowns (D6740) and pontic (D6245) provided 
on January 17, 2022. 
 
You asked the Plan to pay for the dental services. You say that the provider billed for bridge work. You say 
that the claim should have been billed for crown repair. You also say that you would like the plan to pay for 
half, up to the $2,500 allowance. The Plan denied your request. The Plan says the retainer crowns and pontic 
are not listed as 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 retainer crowns and pontic are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 2 
retainer crowns (D6740) and pontic (D6245) provided on January 17, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve the Otto Bock Pheon knee system described by code L5845.
You asked the Plan to pre-approve the knee coded with L5845. You say that this is the correct way to code the requested type of knee. The Plan denied your request. The Plan says that this knee is not correctly coded with L5845.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan has not provided sufficient proof to justify its denial of this code. The Otto Bock Pheon knee has not been reviewed by the Pricing, Data Analysis, and Coding (PDAC) contractor and has no officially assigned coding. The Plan has failed to provide a specific citation which supports that the use of L5845 is not allowed to describe this knee. Therefore, we decided that the Plan has to pre-approve the Otto Bock Pheon knee system described by code L5845.
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgery services provided on December 16, 2020, by an
out-of-network (OON) provider.
You asked the Plan to pay for the surgery services. You say that you were unable to get in contact with your
primary care provider and you could not find any in-network provider. The Plan denied your request. The Plan
says they confirmed with the enrollee's primary care physician that they are available by phone at all times, and
they would of gave the enrollee an in-network surgeon and put in a retro-authorization. Also, it was confirmed
with the OON provider that they told the enrollee they are not contracted with the Plan.
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 the surgery services provided on December 16,
2020, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrocardiogram (ECG) interpretation and report (93010) provided on November 5, 2021.
You asked the Plan to pay for the ECG report. You say that this service was billed appropriately and is supported in the record. The Plan denied your request. The Plan says a National Correct Coding Initiatives (NCCI) Procedure to Procedure (PTP) edit exists between 92960 and 93010. This PTP edit has a modifier indicator of 1, meaning modifiers associated with NCCI are allowed. However, an appropriate modifier was not billed with this PTP code edit. This service was not billed appropriately by Medicare coding regulations.
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 93010 is a column II code to column I code 92960. 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 the electrocardiogram (ECG) interpretation and report (93010) provided on November 5, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Fibergraft allograft (CPT code 20930).
You asked the Plan to pre-approve the Fibergraft allograft. You say that the services are necessary. The Plan
denied your request. The Plan says the clinical value and effectiveness of Fibergraft allograft in the setting of
spinal fusion surgery have not been demonstrated in the peer-reviewed literature.
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 the Fibergraft allograft. Our reviewer
says that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found there is limited published, large-scale, long-term peer-reviewed literature that shows
this request to be an effective and/or safe treatment for the noted pathology. There is no compelling rationale
presented or extenuating circumstances noted to support the medical necessity of this request as an exception.
Therefore, the requested Fibergraft allograft in the setting of spinal fusion surgery, in this case, is not medically
reasonable or necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the Fibergraft allograft have not been met. Therefore, we decided that the Plan
does not have to pre-approve the Fibergraft allograft (CPT code 20930).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to approve the acute inpatient level of care. 
 
You asked the Plan to approve acute inpatient hospital care. You say that you disagree with the denial. The 
Plan denied your request. The Plan says the inpatient level of care is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
 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 approve acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient care are met. Our physician reviewer 
found the enrollee is medically stable and has been cleared to undergo a total knee arthroplasty. The procedure 
is approved at the ambulatory level. There is no documentation to support the expectation that the enrollee will 
require at least two midnights of inpatient hospital care for the elective procedure. The inpatient level of care is 
not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to approve the acute inpatient level of care.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on September 14, 2021.
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 services were not billed correctly.
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT
codes describing the component test results.
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on September 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental care to be provided by an out-of-network 
provider. 
 
You asked the Plan to pre-approve out-of-network dental care. You say that this dentist can provide proper care 
that you need due to a medical condition, and you are unhappy with your assigned dental provider. The Plan 
denied your request. The Plan says the requested provider is not part of your dental network, and they are not 
your assigned dentist. You need to contact the dental insurer to request a change in dental providers within the 
network. 
 
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. 
 
We looked at the file and the Plans rules. The requested provider in this case is not your assigned dentist, nor 
are they part of the Plans specified dental vendor network. Based on this information, we decided that the 
Plans rules for coverage of supplemental dental care are not met. Therefore, we decided that the Plan does not 
have to pre-approve dental care to be provided by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical placement of implant body: endosteal implant 
(D6010) and surgical access to an implant body (second stage implant surgery) (D6011). 
 
You asked the Plan to pre-approve endosteal implants and surgical access to implants. You say that you need 
these services so you can eat. The Plan denied your request. The Plan says these services are not covered under 
your 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 
surgical placement of implant body: endosteal implant (D6010) and surgical access to an implant body (second 
stage implant surgery) (D6011).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient surgery provided on January 14, 2022.
You asked the Plan to waive the copayment for outpatient surgery. You say that you should have been made aware of what would be done before going into this appointment. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.
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 $345 copayment for outpatient surgery at an outpatient hospital facility. 
You have been asked to pay $345 copayment for outpatient surgery. outpatient surgery falls within the Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 copayment for outpatient surgery provided on January 14, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrocardiogram, routine ECG with at least 12 leads, 
provided on October 6, 2021. 
 
You asked the Plan to pay for the ECG provided on October 6, 2021. You say that the services should be 
covered. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of 
the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the 
enrollee's coverage before rendering services and to know proper billing procedures for a member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the electrocardiogram, routine ECG with at least 12 leads, 
provided on October 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an opt-out provider on December 
2, 2021. 
 
You asked the Plan to pay for dental services. You say that you would like the Plan to pay for this. The Plan 
denied your request. The Plan says the rendering physician has opted-out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for dental 
services provided by an opt-out provider on December 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone replacement grafts for ridge preservation - per site 
(D7953). 
 
You asked the Plan to pre-approve bone replacement grafts. You say that the enrollee needs this service. The 
Plan denied your request. The Plan says this service is not covered the enrollee's 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 bone 
replacement grafts for ridge preservation - per site (D7953).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital discharge day management (99239) provided on 
October 20, 2021. 
 
You asked the Plan to pay for hospital discharge day management. You say that the services at issue were a 
medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not 
been met. 
 
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 99239 is "Hospital discharge day management; more than 
30 minutes." 
 
We find that CPT code 99239 is not supported in the medical record. Specifically, the available medical documentation does not record discharge day management spanning more than 30 minutes on the date of 
service. Based on this information, we decided that Medicare rules for coverage of hospital discharge day 
management have not been met. Therefore, we decided that the Plan does not have to pay for hospital 
discharge day management (99239) provided on October 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cardiac risk assessment genetic screening testing coded with 
81404, 81749 provided May 6, 2021.  
You asked the Plan to pay for the laboratory services. You say that you believe that the treatment sought is 
medically necessary to treat the enrollee based on the enrollee's medical condition. Please reconsider the denial. 
The Plan denied your request. The Plan says services do not meet coverage requirements. 
 
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. Outreach to the doctor's office confirmed that they did not order this 
testing and found no orders for this service. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay 
for cardiac risk assessment genetic screening testing coded with 81404, 81749 provided May 6, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for adjacent tissue transfer or rearrangement provided to the enrollee on August 5, 2021.
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 denied code is not supported by the medical records submitted.
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 14040 is "Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10 sq cm or less." 
We asked our coder 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 services at issue in this case were not supported by the medical records. Our reviewer found that the denied procedure was not documented in the medical records. The review has determined that the denied code was not supported by the medical records submitted. 
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 adjacent tissue transfer or rearrangement provided to the enrollee on August 5, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided the Plan does not have to pay for radiology services billed to the enrollee for September 19, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says these services were paid on a previous claim. We overturned the Plan's denial for
insufficient claim information in the case file to show these services were previously paid. The Plan requested a
reopen and provided additional information. The plan states this is an administrative determination
inappropriate claim submission. The records show the enrollee had professional interpretation of a chest x-ray
September 19, 2021. The submitted documentation supports 1 (one) unit of 71045-26, which was previously
approved/paid to a different provider of the same group submitting the second claim. There is no additional
documentation supporting an additional study by the appealing provider.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. In this case, the Plan provided claim information to show these services were
previously paid. Medicare rules for coverage of these services have not been met. Therefore, we decided that
the Plan does not have to pay for radiology services billed to the enrollee for September 19, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on April 14, 2021. 
 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 testing is not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening 
purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan 
does not have to pay for the laboratory services rendered on April 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom abutment (D0657) and an abutment supported 
crown on teeth #'s 5, 7, 8, 9, 10, 13, 18, 19, 30, 31 to be provided by a network provider. 
 
You asked the Plan to pre-approve the custom abutment (D0657) and the abutment supported crown on teeth 
#'s 5, 7, 8, 9, 10, 13, 18, 19, 30, and 31. You say that you are appealing the denial of the services. The Plan 
denied your request. The Plan says the 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 custom abutment (D0657) and the 
abutment supported crown are not among those covered under this benefit. Therefore, we decided that the Plan 
does not have to pre-approve a custom abutment (D0657) and an abutment supported crown on teeth #'s 5, 7, 8, 
9, 10, 13, 18, 19, 30, 31 to be provided by a network provider.