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

 
We decided that the Plan does not have to pay more for tooth extractions (D7140) provided by an out-of-
network provider on November 4, 2021, to November 12, 2021. 
 
You asked the Plan to pay more for the dental services. You say that you think the Plan should pay for this. The 
Plan denied your request. The Plan says you are responsible for any charged amount above the Plans cost-
sharing amount when your services are received from an out-of-network provider. 
 
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. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for tooth extractions (D7140) provided by an 
out-of-network provider on November 4, 2021, to November 12, 2021.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve sacroplasty. 
 
You asked the Plan to pre-approve sacroplasty. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says that the requested services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 sacroplasty. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found you were being treated for fractures of the thoracic and lumbar spine. You presented with low 
back pain with bilateral radicular features. You take Prolia injections for osteoporosis. You had a fall several 
months ago, which increased all of the pain. The exam reveals significant tenderness in the lower lumbar as 
well as sacral region to palpation. Flexion/extension x-rays noted from this date show significant disc 
degeneration and grade 1 anterolisthesis at L5-S1 with transitional anatomy present. The June 2, 2022 findings 
demonstrated a partially imaged left sacral ala and transverse S1-2 junction fracture. The provided 
documentation demonstrates subjective and objective deficits that are corroborated by imaging studies. Trial 
and failure of conservative treatment modalities have been documented. You have trialed medications. The 
physical therapy that was tried was too painful to continue. Based on literature review, the requested 
sacroplasty in this case, is medically reasonable and necessary. 
 
Review of the file shows that the Plan uses Local Coverage Determination (LCD) L38737 to support their 
denial. However, LCD L38737 does not include rules for sacroplasty. Therefore, we cannot use LCD L38737 
to substantiate our decision. In addition, the related Local Coverage Article (LCA) A58897 specifically states 
that sacroplasty is not within the scope of this LCD and will be covered in a future LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of sacroplasty have been met. Therefore, we decided that the Plan has to pre-
approve sacroplasty.  
 
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 lab services provided on February 14, 2022. 
 
You asked the Plan to pay for the lab 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 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. The claim in this case was billed with the laboratory POS code. The 
records do not support that the sample was taken in a laboratory setting. Based on this information, we decided 
that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan 
does not have to pay for lab services provided on February 14, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for genetic testing (81455) provided June 29, 2021. 
 
You asked the Plan to pay for the genetic testing. You say that this service was medically necessary. The Plan 
denied your request. The Plan says that genetic testing panels that test for the FANCC gene are non-covered 
per Medicare Local Coverage Article: Billing and Coding: MolDX: FANCC Genetic Testing (A55183). 
 
The Plan must follow Medicare rules. Medicare rules say that effective for services performed on or after 
March 16, 2018, the Centers for Medicare & Medicaid Services (CMS) has determined that Next Generation 
Sequencing (NGS) as a diagnostic laboratory test is reasonable and necessary and covered nationally. 
 
We looked at the file and Medicare rules. The denial is based upon a local coverage decision. A local coverage 
determination cannot support the denial of a nationally-covered service. Based on this information, we decided 
that Medicare rules for coverage of the genetic testing have been met. Therefore, we decided that the Plan has 
to pay for genetic testing (81455) provided June 29, 2021.  
 
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 lab services (88120) provided January 27, 2022 . 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the diagnosis code billed is not a covered diagnosis for this test. This 
service was for screening purposes and is non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that this service is only covered for diagnosis codes 
that support medical necessity. 
 
We looked at the file and Medicare rules. Per the Local Coverage Article, R31.9 is not listed as a diagnosis 
code that this service is covered for. Based on this information, we decided that Medicare rules for coverage of 
the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services 
(88120) provided January 27, 2022 .
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance (D4910) and gingival irrigation 
 per quadrant (D4921) provided May 18, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like these services covered. The Plan 
denied your request. The Plan says the dental services were received from an out-of-network provider and are 
not covered by your supplemental 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. 
 
 
 
 
 
 
 The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for the periodontal maintenance (D4910) and gingival irrigation  per quadrant (D4921) provided May 
18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (88305) provided on February 17, 2022. 
 
You asked the Plan to pay for code 88305. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We find that code 88305 is not supported in the medical record. Specifically, the records indicate that the 
member was an outpatient on the billed date of service. Payment for code 88305 is included in the payment to 
the facility and is the responsibility of the facility to any vendor. Therefore, we decided that the Plan does not 
have to pay for the laboratory services (88305) provided on February 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composite - two surfaces, posterior (D2392), 
intraoral - periapical first radiographic image (D0220), and endodontic therapy, anterior tooth (excluding final 
restoration) (D3310) provided April 25, 2022. 
 
You asked the Plan to pay for the filling, periapical x-ray and root canal. You say that these services were 
medically necessary because you were getting infections. The Plan denied your request. The Plan says you 
have exhausted your dental benefit. 
 
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 filling, 
periapical x-ray and root canal up to a $1,500 annual maximum.  
 
We looked at the file and Medicare rules. The Plan provided documentation showing that you exhausted your 
$1,500 annual allowance prior to the services at issue being rendered. Therefore, we decided that the Plan does 
not have to pay for the resin-based composite - two surfaces, posterior (D2392), intraoral - periapical first 
radiographic image (D0220), and endodontic therapy, anterior tooth (excluding final restoration) (D3310) 
provided April 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation services coded 99153 provided on 
October 22, 2021. 
 
You asked the Plan to pay for the moderate sedation services. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the services are not payable as billed. 
 
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 99153 is not supported in the medical record. Specifically, this code has a professional 
component/technical component of 3. Modifiers 26 and TC cannot be used with these codes. This means the 
code was billed with an invalid modifier. Based on this information, we decided that Medicare rules for 
coverage of the moderate sedation services have not been met. Therefore, we decided that the Plan does not 
have to pay for the moderate sedation services coded 99153 provided on October 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve total disc arthroplasty (artificial disc) (CPT code(s): 
22856 and 22858). 
 
You asked the Plan to pre-approve the services. You say that the enrollee is in pain and needs this surgery to 
help. You state pain, spinal cord compression, upper weakness which is progressing due to conditions not being 
treated. The Plan denied your request. The Plan says the enrollee's request is not medically necessary because 
their records show the enrollee's doctor is requesting disc replacement at two (2) non-contiguous levels (C3-4, 
C6-7), as well as a combined use of artificial cervical disc and fusion. 
 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 services. Our physician reviewer 
found cervical total disc replacement is experimental at two (2) noncontiguos level in the neck. More research 
is needed. It is not FDA approved for this. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve total disc arthroplasty (artificial disc) (CPT code(s): 22856 and 22858).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve correction, hallux valgus (bunionectomy), with 
sesamoidectomy, when performed; with distal metatarsal osteotomy, any method (CPT code 28296). 
 
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says the service is not 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 the service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found CPT code 28296 does not appear medically reasonable or necessary at this time. There is no 
medical evidence enclosed in this chart that would indicate that this enrollee's bunion requires a distal 
metatarsal osteotomy for correction. Medicare does pay for procedures that will improve the functioning of a 
malformed body member such as a bunion deformity. However, a distal metatarsal bunionectomy does not 
appear to be furnished within the accepted standards of medical practice for this enrollees type of bunion.  
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve correction, hallux valgus (bunionectomy), with sesamoidectomy, when performed; with 
distal metatarsal osteotomy, any method (CPT code 28296).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (83789) provided October 26, 2021. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
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, we find that the testing described by the billed 
code is considered specimen validity testing which is not separately payable. Therefore, we decided that the 
Plan does not have to pay for lab services (83789) provided October 26, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (11042) provided March 23, 2022.
You asked the Plan to pay for the surgical services. You say that this service was medically necessary. The
Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim and was correctly
denied.
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be
exact duplicates of another claim or claim line are denied. However, such denials may be appealed.
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were
reimbursed by the Plan on May 2, 2022. Comparison of the two claims shows these are exact duplicates. There
is no evidence presented to support that the billed items/services were provided twice on the same date. Based
on this information, we decided that the Medicare rules for the surgical services have not been met. Therefore,
we decided that the Plan does not have to pay for surgical services (11042) provided March 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87631) provided December 15, 2021 . 
 
You asked the Plan to pay for the lab services. You say that the service was medically necessary. The Plan 
denied your request. The Plan says the units billed exceed the allowable amount. 
 The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 87631 is 1. You billed 4 units of this code, exceeding the MUE. Based on 
this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, 
we decided that the Plan does not have to pay for lab services (87631) provided December 15, 2021 .
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an amalgam filling on tooth #1 (D2160) provided on 
February 2, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were misinformed, and this service should 
have been covered at 80%. 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 March 19, 2021. 
Therefore, we decided that the Plan does not have to pay for an amalgam filling on tooth #1 (D2160) provided 
on February 2, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found it is not clear whether it is reasonable to expect that the enrollee in this case will be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement prosthetic for an above-elbow-arm 
(L6250, L6660, L6665, L6676, L6682, L6688, L7401, L7404, L8435, L8485). 
 
You asked the Plan to pre-approve a replacement prosthetic. You say that you disagree with the denial and are 
requesting reconsideration as the current prosthesis is too heavy for the enrollee. The Plan denied your request. 
The Plan says Medicare does not cover the requested replacement prosthesis. The requested prosthetic arm is 
functional upper limb prosthesis and no issues with fit or functionality since the enrollee received the arm. 
Manufacturing issues (build weight) are the responsibility of the supplier 
 
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. The records show that your current prosthesis is 2 years old, which is still under 
warranty. Manufacturing issues (build weight) are the responsibility of the supplier. Based on this information, we 
decided that Medicare rules for coverage of a replacement prosthetic have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a replacement prosthetic for an above-elbow-arm (L6250, L6660, L6665, 
L6676, L6682, L6688, L7401, L7404, L8435, L8485).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited bilateral noninvasive physiologic studies of upper 
or lower extremity arteries (93922) provided on April 1, 2022. 
 
You asked the Plan to pay for code 93922. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered as billed.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
Medicare guidelines say that ICD-10-CM has a coding convention that requires the underlying condition to be 
sequenced first, followed by the manifestation. In this case, I70.92 is a manifestation code and cannot be used 
as the primary or first-listed diagnosis code on the claim. Therefore, we decided that the Plan does not have to 
pay for the limited bilateral noninvasive physiologic studies of upper or lower extremity arteries (93922) 
provided on April 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the power seat elevation feature (E2300) and stealth gel 
pads (K0108). 
 
You asked the Plan to pre-approve the power seat elevation feature and stealth gel pads. You say that this 
equipment is necessary. The Plan denied your request. The Plan says this equipment is not covered by 
Medicare or the Plan.  
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The items at issue in this appeal do not serve a purpose that is primarily medical in nature. These items are 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve the power seat elevation feature (E2300) and stealth gel 
pads (K0108).