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

 
We decided that the Plan does not have to pre-approve an Intracept procedure (64628). 
 You asked the Plan to pre-approve an Intracept procedure. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the request is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an Intracept procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the Intracept procedure is experimental. More research is needed to demonstrate 
its safety and efficacy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure (64628).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device and related supplies 
provided on August 11, 2022. 
 
You asked the Plan to pay for the billed services. You say that procedures greatly increase the risk of deep vein 
thrombosis. The Plan denied your request. The Plan says the services are not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The file shows the services were provided in an ambulatory surgical center. Although this item may be helpful, 
neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan 
does not have to pay for the pneumatic compression device and related supplies provided on August 11, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiological services provided on October 20, 2022. 
 
You asked the Plan to pay for radiology services provided. You say that the claim was billed correctly and 
should be paid. 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 November 25, 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 radiology services provided have not been met. Therefore, we decided that the Plan does not have to pay for radiological services provided on October 20, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefit for the chronically ill 
(SSBCI) benefits. 
 
You asked the Plan to pre-approve SSBCI benefits. The Plan denied your request. The Plan says the enrollee 
does not qualify for these benefits. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for 
enrollees with an eligible chronic condition.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have one of 
the eligible conditions listed in the Evidence of Coverage. Therefore, we decided that the Plan does not have to 
pre-approve special supplemental benefit for the chronically ill (SSBCI) benefits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefit for the chronically ill 
(SSBCI) benefits. 
 
You asked the Plan to pre-approve SSBCI benefits. The Plan denied your request. The Plan says based on the 
information submitted there is no documentation that the enrollee meets criteria for SSBCI benefits. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for 
enrollees with an eligible chronic condition.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have one of 
the eligible conditions listed in the Evidence of Coverage. Therefore, we decided that the Plan does not have to 
pre-approve special supplemental benefit for the chronically ill (SSBCI) benefits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the request for a home mechanical ventilator set in AVAPS mode with 
Auto-EPAP (AE) that could be delivered by BiPAP is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 
 
 
 
 
 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 a home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has a diagnosis of 
chronic respiratory failure consequent to chronic obstructive pulmonary on the prescription for the ventilator 
and a diagnosis of restrictive lung disease but provided records and pulmonary function studies do not support 
this. Records indicate the enrollee has obstructive sleep apnea but has refused positive airway pressure therapy. 
Provided records document that the home ventilator is being requested for use in intelligent volume assured 
pressure support (IVAPS) mode with auto-EPAP which could be provided by a BiPAP device with average 
volume assured pressure support (AVAPS) and a back-up rate. As stated in the Local Coverage Determination 
(L33800): "Claims for ventilators used to provide CPAP or bi-level CPAP therapy for conditions described in 
this RAD policy will be denied as not reasonable and 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 a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications.  
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a history of 
osteoporosis. She has not tried and failed the Plan's required drugs, an oral bisphosphonate and zoledronic acid. 
The records do not show that the required drugs would be contraindicated or less effective; therefore, Prolia 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Prolia.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex Superion Indirect Decompression System 
for implantation of Superion interspinous spacers (22869). 
 
You asked the Plan to pre-approve the Vertiflex Superion Indirect Decompression System for implantation of 
Superion interspinous spacers. You say that the service is medically necessary. The Plan denied your request. 
The Plan says this service is considered experimental. 
 
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 Vertiflex Superion Indirect 
Decompression System for implantation of Superion interspinous spacers. Our reviewer says that the requested 
service is not considered medically reasonable and necessary in this case. Our physician reviewer found this 
service is considered experimental. 
 
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 Vertiflex Superion Indirect Decompression System for implantation of Superion interspinous spacers have not been met. Therefore, we decided that the Plan does not have to pre-
approve the Vertiflex Superion Indirect Decompression System for implantation of Superion interspinous 
spacers (22869).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on March 23, 2022. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the denial. 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 March 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care services rendered on July 19, 2022. 
 
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 claim was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis 
code. 
 
We looked at the file and Medicare rules. The file shows that the services were billed with inappropriate 
diagnosis codes that cannot be billed together. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the 
critical care services rendered on July 19, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the ambulance services (A0428). 
 
You asked the Plan to pre-approve the ambulance services. You say that you are requesting the enrollee be 
transported from the enrollee's residence to the dialysis facility. The Plan denied your request. The Plan says 
medical records were not provided to verify if the service is medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the ambulance services have been met. 
Doctors notes, hospital progress notes, latest physical and occupational therapy notes and the answers to the 
ambulance function questions were not provided to verify if the service is medically necessary. Therefore, we 
decided that the Plan does not have to pre-approve the ambulance services (A0428).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for diagnostic casts (D0470), immediate upper denture 
(D5130) #01-16, immediate lower denture (D5140) #17-32, , extraction, erupted tooth (D7210) 
#2,5,6,7,9,10,11,15,20-29 and bone graft preserve ridge (D7953). 
 
You asked the Plan to pay more for the dental services. You say that you would like your insurance to cover 
the dental services you received because they were medically necessary. 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. This benefit includes the 
requested limited oral evaluation (D0140) but is limited to one every six months. This benefit includes only 
those items and services specifically listed in your Plan contract. Diagnostic casts (D0470) and bone graft 
preserve ridge (D7953) are not covered under the Plans dental benefits. This benefit also includes a $2,000 
maximum annual allowance. You pay 20% coinsurance for restorative services, endodontics, periodontics, and 
extractions and 40% coinsurance for prosthodontics, other oral/maxillofacial surgery, and other services. 
 
You have been asked to pay $5,039.32 for dental services. 
 
Date of Service Code Allowed Amount 40% Coinsurance Not Covered 
September 22, 
2022 
D0470 $132  $132 
September 26, 
2022 
D0140 $103  $103 
September 26, 
2022 
D7953 x3 $1,390  $1,390 
September 26, 
2022 
D5130 $830.78 $332.31  
September 26, 
2022 
D5140 $832.91 $333.16  
September 26, 
2022 
D7210 x12 $1,662.12 $664.80  
September 26, 
2022 
D7210 x1 $138.51 $55.40 $78.65 
September 26, 
2022 
D7210 x5 $1,950  $1,950 
TOTAL:   $1,385.67 $3,653.65 
 
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 diagnostic casts (D0470), immediate upper denture 
(D5130) #01-16, immediate lower denture (D5140) #17-32, , extraction, erupted tooth (D7210) 
#2,5,6,7,9,10,11,15,20-29 and bone graft preserve ridge (D7953).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service August 31, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the claim was billed correctly and should be 
paid The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for code 
70496. 
 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 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service August 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 92929 billed for date of service October 9, 
2022. 
 
You asked the Plan to pay for procedure code 92929. You say that you disagree with the denial. The Plan 
denied your request. The Plan says procedure code 92929 is considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 92929 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 92929 is not separately payable. Based on this information, we decided that Medicare rules for coverage of procedure code 92929 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 92929 billed for date of service October 9, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the cervical, multiple post collar, occipital/mandibular supports, 
adjustable (L0180) provided on October 26, 2022. 
 
You asked the Plan to pay for the neck brace. You say that the neck brace was medically necessary. The Plan 
denied your request. The Plan says that the documentation submitted did not sufficiently support the billed 
supply code. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record contains a valid physician order, proof of delivery, a d relevant medical records which support 
medical necessity for the supplies provided in this case. Therefore, we decided that the Plan has to pay for the 
cervical, multiple post collar, occipital/mandibular supports, adjustable (L0180) provided on October 26, 2022.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction (D7210 x 2) and placement of intra-socket 
biological dressing (D7922 x 2) provided on November 18, 2022. 
 
You asked the Plan to pay for the dental services. You say that the reason the Plan is not paying this claim is 
that you have other insurance, you say this is not true. 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 claim number 0041774013 when your 
quarterly allowance was met. Therefore, we decided that the Plan does not have to pay for the extraction 
(D7210 x 2) and placement of intra-socket biological dressing (D7922 x 2) provided on November 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound polymerase chain reaction (PCR) panel (87798, 
87481) provided on April 25, 2022. 
 
You asked the Plan to pay for the wound PCR panel. You say that this testing was medically necessary. The 
Plan denied your request. The Plan says this testing should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This testing was not billed with a single panel code as required. 
Based on this information, we decided that Medicare rules for coverage of the wound PCR panel have not been 
met. Therefore, we decided that the Plan does not have to pay for the wound polymerase chain reaction (PCR) 
panel (87798, 87481) provided on April 25, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service November 
13, 2022. 
 You asked the Plan to pay for procedure code 70450. You say that the claim was billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for code 
70496. 
 
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 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service November 13, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87798) provided on September 29, 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 this code is not separately payable. 
 
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 87798 is not supported in the medical record. Specifically, multiple unbundled codes 
cannot be billed for a single panel. Code 87801 was already approved by the plan. 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 (87798) provided on September 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical testing (97750) provided on November 1, 2022. 
 
You asked the Plan to pay for the physical testing. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed service. 
 
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 97750 is Physical performance test or measurement (e.g., 
musculoskeletal, functional capacity), with written report, each 15 minutes. 
 
We find that CPT code 97750 is not supported in the medical record. Specifically, the record does not 
document how much time was spent on this service. Based on this information, we decided that Medicare rules 
for coverage of the physical testing have not been met. Therefore, we decided that the Plan does not have to 
pay for physical testing (97750) provided on November 1, 2022.