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

 
We decided that the Plan does not have to pay for injection services (procedure code 62326) provided to the 
enrollee on January 31, 2022. 
 
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 there is a more appropriate to code to use in this case. 
 
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 62326 is "Injection(s), including indwelling catheter 
placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, 
antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or 
subarachnoid, lumbar or sacral (caudal); without imaging guidance." 
 
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 procedure report describes 
injection given for post-operative pain management. In this case, documentation supports a post-operative pain injection performed by anesthesia at the request of the surgeon. However, there is a more appropriate code to 
report for service provided. CPT 62326 would be reported with placement of indwelling catheter placement, 
continuous infusion or intermittent bolus. The documentation does not support per CPT 62326 code description 
"placement of indwelling catheter placement, continuous infusion or intermittent bolus" was performed, and 
therefore this procedure code 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 injection services (procedure code 62326) provided to the enrollee on January 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and a panoramic x-
ray (D0330) provided on April 27, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says your benefit for the requested items or services 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 a panoramic x-ray was exhausted on date of service March 11, 2021. The record also 
shows your benefit for a comprehensive oral evaluation was exhausted on date of service March 21, 2022. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and a 
panoramic x-ray (D0330) provided on April 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the retainer crowns-porcelain fused to high noble metal 
(D6750 x 3) and the porcelain/ceramic retainer crowns (D6740 x 3) provided on January 5, 2021. 
 
You asked the Plan to pay for these dental items. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these dental items are not covered by the Plan 
or by Medicare. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The items you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your 
teeth or the structures directly supporting your teeth. These are dental items that are not covered or paid for by 
Medicare. Therefore, we decided that the Plan does not have to pay for the retainer crowns-porcelain fused to 
high noble metal (D6750 x 3) and the porcelain/ceramic retainer crowns (D6740 x 3) provided on January 5, 
2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs (A9270) provided from April 1, 
2022, through April 4, 2022. 
 
You asked the Plan to pay for these items. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says these items are not covered under your contractual 
policy or by Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs provided are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
(A9270) provided from April 1, 2022, through April 4, 2022.  Benefits for these items may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for local anesthesia (D9215) provided on April 21, 2022. 
 
You asked the Plan to pay for anesthesia. You say that you disagree with the denial of dental services. The Plan 
denied your request. The Plan says local anesthesia (D9215) is not covered by your routine dental 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 pay for local 
anesthesia (D9215) provided on April 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an amalgam filling on tooth #3 (D2140) and core build up on 
tooth #3 (D2950) provided on November 27, 2021. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
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, an amalgam filling is not covered under this benefit when received from an out-of-network provider. Core build up is not covered under this benefit. Therefore, we 
decided that the Plan does not have to pay for an amalgam filling on tooth #3 (D2140) and core build up on 
tooth #3 (D2950) provided on November 27, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (0202U) provided on January 30, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not 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 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 use of code 0202U is 
not supported by the records provided. Our reviewer found that per coding guidelines to document 0202U, the 
following information needs to be provided: "Report 0202U for the BioFire FilmArray Respiratory Panel 2.1 
(RP2.1) from BioFire Diagnostics, which is an automated PCR test on a nasopharyngeal specimen for the most 
common viral and bacterial respiratory pathogens, including SARSCoV2." This information was not 
recorded. 
 
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 (0202U) provided on January 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen system. 
 
You asked the Plan to pre-approve the requested services. You say that the tanks are too heavy for you to carry 
around. The Plan denied your request. The Plan says you have the standard item that meets your medical needs. 
 
The Plan must follow Medicare rules. The rules say that patients who are mobile in the home and would benefit 
from the use of portable oxygen in the home, may qualify for coverage of a portable oxygen system either by 
itself, or to use in addition to a stationary oxygen system.  
 
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 requested services. Our physician 
reviewer found that the available clinical documentation does not support that a portable oxygen system either 
by itself, or to use in addition to a stationary oxygen system is needed. The clinical documentation does not 
support that a portable oxygen concentrator is medically reasonable and necessary for in this case. 
 
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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable oxygen system.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown - porcelain/ceramic (D2740) provided on January 
4, 2021. 
 
You asked the Plan to pay for the crown. You say that you should not be responsible for the providers 
negligence. The Plan denied your request. The Plan says the claim was received on March 25, 2022, which 
made the claim 1 year, 2 months, and 3 weeks late. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the crown was not filed until March 25, 2022. This means that more than one 
calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan 
does not have to pay for a crown - porcelain/ceramic (D2740) provided on January 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate. 
 
You asked the Plan to pre-approve these services. You say that this is medically necessary. The Plan denied 
your request. The Plan says that the clinical value and effectiveness of bone marrow aspirate 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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. There is a lack of 
large volume, long-term peer-reviewed outcome studies to support the use of bone marrow aspirate for your 
medical condition. There is no compelling rationale presented or extenuating circumstances noted to support 
the medical necessity of this request as an exception. Our physician reviewer found that your condition does not meet criteria for coverage of these services. 
 
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 bone marrow aspirate.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for resin-based composites - two surfaces, posterior (D2392) X 2 
provided on March 3, 2022. 
 
You asked the Plan to pay for the dental services. You say that the provider was contracted on the date of 
service. 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 resin-based composites - two surfaces, posterior (D2392) X 2 provided on March 3, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a Freestyle Libre CGM. You say that this is medically necessary. The Plan 
denied your request. The Plan says the enrollee only uses insulin once a day. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based 
on the blood glucose testing results and have had an in-person visit with their treating physician to assesses 
adherence to their CGM regimen and diabetes treatment plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a Freestyle Libre CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Freestyle Libre continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair with a single power option. You asked the Plan to pre-approve the requested service. The Plan denied your request. The Plan says a power 
option is not needed. 
 
The Plan follows Medicare rules. Medicare rules say that wheelchair options and accessories are only covered 
under certain medical indications.  
 
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 requested service. Our physician 
reviewer found while it is stated in the Seating/Mobility Evaluation that the enrollee lacks ability to 
functionally shift their weight for pressure relief at the recommended frequency and duration to prevent skin 
breakdown and needs power tilt, it is also noted that supine to sit, sit to supine, sit to stand, and bed to 
wheelchair transfers require minimum/occasional assistance. The case file does not contain documentation of 
skin breakdown. The documentation is insufficient to support that the enrollee in this case is at high risk for 
development of a pressure ulcer and is unable to perform a functional weight shift, or utilizes intermittent 
catheterization for bladder management and is unable to independently transfer from the wheelchair to bed, or 
the power seating system is needed to manage increased tone or spasticity.  
 
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 requested service have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a group 3 power wheelchair with a single power option.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unlisted molecular pathology testing (81479) provided on 
March 10, 2022. 
 
You asked the Plan to pay for laboratory services. You say that these services were necessary and should be 
covered. The Plan denied your request. The Plan says no medical records were submitted by the provider to 
support the medical necessity of these tests. There is also no pre-approval on file. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 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 laboratory services have been met. 
Specifically, no medical records were provided to support this request. There is no documentation of a test 
order from your physician, and therefore the medical necessity of these services is unclear at this time. 
Therefore, we decided that the Plan does not have to pay for the unlisted molecular pathology testing (81479) 
provided on March 10, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for homemaker services (S5130) provided on February 21, 2022, 
to February 25, 2022. 
 
You asked the Plan to pay for homemaker. You say that you disagree with denial. The Plan denied your 
request. The Plan says the requested services are not a covered benefit under any condition. 
 
The Plan must follow Medicare rules. Medicare rules say that homemaker services are not a covered benefit.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of homemaker service have not been met. Specifically, the requested services are not a covered 
benefit. Therefore, we decided that the Plan does not have to pay for homemaker services (S5130) provided on 
February 21, 2022, to February 25, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the telehealth critical care consultation (G0508) provided on 
January 5, 2022. 
 
You asked the Plan to pay for critical care services. You say that this Plan is the enrollees primary insurer. The 
Plan denied your request. The Plan says the enrollee was under hospice services on the date in question but was 
discharged the same day. Payment for this service is the responsibility of Original Medicare as Medicare 
continues to cover the beneficiary through the end of the month of the date of discharge or revocation. 
 
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 telehealth critical care consultation (G0508) provided on 
January 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) device 
with humidifier. 
 
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 services are not medically necessary. 
 The Plan must follow Medicare rules. Medicare rules say that CPAP is covered when specific criteria are met. 
 
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 records document that the enrollee 
used the CPAP for more than four hours per day 53.3 percent of the time, which does not meet the criteria for 
coverage. The Medicare rules require four hours or greater use per night for 70 percent of the nights for 30 
consecutive days during the three months of initial usage. The services are therefore 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 a continuous positive airway pressure (CPAP) device with humidifier.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic radiographic image (D0330) provided on May 
13, 2021. 
 
You asked the Plan to pay for the panoramic image. You say that you were told services would be covered and 
you expect payment. The Plan denied your request. The Plan says panoramic x-rays are not covered under your 
dental benefit plan. 
 
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 pay for a 
panoramic radiographic image (D0330) provided on May 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a resin-based composite (D2392) provided by a participating 
provider on January 4, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were never told that this provider was out-
of-network. 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 a resin-based composite (D2392) provided by an out-of-network provider on January 4, 2022.