Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services (99100) provided on August 4, 2021. 
 
You asked the Plan to pay for code 99100. 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. 
Providers must report services with the appropriate CPT code. 
 
We looked at the file and Medicare rules. Code 99100 has a status code of "B" under the Medicare Physicians 
Fee Schedule Database (MPFSDB) and no separate payment is made for this code under the fee schedule as 
payment is bundled into the payment for the services to which this code is incident to. Therefore, we decided 
that the Plan does not have to pay for the anesthesia services (99100) provided on August 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided by an out-of-network provider on 
November 22, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
approved in advance. 
 
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 services at issue in this appeal. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for the services provided by an out-of-network provider on 
November 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral - complete series of radiographic images 
(D0210) provided December 14, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the complete series of x-rays. You say that you feel the provider did not give 
accurate information about coverage. The Plan denied your request. The Plan says dental services are not 
covered when provided OON. 
 
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 Plan covers the complete 
series of x-rays when provided by a network provider.  
 
We looked at the file and Medicare rules. 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. Based on this information, we decided that the Plan's rules for coverage of 
the complete series of x-rays have not been met. Therefore, we decided that the Plan does not have to pay for 
the intraoral - complete series of radiographic images (D0210) provided December 14, 2021, by an out-of-
network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2740), and a resin-based composite (D2391) 
provided by an out-of-network on June 28, 2021, to November 15, 2021. 
 
You asked the Plan to pay for a crown and a resin-based composite. You say that you would like the Plan to 
pay for this. The Plan denied your request. The Plan says the rendered dental 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 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 crown 
(D2740), and a resin-based composite (D2391) provided by an out-of-network provider on June 28, 2021, to 
November 15, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on October 20, 
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 documentation received did not support the use of the 59 modifier. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
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 pay for the services Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found the 
operative report describes a total shoulder and biceps tenodesis on the same shoulder, therefore, these 
procedures would not be billed separately. AAOS considers a biceps tenodesis separately reportable when 
performing a total shoulder however it is bundled in CCI so would not be reportable to Medicare. 
 
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 pay for surgical services provided to the enrollee on 
October 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral hygiene instruction (D1330), and additional 
periapical x-ray (D0230) provided on December 21, 2021. 
You asked the Plan to pay for the oral hygiene instruction and additional periapical x-ray. You say that you 
made it clear that you only wanted work done if it was going to be covered. You say that you did your due 
diligence. You also say that you should not be responsible for this bill. The Plan denied your request. The Plan 
says the frequency limit for periapical x-rays has been exhausted. The Plan also says that oral hygiene 
instruction is not a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage and periapical x-rays are listed as 
covered, the frequency limit has been exceeded. Additionally, oral hygiene instruction is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the oral hygiene 
instruction (D1330), and additional periapical x-ray (D0230) provided on December 21, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an EliteMed pharmacogenomics panel. 
 
You asked the Plan to pre-approve an EliteMed pharmacogenomics panel. You say that the records provided 
support that the requested genetic testing is medically necessary. The Plan denied your request. The Plan says 
the records provided do not support that the guidelines for coverage have been met. 
 
The Plan follows Medicare rules. Medicare rules say that pharmacogenetics testing is covered for certain 
clinical indications and when medically reasonable and 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 an EliteMed pharmacogenomics panel. 
Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the 
documentation in the case file does not support that an EliteMed pharmacogenomics panel is medically 
reasonable and necessary for the enrollee in this case. The documentation does not support that the enrollee has 
a condition where the clinical evaluation has determined the need for a medication that has a known gene-drug 
interaction(s) for which the test results would directly impact the drug management of her condition. 
 
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 EliteMed pharmacogenomics panel have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an EliteMed pharmacogenomics panel.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found you appear to be unstable and not improving currently requiring additional acute care 
services that can be safely administered at the current facility for the time being. There are no services at the 
LTACH that you require that are not already available and covered at the current facility. Transfer may be 
considered when you are more stable and treatment has completed. 
 
 
 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
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 8, 
2021. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. 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 8, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial nursing facility care (99306) and subsequent 
nursing facility care (99309) provided from October 14, 2021, to October 29, 2021. 
 
You asked the Plan to pay for the nursing facility care. You say that the enrollee's hospice election was revoked 
prior to the dates of service in this case. The Plan denied your request. The Plan says the enrollees 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 
providers responsibility to verify the enrollees coverage before rendering services and to know proper billing 
procedures for a Medicare Advantage member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on October 6, 2021. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the initial nursing 
facility care (99306) and subsequent nursing facility care (99309) provided from October 14, 2021, to October 
29, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chimeric antigen receptor (CAR) T-cell therapy for the 
enrollee. 
 
You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your 
request. The Plan says this would be considered a new to market provider-administrated specialty pharmacy 
product, and excluded from coverage. 
 
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 therapy. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found Carvytkti is FDA approved for the treatment of relapsed or refractory multiple myeloma in adults after 
four or more prior lines of therapy, including a proteasome inhibitor, an immunomodulatory agent, and an anti-
CD38 monoclonal antibody. However, the study did not include patients that had received prior CAR T-cell 
therapy. The safety in this heavily pretreated patient is unknown. The service 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 the therapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve chimeric antigen receptor (CAR) T-cell therapy for the enrollee.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia (J0897). 
 
You asked the Plan to pre-approve Prolia. The Plan denied your request. The Plan says this request does not 
meet the Plan's Part B coverage criteria for Prolia. 
 
  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 Prolia. Our reviewer says that Prolia is 
not medically reasonable and necessary for the enrollee. Our physician reviewer found the Plan requires a trial 
of Zoledronic Acid before they will approve the requested drug. Our reviewer found that in this case, the 
enrollee has not tried and failed the required drug. Our physician reviewer also found that there is no 
documentation provided indicating that the Plans required drug would likely be less effective and/or likely 
have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia (J0897).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient observation services (99217, 99220, 99225) 
provided from June 16, 2021, to June 18, 2021. 
 
You asked the Plan to pay for outpatient observation. You say that these services are supported in the record 
and were billed appropriately. 
 The Plan denied your request. The Plan says these services are not supported in the record. 
 
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 99220 is initial observation care, per day, for the 
evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and medical decision making of high complexity. 
 
The CPT Code Manual definition of code 99225 is subsequent observation care, per day, for the evaluation and 
management of a patient, which requires at least 2 of these 3 key components: An expanded problem focused 
interval history; An expanded problem focused examination; Medical decision making of moderate complexity. 
 The CPT code manual definition of code 99217 is observation care discharge day management (This code is to 
be utilized to report all services provided to a patient on discharge from outpatient hospital "observation status" 
if the discharge is on other than the initial date of "observation status". To report services to a patient 
designated as "observation status" or "inpatient status" and discharged on the same date, use the code for 
Observation or Inpatient Care Services. 
 
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 outpatient observation. Our reviewer says that these services 
are not supported as billed. Our reviewer found that the medical report includes an evaluation and management 
for these services; however, the documentation does not support that the enrollee was observation status at the 
time of services, and therefore observation procedure codes 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 outpatient observation have not been met. Therefore, we decided that the Plan 
does not have to pay for outpatient observation services (99217, 99220, 99225) provided from June 16, 2021, 
to June 18, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on July 27, 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 there is a more appropriate code to use for these services. 
 
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 the denied codes is: 
 
CPT 11403: 
 
Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; 
excised diameter 2.1 to 3.0 cm 
 
CPT 11406: 
 
Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter over 4.0 cm 
 
CPT 11443: 
 
Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, ears, eyelids, 
nose, lips, mucous membrane; excised diameter 2.1 to 3.0 cm 
 
CPT 11446: 
 
Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, ears, eyelids, 
nose, lips, mucous membrane; excised diameter over 4.0 cm 
 
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 after a careful review of 
documentation, a procedure report was not found to support this procedure.  However, a letter of explanation of 
procedure was reviewed. In this case, documentation does not support excision, as the documentation describes 
double cryosurgery and curettage for hyperplastic actinic keratosis performed,  and therefore 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 surgical services provided to the enrollee on July 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction, erupted tooth requiring removal of bone 
and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210) and intravenous 
(IV) moderate (conscious) sedation/analgesia- first 15 minutes (D9239) provided November 10, 2021. 
You asked the Plan to pay for the tooth extraction and IV sedation. You say that you were never informed that 
the provider had opted out of Medicare. The Plan denied your request. The Plan says this service is not covered 
because the provider has opted out of Medicare. 
 
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 tooth 
extraction and IV sedation when you see any licensed dental provider who accepts Medicare patients in the 
United States and has not opted out of Original Medicare. If you use a provider who has opted out of Medicare, 
you will not receive reimbursement. 
 
We looked at the file and Medicare rules. 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. Based on this information, 
we decided that the Plan's rules for coverage of the tooth extraction and IV sedation have not been met. 
Therefore, we decided that the Plan does not have to pay for the extraction, erupted tooth requiring removal of 
bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210) and 
intravenous (IV) moderate (conscious) sedation/analgesia- first 15 minutes (D9239) provided November 10, 2021.