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

 
We decided that the Plan does not have to pre-approve an extraction (D7140) for tooth #21. 
 
You asked the Plan to pre-approve the dental service. You say that the requested dental service is medically 
necessary. The Plan denied your request. The Plan says the tooth has already been removed; therefore, the 
requested dental service is not necessary. 
 
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 dental 
service when the services are medically necessary and reasonable.  
 
  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 dental service. Our reviewer says 
that the extraction for tooth #21 is not medically necessary. Our physician reviewer found that the provided x-
ray is unclear as to orientation, and as such which teeth are present in the arch. Standard orientation would 
place tooth #21 on the right-side of the screen as it is viewed, being the left side of the mouth. From the 
provided film it is not apparent that tooth #21 is present. There are no orientation marks on the panoramic film. 
A properly oriented x-ray with left and right designation is necessary to determine the teeth that are present in 
the arch and their condition. Given the lack of ability to determine which teeth are present due to the unmarked 
x-ray, medical necessity cannot be determined at this time. Properly marked x-rays, preferably periapical films 
where anterior teeth are involved due to panoramic distortions, are necessary to assess the situation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental service have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an extraction (D7140) for tooth #21.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chronic care management services provided on 
September 30, 2022. 
 
You asked the Plan to pay for the chronic care management services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the chronic care 
management services provided on September 30, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0480 provided on November 8, 2022. 
 
You asked the Plan to pay for procedure code G0480. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the records do not support the services 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. 
 
In this case, the CPT Code Manual definition of code G0480 is Drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 1-7 drug 
class(es), including metabolite(s) if performed. 
 
We find that CPT code G0480 is not supported in the medical record. Specifically, the records show that more 
than 7 drug classes were tested. Based on this information, we decided that Medicare rules for coverage of 
procedure code G0480 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code G0480 provided on November 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture services provided on October 25, 2022, to 
December 05, 2022. 
 
You asked the Plan to pay for acupuncture services. You say that you do not agree with not being reimbursed 
for these services. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for acupuncture services 
provided on October 25, 2022, to December 05, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ophthalmological services provided on September 19, 2022. 
 
You asked the Plan to pay for ophthalmological services. You say that the enrollee resides at nursing home and 
the nursing home requested that the enrollee be seen. The Plan denied your request. The Plan says that 
unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for ophthalmological 
services provided on September 19, 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 December 
11, 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 December 11, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the polymerase chain reaction (PCR) respiratory panel 
provided on September 6, 2022. 
 
You asked the Plan to pay for the PCR panel. The Plan denied your request. The Plan says this is not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that molecular syndromic panels are covered for the 
indications established in the applicable LCD.  
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 PCR panel. Our reviewer says that the 
requested testing is not medically reasonable and necessary. Our physician reviewer found that the 
documentation available for review does not support the medical necessity for the laboratory testing performed.  
Additionally, the service was billed with 10 codes instead of a single code used to identify a panel. 
 
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 PCR panel have not been met. Therefore, we decided that the Plan does not 
have to pay for the polymerase chain reaction (PCR) respiratory panel provided on September 6, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the allograft, morselized, or placement of 
osteopromotive material, for spine surgery only (list separately in addition to code for primary procedure) 
(20930). 
 
You asked the Plan to pre-approve the allograft. You say that please review the case and move in the direction 
of approval of a redo decompression with instrumental lateral fusion. The Plan denied your request. The Plan 
says the requested allograft has not been proven to be a better alternative to standard bony allografts. 
 
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 allograft. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that osteopromotive allograft is experimental in spine surgery. Iliac crest autograft is the gold 
standard. 
 
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 allograft have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the allograft, morselized, or placement of osteopromotive material, for spine surgery only 
(list separately in addition to code for primary procedure) (20930).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulator (TENS) device 
(E0730) provided on October 9, 2022. 
 
You asked the Plan to pay for the TENS device. You say that the billed code is appropriate. The Plan denied 
your request. The Plan says the proof of delivery is not valid. 
 
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 does not contain a valid proof of delivery for the supplies provided in this case. The record shows 
that the proof of delivery included in the case file does not match the date of service in this case. The record 
shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, 
we decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulator (TENS) device 
(E0730) provided on October 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation - established patient (D0120), and 
prophylaxis - adult (D1110) provided on December 7, 2022. 
 
You asked the Plan to pay for the dental services. You say that you received no notice that the provider was 
out-of-network and are asking for the claim  to be paid. 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 periodic oral evaluation - established patient 
(D0120), and prophylaxis - adult (D1110) provided on December 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodic oral evaluation (D0120) provided on December 14, 
2022. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. 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 May 26, 2022, and 
September 29, 2022. Therefore, we decided that the Plan does not have to pay for periodic oral evaluation 
(D0120) provided on December 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for limited oral evaluation- problem focused (D0140) provided 
on October 11, 2022, and November 15, 2022. 
 
You asked the Plan to pay for limited oral evaluation. You say that this should be covered. The Plan denied 
your request. The Plan says this 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 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 limited 
oral evaluation- problem focused (D0140) provided on October 11, 2022, and November 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for limited oral evaluation (D0140) and panoramic radiographic 
image (D0330) provided on January 3, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. 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 panoramic radiographic image was exhausted on date of service June 28, 2021. 
Therefore, we decided that the Plan does not have to pay for limited oral evaluation (D0140) and panoramic 
radiographic image (D0330) provided on January 3, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that you will continue to lose strength in your legs by not having or completing the intense therapy recommended by your doctor and home therapy is not enough to help you get strong enough to walk on your own. The Plan denied your request. The Plan says the services you need can be provided safely in another setting such as a skilled nursing facility, home with home health services or home with outpatient therapy.

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 the clinical documentation does not show any acute complex functional impairments or active medical comorbidities. The complexity of your documented nursing, medical and rehabilitation needs would not be expected to require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. IRF criteria is not met.

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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for custom fabricated abutment (D6057) and implant supported 
crown (D6066) provided on March 22, 2022. 
 
You asked the Plan to pay for custom fabricated abutment and an implant. You say that this should be covered. 
The Plan denied your request. The Plan says this 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 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 custom 
fabricated abutment (D6057) and implant supported crown (D6066) provided on March 22, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for medication assisted treatment, methadone; weekly bundle including 
dispensing and/or administration, substance use counseling, individual and group (code G2067) provided on 
November 21, 2022. 
 
You asked the Plan to pay for medication assisted treatment, methadone; weekly bundle including dispensing 
and/or administration, substance use counseling, individual and group. You say that you have been enrolled in 
the Medicare program to provide Opioid Treatment Program (OTP) services since January 01, 2020. The Plan 
denied your request. The Plan says that this code must be billed by the OTP facility on a facility claim. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the OTP is the billing provider and is Substance Abuse and Mental 
Health Services Administration (SAMHSA) certified. The rules cited by the Plan do not provide a valid reason 
to deny this claim given that the OTP meets the Medicare coverage criteria. This provider continues to use the 
professional claim, which is allowed under Medicare rules. Therefore, we decided that the Plan has to pay for medication assisted treatment, methadone; weekly bundle including dispensing and/or administration, 
substance use counseling, individual and group (code G2067) provided on November 21, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care services coded 99233 provided 
from April 20, 2022, to April 21, 2022. 
 
You asked the Plan to pay for the subsequent hospital care services. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services billed are not supported. 
 
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 99233 is subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed 
interval history; A detailed examination; Medical decision making of high complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is 
unstable or has developed a significant complication or a significant new problem. Typically, 35 minutes are 
spent at the bedside and on the patient's hospital floor or unit. 
 
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 subsequent hospital care services. Our reviewer says that 
the documentation does not support the code billed. Our reviewer found the provided records in this case do not 
document a detailed history with a chief complaint, an extended history of present illness, a problem pertinent 
review of systems and pertinent past, family and social history. The provided records do not document medical 
decision making of high complexity with an extensive number of diagnoses or management options, an 
extensive amount and complexity of data reviewed and high risk of complication. Therefore, code 99233 is not 
supported. 
 
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 subsequent hospital care services have not been met. Therefore, we decided 
that the Plan does not have to pay for the subsequent hospital care services coded 99233 provided from April 
20, 2022, to April 21, 2022.