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

 
We decided that the Plan does not have to pre-approve intraosseous ablation of the basivertebral nerve, which 
is accomplished with the Intracept Procedure (64628). 
 
You asked the Plan to pre-approve the Intracept Procedure. You say that this procedure fills a treatment gap for 
those enrollees that do not receive adequate relief from traditional conservative methods and don't have 
instability to indicate that fusion is the appropriate treatment. The Plan denied your request. The Plan says 
unproven and not medically necessary procedures are not covered by Medicare due to insufficient evidence of 
efficacy. 
 
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 Intracept Procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was being treated for vertebrogenic low back pain. The enrollee 
presented with pain in the low back and mid-back. The pain is intermittent. The pain is aching, shooting, and 
stabbing rated at 8. However, per the FDA, this procedure is indicated at levels L3-S1. This would not include 
the requested L2 level. Moreover, the MRI from January 26, 2023, did not corroborate Modic changes at the 
L5 and S1 levels on the formal report. Additionally, there are multiple plausible pathologic sources of 
significant pain generation. The back pain, the noted pain-aggravating factors (work, walking, bending, 
standing, physical activities, travel, and other), pain-relieving factors (rest, applying heat, lying flat, and 
position change), along with the limited objective exam are all non-specific to any pathologic entities. Overall, 
documentation is lacking regarding reasonably detailed and/or evidenced findings supportive of the spinal 
vertebral bodies as being the overwhelming primary generators of the enrollees chronic persistent pain. 
Documentation does not support actual formal surgical ablation of pre-designated basivertebral nerves as being 
medically necessary and/or reasonable at this time. There is no compelling rationale presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested 
Intracept intraosseous basivertebral nerve ablation at L2, L5, and S1 vertebral bodies, in this case, is not 
medically reasonable or 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 Intracept Procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve intraosseous ablation of the basivertebral nerve, which is accomplished with the 
Intracept Procedure (64628).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99252 billed for date of service September 
27, 2022. 
 
You asked the Plan to pay for procedure code 99252. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
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 99252 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 99252 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 99252 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99252 billed for date of service September 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and laryngoscopy provided on June 14, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit and laryngoscopy. You say that the enrollee had worsening 
symptoms with swallowing and speech while visiting family. The Plan denied your request. The Plan says 
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 at issue in this case is not a network provider with the Plan. 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 office visit and laryngoscopy. Our reviewer says that the records do not 
indicate that the care provided was medically necessary. Our physician reviewer found records indicate the 
enrollee had previously seen a laryngologist for this problem. It would have been medically reasonable to delay 
the services until the  enrollee returned to the service area. 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 office visit and laryngoscopy have not been met.  
 
The Plan has network providers available who can provide the items/services at issue in this appeal. We found 
no exception that would require the Plan to pay for the office visit and laryngoscopy. Therefore, we decided 
that the Plan does not have to pay for an office visit and laryngoscopy provided on June 14, 2022, by an out-of-
network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (K0862) and accessories. 
 
You asked the Plan to pre-approve the power wheelchair and accessories. You say that the requested items are 
medically necessary. The Plan denied your request. The Plan says that the coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for 
enrollees who have a mobility limitation that is due to: 
 
1. A neurological condition; 
 
2. Myopathy; or 
 
3. Congenital skeletal deformity. 
 
 
 The file does not show that the enrollee has a mobility limitation that is due to a neurological condition, 
myopathy or congenital skeletal deformity. Therefore, we decided that the Plan does not have to pre-approve a 
Group 3 power wheelchair (K0862) and accessories.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Intracept procedure. 
 
You asked the Plan to pre-approve the procedure. You say that the Intracept procedure is medically necessary 
and supported by strong science. The Plan denied your request. The Plan says the requested procedure 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 the procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that in this case, there were/are multiple plausible pathologic sources of significant pain 
generation. The noted back pain and limited exam were/are all non-specific to any pathologic entities. Overall, 
documentation was/is lacking regarding reasonably detailed and/or evidenced findings supportive of the spinal 
vertebral bodies as being the overwhelming primary generators of the enrollees chronic persistent pain. 
Documentation does not support actual formal surgical ablation of pre-designated basivertebral nerves as being 
medically necessary and/or reasonable at this time. There is no compelling rationale presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested Intracept intraosseous basivertebral nerve ablation at L5 and S1 vertebral bodies, in this case, is not medically 
reasonable or 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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Intracept procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve outpatient psychological testing (96130, 96131 x 3, 
96138, 96139 x 3). 
 
You asked the Plan to pre-approve the psychological testing. You say that the enrollee was referred for a pre-
surgical evaluation prior to a stimulator implant. The Plan denied your request. The Plan says the requested 
psychological testing is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that that central nervous system assessments/tests are 
testing which is intended to diagnose and characterize the neurocognitive effects of medical disorders that 
impinge directly or indirectly on the brain. 
 
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 psychological testing. Our reviewer 
says that the requested psychological testing is not medically necessary. Our physician reviewer found the 
documentation shows that you have been having chronic low back pain and continuously use opioid pain 
medication. The reviewer found that an evaluation for a stimulator implant would not warrant this type of 
diagnostic treatment. Therefore, the reviewer found that the requested psychological testing is not medically 
necessary or reasonable. 
 
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 psychological testing have not been met. Therefore, we decided that the 
Plan does not have to pre-approve outpatient psychological testing (96130, 96131 x 3, 96138, 96139 x 3).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Wegovy injection. 
 
You asked the Plan to pre-approve Wegovy. You say that the requested drug is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the requested drug is considered self-administered. The 
Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also 
says the requested drug is not covered under Medicare Part B. 
 
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 requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Wegovy injection.  
 Benefits for Wegovy 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 the cone beam computed tomography (CT) image capture 
with field of view of both jaws; with or without cranium (D0383), the core buildup, including any pins when 
required (D2950), and the porcelain/ceramic crown (D2740) provided on October 5, 2022. 
 
You asked the Plan to pay for these dental items/services. You say that you are requesting a reconsideration of 
the Plan's denial for payment. The Plan denied your request. The Plan says the dental items/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 that you received the dental items/services from an out-of-network provider. Though the 
Plan offers a dental benefit in excess of Medicare coverage, dental items/services provided by an  
out-of-network provider are not covered. Additionally, cone beam computed tomography and core build ups 
are not covered benefits. Therefore, we decided that the Plan does not have to pay for the cone beam computed 
tomography (CT) image capture with field of view of both jaws; with or without cranium (D0383), the core 
buildup, including any pins when required (D2950), and the porcelain/ceramic crown (D2740) provided on 
October 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the biological materials (D4265), the extractions (D7140), 
the sealant repair (D7921), and the bone replacement graft (D7953) for tooth #7 and #18 provided on October 
26, 2022. 
 
You asked the Plan to pay for the dental services. You say that you have a $5,000 dental allowance and it was 
medically necessary for you to get the dental procedures done. The Plan denied your request. The Plan says the 
denial of payment for these services is correct, because the biological materials, extractions, sealant repair, and 
the bone replacement graft are not covered by the 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 the 
biological materials (D4265), the extractions (D7140), the sealant repair (D7921), and the bone replacement 
graft (D7953) for tooth #7 and #18 provided on October 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluations-problem focused (D0140 x 2) 
provided on November 2, 2022 and November 3, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says your benefit for the services provided 
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 services provided was exhausted on date of service March 17, 2022. Specifically, a 
limited oral evaluation is covered once per plan year. You previously received this service on March 17, 2022, 
less than one year prior, which was paid for by the Plan. Therefore, you have exhausted the allowable benefit 
for this service. Therefore, we decided that the Plan does not have to pay for the limited oral evaluations-
problem focused (D0140 x 2) provided on November 2, 2022 and November 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the removal of impacted tooth (D7230) for tooth #32 
provided on November 2, 2022. 
 
You asked the Plan to pay for the dental service. You say that the bill should have been processed as an 
extraction and should have left you with what Medicare allows. The Plan denied your request. The Plan says 
the denial of payment for this service is correct, because the removal of impacted tooth is not covered by the 
Plan. Also, it was verified with the provider that the proper dental code was billed for the service that was 
rendered. 
 
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 the 
removal of impacted tooth (D7230) for tooth #32 provided on November 2, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the nivolumab injection provided on July 
26, 2022. 
 
You asked the Plan to waive the coinsurance for the injection. You say that you disagree with the coinsurance 
amount. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Medicare Part B drugs.  
 
You have been asked to pay $2,849.76, which is 20% coinsurance of the allowed amount for the injection 
($14,248.80 allowed amount x 20% coinsurance = $2,849.76). This item/service falls within the Medicare Part 
B drugs benefit category. 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 coinsurance for the nivolumab injection 
provided on July 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the extraction, of an erupted tooth requiring removal of 
bone and/or sectioning of tooth (D7210) and the bone replacement graft for ridge preservation-per site (D7953) 
provided on November 14, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says you are responsible for any charged 
amount above the Plans cost-sharing amount when your services are received from an out-of-network 
provider. Additionally, a bone replacement graft is not a covered benefit.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Additionally, a bone replacement graft is not a covered benefit. Therefore, we decided that the Plan does not 
have to pay more for the extraction, of an erupted tooth requiring removal of bone and/or sectioning of tooth 
(D7210) and the bone replacement graft for ridge preservation-per site (D7953) provided on November 14, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supply allowance for a continuous glucose monitor 
(CGM) provided on October 16, 2022. 
 
You asked the Plan to pay for the supply allowance. You say that the enrollee's physician ordered the 30-day 
supply allowance. The Plan denied your request. The Plan says the date of service does not match the 
delivery/shipping date. 
 
The Plan must follow Medicare rules. Medicare rules say that suppliers may use the shipping date as the DOS 
or the date of delivery as the DOS on the claim.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for a valid 
POD coverage of the supply allowance for the CGM have not been met, specifically that there was a tracking 
number on the invoice but there were no delivery services records. Therefore, we decided that the Plan does 
not have to pay for the supply allowance for a continuous glucose monitor (CGM) provided on October 16, 
2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for the catheter placement provided on 
October 03, 2022. 
 
You asked the Plan to reduce the coinsurance for the catheter placement. You say that you should only have a 
$275 copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for diagnostic testing. 
 
You have been asked to pay 20% coinsurance for the catheter placement. This item/service falls within the 
diagnostic testing benefit category. 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. The total you owe is $533.81, which is 20% of the allowed amount ($2,669.04 allowed x 20% = 
$533.81). Therefore, we decided that the Plan does not have to reduce the coinsurance for the catheter 
placement provided on October 03, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pulp vitality tests (D0460), treatment of root canal 
obstruction (D3331) and a consultation (D9310) provided on September 29, 2022. 
 
You asked the Plan to pay for the dental services. You say that D3331 should be covered. The provider's office 
stated the consultation was needed in order to get the root canal and was performed by someone in the same 
office. The Plan denied your request. The Plan says these services are not covered by the Plan's 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 the pulp 
vitality tests (D0460), treatment of root canal obstruction (D3331) and a consultation (D9310) provided on 
September 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cone beam CT capture and interpretation for TMJ series 
including two or more exposures (D0368) provided on November 7, 2022. 
 
You asked the Plan to pay for the cone beam CT capture. You say that you disagree with the denial and are 
asking the Plan to reconsider payment. The Plan denied your request. The Plan says this service is not covered 
under the benefit package. 
 
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 cone 
beam CT capture and interpretation for TMJ series including two or more exposures (D0368) provided on 
November 7, 2022.