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

 
We decided that the Plan has to pre-approve a crown (D2751) and a post and core in addition to a crown 
(D2952) for tooth #2. 
 
You asked the Plan to pre-approve a crown and a post. You say that the services should be covered because the 
current crown is not able to make contact with your bottom tooth. You cannot chew food with that area of your 
mouth at all. You also say you are planning on having the tooth next to the current crown extracted. The dentist 
has not prescribed any medication but would like to complete the procedure as soon as possible. The Plan 
denied your request. The Plan says that you have enough teeth in the back of your mouth that touch when you 
bite down. 
 
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 a crown and a 
post once every 60 months per tooth. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a crown and a post. Our reviewer says 
that the service is medically necessary. Our physician reviewer found the documentation provided meets the 
criteria for coverage for a post/core and crown restoration for tooth #2. 
 
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 a crown and a post have been met. Therefore, we decided that the Plan has to 
pre-approve a crown (D2751) and a post and core in addition to a crown (D2952) for tooth #2.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on June 3, 2021, through 
June 7, 2021 and billed with Diagnosis Related Group (DRG) 190. 
 You asked the Plan to pay for the inpatient hospital services billed with DRG 190. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation 
submitted does not support the DRG billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 190 and secondary diagnosis code J96.01. 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 inpatient hospital services billed with 
DRG 190. Our reviewer says that the diagnoses of acute respiratory failure with DRG 190 are not supported by 
the documentation. Our physician reviewer found there was insufficient evidence from the documentation to 
describe acute respiratory failure as she only required low dose oxygen and was not in acute distress on 
admission.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on June 3, 2021, through June 7, 2021 and billed with Diagnosis 
Related Group (DRG) 190.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous intraoperative neurophysiology monitoring 
(G0453) provided on February 4, 2021. 
 You asked the Plan to pay for the continuous intraoperative neurophysiology. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says an edit exists 
between CPT codes G0453 and 95940. 
 
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 G0453 is a column II code to column I code 95940; however, G0453 
was billed with a modifier.  
 
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 continuous intraoperative neurophysiology. Our reviewer 
says that CPT code G0453 does not meet criteria for billing or reimbursement consideration. Our reviewer 
found the provider reported 2 neuromonitoring procedure codes. CPT 95940 Continuous monitoring in the 
operating room, one on one monitoring, and HCPCS G0453 Continuous monitoring from outside the operating 
room, with modifier 59. In this case, documentation does not support this procedure as a distinct separate 
procedure, 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 continuous intraoperative neurophysiology have not been met. Therefore, 
we decided that the Plan does not have to pay for the continuous intraoperative neurophysiology monitoring 
(G0453) provided on February 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical assistant services provided to the enrollee on August 
20, 2021. 
 
You asked the Plan to pay for the services. You say that these are payable codes, and were done in the best 
interest of the patient. The Plan denied your request. The Plan says medical necessity is not established for an 
assistant surgeon. 
 
 
 
 The Plan follows Medicare rules. Medicare rules say that items and services that are not medically necessary 
are not covered. Medicare rules say that for procedures with an assistant surgery indicator of 0, the payment 
restriction for assistants at surgery applies to this procedure unless supporting documentation is submitted to 
establish medical necessity. In this case, you billed assistant surgery services. The Medicare Fee Schedule 
Database contains a surgical indicator of 0 for this procedure.  
 
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 medically reasonable or necessary. Our physician reviewer found that in 
this case, the record indicates that the enrollee underwent a left intraoperative ultrasound-guided needle 
localization lumpectomy, local soft tissue flaps with BioZorb in dissolvable breast implant, and sentinel lymph 
node biopsy. The operative provided does not document the medical necessity, as defined by Medicare rules, of 
an assistant at surgery for the procedures that have been denied in the enrollee's specific clinical scenario.  The 
elements of the coverage criteria are not satisfied 
 
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 assistant services provided to the enrollee on August 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nerve conduction studies (95912) and needle 
electromyography (95885) provided on August 6, 2021. 
 
You asked the Plan to pay for the nerve conduction studies and needle electromyography. You say that you 
would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the 
documentation submitted does 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. 
 
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 nerve conduction studies and needle electromyography. 
Our reviewer says that CPT code 95912 does not meet criteria for billing or reimbursement consideration.  
 The Intraoperative Neurophysiology Report does not include documentation of nerve conduction studies 
procedure, and therefore this procedure cannot be verified as performed. Our reviewer found CPT code 95885 
does not meet criteria for billing or reimbursement consideration. The Intraoperative Neurophysiology Report 
does not include documentation of needle electromyography each extremity, and nerve conduction studies 
procedure, and therefore this procedure cannot be verified as performed. 
 
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 nerve conduction studies, and needle electromyography have not been met. 
Therefore, we decided that the Plan does not have to pay for the nerve conduction studies (95912) and needle 
electromyography (95885) provided on August 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar facet joint radiofrequency ablations (RFAs). 
 
You asked the Plan to pre-approve lumbar facet joint RFAs. You say that the enrollee obtained greater than 
80% pain relief from the initial injection. The Plan denied your request. The Plan says the denial of 
authorization for this service is correct, because the enrollee has only had one set of medial branch blocks 
(MBBs) and needs a second confirmatory set. 
 
The Plan follows Medicare rules. Medicare rules state that facet joint radiofrequency ablation may be covered 
if certain 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 lumbar facet joint RFAs. Our reviewer 
says that the enrollee does not meet the Medicare criteria for the requested radiofrequency ablation (RFA). Our 
physician reviewer found diagnostic procedures should be performed with the intent that if successful, 
radiofrequency ablation (RFA) would be considered the primary treatment goal at the diagnosed level. The 
second diagnostic procedure may only be performed a minimum of 2 weeks after the initial diagnostic 
procedure. However, the enrollee has not had a second confirmatory set of diagnostic medial branch blocks 
(MBBs). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of lumbar facet joint RFAs have not been met. Therefore, we decided that the Plan 
does not have to pre-approve lumbar facet joint radiofrequency ablations (RFAs).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transthoracic echocardiograph with complete Doppler 
provided on August 17, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the diagnostic test. You say that the services were rendered to the enrollee in 
good faith. The Plan denied your request. The Plan says if you choose a primary care physician (PCP) that is 
part of an independent practice association (IPA) or medical group, the specialists, ancillary providers, and 
hospitals available to you may be limited to only those contracted with the PCPs IPA or medical group. The 
Plan also says that prior authorization was not obtained from the enrollee's PCP. 
 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 in this case is not a network provider with the enrollee's PCP group. 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. 
Therefore, we decided that the Plan does not have to pay for the transthoracic echocardiograph with complete 
Doppler provided on August 17, 2021 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for unlisted cardiovascular service or procedure (CPT code 
93799) provided on October 31, 2021. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says payment is not allowed for this service because it is not appropriate for the CPT codes 
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 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 found the documentation 
submitted was reviewed and does not meet criteria. Operative report states "Intraoperative ultrasound utilizing 
Medistim ultrasound flow probe" is the procedure being reported with the unlisted cardiovascular procedure.  
There is a more appropriate code to report for ultrasound flow probe procedure.  In this case, an unlisted 
procedure code would not be reported for procedure documented. 
 
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 unlisted cardiovascular service or procedure (CPT code 93799) provided on October 31, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a therapeutic CGM. You say that this item is medically necessary for the 
enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
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 assess 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 therapeutic CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
therapeutic continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for supply allowance for therapeutic continuous glucose monitor 
(CGM), includes all supplies and accessories, 1 month supply (K0553) provided March 8, 2021. 
 
You asked the Plan to pay for the supply allowance for therapeutic CGM. You say that the medical records 
provided support the necessity of the services in dispute. The Plan denied your request. The Plan says there is 
evidence of misrepresented services and the billed supply code cannot be verified. 
 
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 K0553 is supply allowance for therapeutic continuous 
glucose monitor (CGM), includes all supplies and accessories, 1 month supply. 
  
 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 supply allowance for therapeutic CGM. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
reviewer found the documentation submitted was reviewed and does not meet criteria. The delivery ticket 
documents "FreeStyle 14-day Senosor" was delivered. HCPCS K0553 describes a supply allowance used with 
a therapeutic CGM device. The supply allowance includes all items necessary for the use of the device. 
Therefore, this service 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 supply allowance for therapeutic CGM have not been met. Therefore, we 
decided that the Plan does not have to pay for supply allowance for therapeutic continuous glucose monitor 
(CGM), includes all supplies and accessories, 1 month supply (K0553) provided March 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aid (V5260), provided on August 24, 2021. 
 
You asked the Plan to pay for the hearing aid. You say that the item should be covered. The Plan denied your 
request. The Plan says this item was obtained out-of-network. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only obtained through a network provider..  
 
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 hearing aid. Our reviewer says that  Our 
physician reviewer found  
 
We looked at this physician's review, the file, and the Plan's rules. Based on this information, we decided that 
the Plan's rules for coverage of the hearing aid have not been met. Therefore, we decided that the Plan does not 
have to pay for the hearing aid (V5260), provided on August 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the insertion of a drug-eluting implant (0356T) provided on 
August 4, 2021. 
 
You asked the Plan to pay for the insertion of a drug-eluting implant. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says medical records 
were requested and not received. 
 
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 the insertion of a drug-eluting implant 
(0356T) provided on August 4, 2021. have been met. Specifically, the documentation submitted does not 
include any clinical information to verify what services were rendered on the billed date of service.. Therefore, 
we decided that the Plan does not have to pay for the insertion of a drug-eluting implant (0356T) provided on 
August 4, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Caris targeted genomic sequencing (81479) provided on 
September 8, 2021. 
 
You asked the Plan to pay for the Caris targeted genomic sequencing. You say that you would like 
reconsideration because this enrollee meets Medicare criteria for coverage. The Plan denied your request. The 
Plan says this testing was 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 pay for the Caris targeted genomic sequencing. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the use of molecular studies, such as with Caris, is indicated in recurrent or 
persistent ovarian cancer according to the NCCN Guidelines.  Data are limited on primary and maintenance 
therapy for recurrent/persistent clear cell ovarian cancer. 
 
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 Caris targeted genomic sequencing have not been met. Therefore, we 
decided that the Plan does not have to pay for the Caris targeted genomic sequencing (81479) provided on 
September 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vision service (V2799), and bifocal lens (V2200), 
provided on November 18, 2021. 
 
You asked the Plan to pay for the vision service and bifocal lens. You say that the items should be covered. The 
Plan denied your request. The Plan says you received an in-store discount on these items.  
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services up to $200. Benefits available under this plan cannot be combined 
with any other in-store discounts. 
 
We looked at the file and the Plan's rules. You received an in-store discount on these items. Based on this 
information, we decided that the Plan's rules for coverage of the vision service and bifocal lens have not been 
met. Therefore, we decided that the Plan does not have to pay for the vision service (V2799), and bifocal lens 
(V2200), provided on November 18, 2021.