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

 
We decided that the Plan does not have to pre-approve insertion of a subcutaneous rhythm monitor for the 
enrollee. 
 You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the health plan has no contractual obligation to cover services that are not covered by 
Medicare. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the patient had no history of atrial fibrillation, nor were any significant cardiac arrhythmias noted on 
electrocardiogram (ECG) monitoring. A recent randomized clinical trial found that continuous monitoring for 
atrial fibrillation with an implanted loop recorder (ILR) (followed by treatment with oral anticoagulation if 
atrial fibrillation was detected) was not superior to usual care in reducing stroke or systemic embolism among 
patients at high risk of stroke but without a known prior history of atrial fibrillation. At this time, insertion of 
an ILR would not be considered medically appropriate and necessary in this patients clinical management. 
 
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 pre-approve insertion of a subcutaneous rhythm monitor for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on January 14, 2022. 
 
You asked the Plan to pay for the services provided. You say that  The Plan denied your request. The Plan says 
the code cannot be separately reimbursed. 
 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.   
 
The file shows that code 87640 was billed with a -59 modifier. The medical records provided do not show that 
the service billed with the -59 modifier was a distinct procedural service. Based on this information, we 
decided that Medicare rules for coverage of services billed with a -59 modifier have not been met. Therefore, 
we decided that the Plan does not have to pay for the lab services provided on January 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on December 10, 2021 billed 
with codes 81206, 81162, 81292, 81295, 81298, 81301, 81311, 81317, 81194 and 81309. 
 
You asked the Plan to pay for the genetic testing billed. You say that you request reconsideration of this 
determination and coverage of the Tempus Gene Panel test at the in-network benefit level. The Plan denied 
your request. The Plan says the request does not meet Medicare rules as the testing performed was not FDA 
approved. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
December 10, 2021 billed with codes 81206, 81162, 81292, 81295, 81298, 81301, 81311, 81317, 81194 and 
81309.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the removal of impacted tooth covered by soft tissue 
(D7220), two removals of partially bony impacted teeth (D7230 x2), consultation (D9310), and panoramic x-
ray (D0330) provided on February 3, 2022, and February 10, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were advised to have your teeth removed. 
You also say that you are on a fixed income. The Plan denied your request. The Plan says the removals of 
impacted teeth and consultation are not covered under the Plan. The Plan also says that the panoramic x-ray 
exceeds the maximum allowed per period. 
 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 removal of impacted tooth covered 
by soft tissue (D7220), removal of partially bony impacted tooth (D7230), and consultation (D9310) are not 
among those covered under this benefit. The contract says that panoramic x-ray (D0330) is limited to one 
procedure every three plan years. The record shows that you received a panoramic x-ray (D0330) on November 
9, 2020, and your panoramic x-ray (D0330) benefit has been exhausted. Therefore, we decided that the Plan 
does not have to pay for the removal of impacted tooth covered by soft tissue (D7220), two removals of 
partially bony impacted teeth (D7230 x2), consultation (D9310), and panoramic x-ray (D0330) provided on 
February 3, 2022, and February 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator implant trial. 
 
You asked the Plan to pre-approve a spinal cord stimulator implant trial. You say that  The Plan denied your 
request. The Plan says a spinal cord stimulator implant trial is not medically necessary and does not meet the 
Medicare coverage criteria. 
 
The Plan follows Medicare rules. 
 
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 spinal cord stimulator implant trial. 
Our reviewer says that a spinal cord stimulator implant trial is not medically necessary. Our physician reviewer 
found that the enrollee has chronic neck and back pain that has not responded to non-surgical treatment with 
medications and physical therapy. The enrollee has not had any spinal injections (such as epidural blocks or 
medial bundle branch blocks). No advanced imaging of the spine to eliminate other potential causes of pain is 
submitted for review. Even though the enrollee is still undergoing chemotherapy, other reasons for the pain 
such as metastases of your nasal cancer have not been ruled out prior to proceeding to a spinal cord stimulator. 
The records also do not document that the enrollee has been evaluated by a spine surgeon to determine whether 
or not the enrollee would be a surgical candidate. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a spinal cord stimulator implant trial have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a spinal cord stimulator implant trial.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a maxillary partial denture (D5213) provided on February 
14, 2022. 
 
You asked the Plan to pay for the partial denture. You say that the pre-determination said the dentures were 
covered in full. The Plan denied your request. The Plan says your annual dental maximum has been exhausted. 
 
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 enrollees have a 
$1,000 annual dental maximum. 
 The record shows the benefits are based on when the services are received. You have been asked to pay for the 
maxillary partial denture. Partial dentures fall within the Dental Services 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 pay for a maxillary partial denture (D5213) provided on February 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic radiographic image (D0330) provided April 
19, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were not told that a panoramic and full 
mouth x-ray were in the same category. 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 September 9, 2021. 
Therefore, we decided that the Plan does not have to pay for the panoramic radiographic image (D0330) 
provided April 19, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70544 billed for date of service March 2, 
2022. 
 
You asked the Plan to pay for procedure code 70544. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70544 is bundled into payment for 
code 70551. 
 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 70544 
is a column II code to column I code 70551. 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 70544 billed for date of service March 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency medical services provided on February 4, 2022. 
 
You asked the Plan to pay for emergency medical services. You say that the services at issue were emergency 
services that were medically necessary for the enrollee. The Plan denied your request. The Plan says rules for 
payment have not been met. 
 
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 emergency medical services provided 
on February 4, 2022. have been met. Specifically, the case record does not contain medical documentation to support the necessity of the services at 
issue. Therefore, we decided that the Plan does not have to pay for emergency medical services provided on 
February 4, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for grab bars (E0243) provided on March 1, 2022, and March 
22, 2022. 
 
You asked the Plan to pay for grab bars. You say that the items at issue were a medical necessity for you. The 
Plan denied your request. The Plan says the items at issue are not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that grab bars are not covered because 
they are not primarily medical in nature.  
 
While a grab bar may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pay for grab bars (E0243) provided on March 1, 2022, and 
March 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic manipulation of the extra spinal regions and an 
office visit provided from March 30, 2022, to April 13, 2022. 
 
You asked the Plan to pay for the chiropractic manipulation of the extra spinal regions and an office visit. You 
say that the enrollee is entitled to all Medicare approved services. The Plan denied your request. The Plan says 
only manual manipulation of spine to correct subluxation is a covered chiropractic service. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the chiropractic manipulation of the extra spinal regions and an office visit 
provided from March 30, 2022, to April 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the endodontic therapy (D3330) provided on December 27, 
2021. 
 
You asked the Plan to pay for the endodontic therapy. You say that this procedure was of an urgent and 
emergency nature. The Plan denied your request. The Plan says your benefits for this service have been 
satisfied and the frequency limitation has been exceeded. The Plan also says that you did not contact the Plan 
prior to this date of service to verify benefits and provider eligibility. 
 
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, root canal is limited to one procedure 
per calendar year. The record shows that you received an endodontic therapy (D3330) on October 4, 2021, and 
your root canal benefit was exhausted.  
 
 
  
Therefore, we decided that the Plan does not have to pay for the endodontic therapy (D3330) provided on 
December 27, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on August 6, 2021 billed with 
codes 81206, 81162, 81301, and 81311. 
 
You asked the Plan to pay for the genetic testing billed. The Plan denied your request. The Plan says the 
services were billed incorrectly. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
August 6, 2021 billed with codes 81206, 81162, 81301, and 81311.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hypoglossal nerve stimulator system (Inspire) (64582, 
C1778, C1767, C1787). 
 
You asked the Plan to pre-approve the Inspire device. You say that the medical records provided support the 
necessity of the requested service. The Plan denied your request. The Plan says the enrollee did not meet the 
coverage criteria for the hypoglossal nerve stimulator system. 
 
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 Inspire device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is a 70-year-old male with obstructive sleep apnea and BMI 34. He has 
tried CPAP with different masks with variable success. Reported AHI was 1.9 with CPAP use for one year 
leading up to recent notes. A request for hypoglossal nerve stimulator system (Inspire) was made as he reported 
he didn't like to travel with or use the CPAP. However, it appears that the CPAP was benefiting the enrollee 
with only minor issues and there was no other medical reason for the Inspire device such as truly failed CPAP 
use or other contraindication. Therefore, this request for Inspire will be considered not medically necessary 
based on the provided documentation. 
 
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 Inspire device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve hypoglossal nerve stimulator system (Inspire) (64582, C1778, C1767, C1787).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a fixed partial denture sectioning (D9120) and an upper 
partial denture (D5213). 
 
You asked the Plan to pre-approve this item/service. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says you have exhausted the allowable benefit for the 
requested partial denture. Additionally, your request for a fixed partial denture sectioning is not covered. 
 
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 partial denture was exhausted on date of service June 8, 2021. The Plan 
contract states that one upper and/or one lower partial denture is covered every five calendar years. You 
previously received an upper partial denture on June 8, 2021, which was paid for by the Plan. Therefore, the 
benefit for this dental item has been exhausted.  Additionally, a fixed partial denture sectioning is not a covered benefit under your contractual policy. 
Therefore, we decided that the Plan does not have to pre-approve a fixed partial denture sectioning (D9120) 
and an upper partial denture (D5213).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pathology services (81479) provided on January 6, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for pathology services. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the services are not authorized because this provider is a non-network 
provider who does not work with the Plan, and the member was referred by a provider who also does not work 
with the Plan. The Plan also says that the member's primary care physician did not refer for services. 
 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 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. 
Therefore, we decided that the Plan does not have to pay for pathology services (81479) provided on January 6, 
2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infectious agent detection by nucleic acid services coded 
87631 provided on March 14, 2022. 
 
You asked the Plan to pay for the infectious agent detection by nucleic acid 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 by the 
documentation. 
 
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 87631 is infectious agent detection by nucleic acid (DNA 
or RNA); respiratory virus (eg, adenovirus, influenza virus, coronavirus, metapneumovirus, parainfluenza 
virus, respiratory syncytial virus, rhinovirus), includes multiplex reverse transcription, when performed, and 
multiplex amplified probe technique, multiple types or subtypes, 3-5 targets.  
We find that CPT code 87631 is not supported in the medical record. Specifically, this code represents three (3) 
to five (5) targets. The documentation supports that more than five (5) targets were provided. This means there 
is a more appropriate code to be billed for the services rendered. Based on this information, we decided that 
Medicare rules for coverage of the infectious agent detection by nucleic acid services have not been met. 
Therefore, we decided that the Plan does not have to pay for the infectious agent detection by nucleic acid 
services coded 87631 provided on March 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services provided on May 7, 2021. 
 
You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says all dental 
services, other than emergency dental and limited oral surgery are excluded from coverage. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
the enrollees teeth or the structures directly supporting the enrollees teeth. These are dental services that are 
not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the dental 
services provided on May 7, 2021.