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

 
We decided that the Plan does not have to pre-approve Xiidra drops. 
 
You asked the Plan to pre-approve Xiidra drops. You say that the patient is uncomfortable due to dry eyes and 
used over-the-counter tears with incomplete relief. You say that she has been using Xiidra since April 27, 2021, 
and reports better relief with comfort when using the drops. The Plan denied your request. The Plan says 
outpatient prescription drugs are not covered. 
 
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 Xiidra drops.  
  Benefits for Xiidra drops 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services (98940, 99203) provided on September 
28, 2021, to October 15, 2021, by an out-of-network (OON) provider. 
 You asked the Plan to pay for chiropractic services. You say that you had previously appealed another 
member's services, and the Plan overturned the denial and paid you stating that because you are out of network, 
claims should have, in fact been paid by the Plan. The Plan denied your request. The Plan says the services 
under appeal were rendered by a provider who is not under contract with the Plan or in the Plan's service area. 
The Plan also states that the claims were denied as not authorized, and the member was self-referred. 
 
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 chiropractic services (98940, 99203) provided on 
September 28, 2021, to October 15, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the partial upper denture with flexible base (D5225), and 
partial lower denture with flexible base (D5226) provided on January 15, 2021. 
 
You asked the Plan to pay for the dentures. You say that you were advised by your dentist that these services 
would be covered. You also say that if you had known they were not covered, you would not have had them 
done. The Plan denied your request. The Plan says partial dentures are not listed as covered services. 
 
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 partial dentures are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the partial upper denture with flexible base (D5225), and partial lower denture with flexible base (D5226) provided on January 
15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral exam (D0150), oral photographic 
image (D0350), and intraoral complete series (D0210), provided on October 25, 2021. 
 
You asked the Plan to pay for the routine dental services. You say that the services should be covered. The Plan 
denied your request. The Plan says dental code D0350 is not covered under the member's contract under any 
normal circumstances. Per the members 2021 Evidence of Coverage this service is excluded from coverage. 
Dental code D0150 is covered one procedure every three plan years and payment was previously issued for this 
service billed on date of service October 22, 2021. Dental code D0210 paid with the out-of-network member 
liability. 
 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 
comprehensive oral exam (D0150), oral photographic image (D0350), and intraoral complete series (D0210), 
provided on October 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services with an out of network provider. 
 
You asked the Plan to pre-approve dental services. You say that you need these services. The Plan denied your 
request. The Plan says the provider in this case is out of network. The Plan also says services you receive out of 
network are 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, the requested dental services are not 
among those covered under this benefit when you receive them out of network. Therefore, we decided that the 
Plan does not have to pre-approve dental services with an out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation feature and power standing 
feature for a power wheelchair. 
 
You asked the Plan to pre-approve power seat elevation feature and power standing feature. You say that the 
enrollee needs this device. The Plan denied your request. The Plan says the denial of authorization for these 
components is correct, because power seat elevation features and power standing features are not covered by 
Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature and power 
standing feature are not covered by Medicare. 
 
We looked at the file and Medicare rules. These components are not covered by Medicare. Based on this 
information, we decided that Medicare rules for coverage of power seat elevation feature and power standing 
feature have not been met. Therefore, we decided that the Plan does not have to pre-approve a power seat 
elevation feature and power standing feature for a power wheelchair.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for excision of malignant tumor of mandible; radical resection 
(21045), tracheostomy, fenestration procedure with skin flaps (31610) and bone graft, any donor area; major or 
large (20902) provided on September 30, 2021. 
 
You asked the Plan to pay for the excision of tumor, tracheostomy and bone graft. You say that these services 
were necessary and are appropriate as billed. The Plan denied your request. The Plan says the submitted 
documentation does not support the services were provided as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 In this case, the CPT Code Manual definition of code 20145 is excision of a malignant tumor of mandible; 
radical resection. The definition of code 31610 is tracheostomy, fenestration procedure with skin flaps, and the 
definition of CPT code 20902 is bone graft, any donor area; major or large. 
 
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 excision of tumor, tracheostomy and bone graft. Our 
reviewer says that these services are not supported as meeting the criteria as billed. Our reviewer found that the 
operative report describes a tumor mapped for size, and a panedoscopy was performed. The tumor and margins 
were resected. Therefore, code 21045 is not supported. A tracheostomy would be performed as a component of 
the primary procedure, and therefore code 31610 is not supported as billed. In addition, the procedure which 
was billed with code 20902 does not include enough information in the procedure documentation to support 
that this procedure has been performed to support (per National Correct Coding Initiative (NCCI) guidelines) 
an incision overlying the rib, ilium, fibula, or other site from which the autograft will be harvested. Fascia and 
muscles are incised and retracted. A knife, chisel, cutter, or saw may be used to obtain the bone graft, which 
will be prepared as needed for implantation. Cancellous bone chips may be obtained, as well. The incision is 
closed with sutures". This procedure cannot be confirmed as billed based on the documentation provided. 
 
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 excision of tumor, tracheostomy and bone graft have not been met. 
Therefore, we decided that the Plan does not have to pay for excision of malignant tumor of mandible; radical 
resection (21045), tracheostomy, fenestration procedure with skin flaps (31610) and bone graft, any donor area; 
major or large (20902) provided on September 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two removals of an impacted tooth (D7240 x2). 
 
You asked the Plan to pre-approve the removals of an impacted tooth. You say that you would like the Plan to 
reconsider their decision and allow coverage for this service to be performed. The Plan denied your request. 
The Plan says this service is not covered under your 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 pre-approve two 
removals of an impacted tooth (D7240 x2).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services coded 99140 provided on April 30, 
2021. 
 
You asked the Plan to pay for the anesthesia services. You say that you would like this claim reprocessed based 
on the medical documentation. The Plan denied your request. The Plan says no separate payment is made per 
Medicare rules. 
 
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 99140 is anesthesia complicated by emergency 
conditions (specify) (List separately in addition to code for primary anesthesia procedure). 
 We looked at the file and Medicare rules. In this case, this code has a Status Code of B under the Physician 
Fee Schedule. This Status Code indicates that payment for covered services is always bundled into payment for 
other services not specified. No separate payment will be made based on Medicare rules. Based on this 
information, we decided that Medicare rules for coverage of the anesthesia services have not been met. 
Therefore, we decided that the Plan does not have to pay for the anesthesia services coded 99140 provided on 
April 30, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lidocaine-Prilocaine cream.
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied
your request. The Plan says Lidocaine-Prilocaine cream is a self-administered drug and does not fall under Part
B coverage. The Plan states the enrollee has prescription coverage through a different insurance not affiliated
with this health plan.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Lidocaine-Prilocaine cream.
Benefits for the medication 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chest x-ray (71045) provided on September 30, 2021. 
 
You asked the Plan to pay for the chest x-ray. 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 71045 and 71046. 
 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 71045 
is a column II code to column I code 71046. 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 the chest x-ray (71045) provided on September 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core build up (D2950), and crown (D2740), provided on 
October 14, 2021. 
 
You asked the Plan to pay for the core build up and crown. You say that the services should be covered. The 
Plan denied your request. The Plan says these are not covered services. 
 
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 
your teeth or the structures directly supporting your 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 core build up (D2950), and 
crown (D2740), provided on October 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implant (D6010) for tooth # 3. 
 
You asked the Plan to pre-approve the dental service. You say that the implant for tooth # 3 is necessary to 
restore masticatory function. The Plan denied your request. The Plan says dental implants and all associated 
services are excluded from coverage. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested implant not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an implant 
(D6010) for tooth # 3.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 83036, 84439, 84443, 
84480, 84481, 85025) provided on March 4, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the laboratory services have not been met. CPT code(s): 83036, 
84439, 84443, 84480, 84481, 85025 remain not supported. The place of service on the CMS-1500 form line 
24B must reflect the location of the patient when the specimen was obtained. The submitted claim form 
indicates the laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical 
documentation and/or claim history indicates that the specimen was obtained in an office setting POS 11; 
therefore, the billed code cannot be verified. It is noted multiple attempts were made to obtain additional 
information from the provider. Therefore, we decided that the Plan does not have to pay for the laboratory 
services (CPT code(s): 83036, 84439, 84443, 84480, 84481, 85025) provided on March 4, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81206, 81301, 81311) provided May 10, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 81206, 81301, & 81311 are not supported in the medical record. Specifically, multiple 
unbundled codes were billed for a single genetic panel. Based on this information, we decided that Medicare 
rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to 
pay for lab services (81206, 81301, 81311) provided May 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99203) provided on July 14, 2021, by an outof-
network (OON) provider.
You asked the Plan to pay for an office visit. You say that authorization is not required for an office visit. The
Plan denied your request. The Plan says the unauthorized services rendered were by a non-participating
provider. The Plan also says that it was determined that the services received were not urgent/emergent, and the
member does not have out of network coverage for services determined to be non-urgent/emergent.
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 an office visit (99203) provided on July 14, 2021,
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office or other outpatient visit for the evaluation and management of an established patient (CPT code 99213-25) provided to the enrollee on September 16, 2021.
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. The Plan says the service is not supported.
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.
Medicare guidance says the evaluation and management (E/M) service must be a significant, separately identifiable E/M service that is above and beyond the usual pre-, intra- and post-operative work of the osteopathic manipulation. The provider reported an E/M with an osteopathic manipulation code, which does not follow industry standard coding rules. The CMS Physician Fee Schedule designates that Osteopathic Manipulative Treatment (OMT) codes have a global period of 000. (CMS-PFS). The documentation submitted did not indicate that a different anatomical site, a different condition or a related but unusual condition was addressed during the osteopathic manipulation visit. Therefore, we decided that the Plan does not have to pay for the office or other outpatient visit for the evaluation and management of an established patient (CPT code 99213-25) provided to the enrollee on September 16, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care admission. 
 
You asked the Plan to pre-approve acute inpatient hospital care admission. You say that requested inpatient 
admission is medically necessary. The Plan denied your request. The Plan says requested inpatient admission 
does not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
 
 
 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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this 
case. Our physician reviewer found the provided records did show the enrollee as having a recent ECHO 
showing moderate to severe mitral valve prolapse with moderate to severe regurgitation and the enrollee has 
reported chronic dyspnea that has not changed significantly. As the enrollee does not appear to be clinically 
severe enough to justify this procedure, it would not be expected that the enrollee would require hospital 
services that would cross 2 midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care admission.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous intraoperative neuromonitoring rendered on 
March 1, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. The provider submitted a claim for procedure codes G0453 and 95955. Code G0453 is a column II code with a 
modifier indicator of 1 when billed with column I code 95955. Code G0453 was not billed with an appropriate 
modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the 
continuous intraoperative neuromonitoring rendered on March 1, 2021.