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

 
We decided that the Plan does not have to pre-approve a cardioMEMS system. 
 
You asked the Plan to pre-approve a cardioMEMS system. You say that the requested device is medically 
necessary due to your worsening heart failure. The Plan denied your request. The Plan says the CardioMEMS 
device has been determined to be of uncertain value as it carries a risk of significant complications including 
death and severe pulmonary artery injury. 
 
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 a cardioMEMS system. Our reviewer 
says that a cardioMEMS system is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there remains a dearth of randomized, blinded clinical studies examining long-term 
clinical outcomes establishing the value of CardioMEMS in patient 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 a cardioMEMS system have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a cardioMEMS system.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a surgical extraction (D7210) provided by a participating 
provider on January 5, 2022. 
 
You asked the Plan to pay for a surgical extraction. You say that this was not a surgical extraction. The Plan 
denied your request. The Plan says this service has been correctly denied. 
 
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. The extraction that was provided was surgical in nature. Therefore, we 
decided that the Plan does not have to pay for a surgical extraction (D7210) provided by a participating 
provider on January 5, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 29, 2021, billed with 
codes 81238, 81226, 81335, 81230, 81241, 81291, and 81240. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
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 
June 29, 2021, billed with codes 81238, 81226, 81335, 81230, 81241, 81291, and 81240.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), intraoral-periapical 
first radiographic image (D0220), intraoral-periapical additional radiographic image (D0230 x 4), bitewing  
x-rays-four radiographic images ( D0274 x 4), and the dental cleaning (D1110) provided on March 2, 2021. 
 
You asked the Plan to pay for these 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 services at issue are not payable as the 
claim was submitted untimely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for these services was not filed until March 29, 2022. This means that more than 
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the 
Plan does not have to pay for the periodic oral evaluation (D0120), intraoral-periapical first radiographic image 
(D0220), intraoral-periapical additional radiographic image (D0230 x 4), bitewing x-rays-four radiographic 
images (D0274 x 4), and the dental cleaning (D1110) provided on March 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64405 billed for date of service September 
29, 2021. 
 
You asked the Plan to pay for procedure code 64405. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 64405 is bundled into payment for code 20610. 
 
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 64405 
is a column II code to column I code 20610. 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 64405 billed for date of service September 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more toward the immediate mandibular denture (D5140), the 
immediate maxillary denture (D5130) and the extractions of erupted teeth (D7140) provided on April 5, 2022. 
 
You asked the Plan to pay more toward the immediate mandibular denture (D5140), the immediate maxillary 
denture (D5130) and the extractions of erupted teeth (D7140). You say that the Plan did not pay as much as 
you thought they would. You also say that you are on a fixed income. The Plan denied your request. The Plan 
says dental services cannot be covered under the medical benefit and the claim processed correctly. 
 
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 Plan is only obligated to pay 20% 
of the cost for the extractions of erupted teeth. The Plan is not obligated to pay for the immediate mandibular 
denture and the immediate maxillary denture as it is not listed as a covered benefit. Therefore, we decided that 
the Plan does not have to pay more toward the immediate mandibular denture (D5140), the immediate 
maxillary denture (D5130) and the extractions of erupted teeth (D7140) provided on April 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that the services are necessary. The Plan denied 
your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found a home ventilator is not medically 
necessary. This enrollee has severe chronic obstructive pulmonary disease (COPD) with recent exacerbations.  
There was mild elevation of the partial pressure of carbon dioxide (PaCO2) during a recent hospitalization. The 
enrollee benefitted from bilevel positive airway pressure (BiPAP) in the hospital. There is no documentation of 
chronic carbon dioxide retention on an arterial blood gas (ABG) done while stable as an outpatient. If the enrollee does have chronic CO2 retention, she may benefit from BiPAP with average volume-assured pressure 
support (AVAPS) mode during sleep. But Medicare does not cover a home ventilator when used as BiPAP. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 83789 billed for date of service March 23, 2022. 
 
You asked the Plan to pay for code 83789. You say that these services were reasonable and necessary. The Plan 
denied your request. The Plan says this service is not separately payable as it is considered specimen validity 
testing and was provided in addition to other laboratory tests on the same specimen. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by the billed code is 
considered specimen validity testing which is not separately payable. Therefore, we decided that the Plan does 
not have to pay for procedure code 83789 billed for date of service March 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an extraction (D7210) and a bone replacement graft (D7953) 
provided on January 14, 2022. 
 
You asked the Plan to pay for the dental services. You say that it was medically necessary to get the dental 
procedures done. The Plan denied your request. The Plan says the dental services were received from an out-of-
network provider and are not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for an extraction (D7210) and a bone replacement graft (D7953) provided on January 14, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the enrollee can 
safely receive services in a less intensive setting. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee's medical problems are stable and there are no complex nursing or 
rehabilitation needs. There is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve OsteoAmp allograft. 
 
You asked the Plan to pre-approve OsteoAmp allograft. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 OsteoAmp allograft. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is insufficient evidence in the peer-reviewed medical literature to support that 
the Osteoamp allograft is medically reasonable and 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 OsteoAmp allograft have not been met. Therefore, we decided that the Plan 
does not have to pre-approve OsteoAmp allograft.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for procedure code 84480 billed for date of service December 
17, 2021. 
 
You asked the Plan to pay for procedure code 84480. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 84480 is bundled into payment for code 84481. 
 
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 84480 
is a column II code to column I code 84481. 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 84480 billed for date of service December 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral imaging (D0210) provided by a participating 
provider on May 17, 2022. 
 
You asked the Plan to pay for intraoral imaging. You say that you would like the Plan to pay for this. The Plan 
denied your request. The Plan says D0210 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. 
 
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 intraoral 
imaging (D0210) provided by a participating provider on May 17, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional four physical therapy (PT) sessions. 
 
You asked the Plan to pre-approve the additional PT sessions. You say that you feel that you still need PT 
services. The Plan denied your request. The Plan says the request is not medically necessary as sufficient visits 
have been approved and your condition is stable. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 additional PT sessions. Our 
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration 
of the enrollee's condition. Our physician reviewer found the manual therapy is not distinguished from massage which is not a unique skill from therapists. The record does not include objective measures of response to 
therapy 
 
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 additional PT sessions have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an additional four physical therapy (PT) sessions.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that it is felt that SNF care is needed. The Plan denied 
your request. The Plan says the enrollee does not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee was admitted on August 31, 2022, for a left hip replacement. Physical 
therapy recommended acute rehabilitation, but the enrollee is refusing rehab and wants to return home. The 
enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled 
therapy needs. The enrollee is ambulating more than 100 feet and tending to daily living activities with 
minimal supervision. The enrollees care needs are custodial and intermittent and can, as a practical matter, be 
provided at a lower level of care 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an extraction of erupted tooth number 18 (D2710), and an 
extraction of an erupted tooth number 10 and tooth number 13 (D7140) provided on April 1, 2022. 
 
You asked the Plan to pay for the dental services. You say that you called your agent to verify that this provider 
accepted your dental coverage. The Plan denied your request. The Plan says the dental services were received 
from an out-of-network provider and are not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for an extraction of erupted tooth number 18 (D2710), and an extraction of an erupted tooth number 10 
and tooth number 13 (D7140) provided on April 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pontics on tooth #4 and 5 (D6245). 
 
You asked the Plan to pre-approve pontics. You say that these services are medically necessary. The Plan 
denied your request. The Plan says pontics (D6245) are not covered by your 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 pre-approve 
pontics on tooth #4 and 5 (D6245).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a gingivectomy on tooth #28 (D4211). 
 
You asked the Plan to pre-approve a gingivectomy. You say that you need to have the growth removed. The 
Plan denied your request. The Plan says gingivectomy (D4211) is not covered by your 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 pre-approve a 
gingivectomy on tooth #28 (D4211).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on February 16, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services provided by an OON provider. You say that you would 
like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services 
provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network 
care. 
 
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 the laboratory services provided on February 16, 
2022, by an out-of-network (OON) provider.