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

 
We decided that the Plan does not have to pay for procedure code 51600 billed for date of service December 
13, 2021. 
 
You asked the Plan to pay for procedure code 51600. You say that the medical records support billing of this 
code. The Plan denied your request. The Plan says procedure code 51600 is not supported in the medical 
record. The submitted record does not include a procedure note to support the injection procedure for 
cystography or voiding urethrocystography was performed. 
 
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 51600 is Injection procedure for cystography or voiding 
urethrocystography. 
 
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 procedure code 51600. Our reviewer says that procedure code 51600 is not supported in the medical record. Our reviewer found the documentation submitted does not 
include documentation of the injection procedure. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 51600 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 51600 billed for date of service December 13, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) Scan - soft tissue neck; 
without contrast material (70490) 
 
You asked the Plan to pre-approve a CT scan of the neck. You say that you have trouble swallowing and a neck 
CT scan would further analyze the issue. The Plan denied your request. The Plan says the CT scan is not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
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 CT scan of the neck. Our reviewer 
says that a CT scan is not medically necessary. Our physician reviewer found that the documentation in the 
case file is notable for an incomplete evaluation of your medical problems. It cannot be determined that a CT 
scan of the neck is medically reasonable and necessary until the results of the previous imaging are available. 
 
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 CT scan of the neck have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a computed tomography (CT) Scan - soft tissue neck; without contrast material 
(70490)
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prophylaxis (D1110) provided on February 7, 2022. 
 
You asked the Plan to pay for the prophylaxis. You say that your understanding is that 1 cleaning is covered 
every 6 months, or in practicality no more than 2 cleanings per year would be covered. You also say that you 
are wondering why your first cleaning of the year would not be covered. The Plan denied your request. The 
Plan says this service exceeds the frequency limitation in your benefit plan. The Plan also says that your dentist 
did not provide any reasons why a dental cleaning was performed sooner than what was listed in your Evidence 
of Coverage. 
 
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, prophylaxis (D1110) is limited to 1 
visit every 6 months. The record shows that you received a prophylaxis (D1110) on November 5, 2021 and 
your prophylaxis (D1110) benefit had been exhausted. Therefore, we decided that the Plan does not have to pay 
for the prophylaxis (D1110) provided on February 7, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that skilled nursing facility care is medically necessary. 
The Plan denied your request. The Plan says you do not meet criteria for coverage of a skilled nursing facility 
admission. 
 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 
skilled nursing facility care is not medically necessary. Our physician reviewer found that you do not require 
skilled nursing or skilled therapy services on a daily basis. Additionally, as a practical matter, you do not meet 
severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 
 
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 inpatient skilled nursing facility (SNF) care.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Procrit. 
 
You asked the Plan to pre-approve Procrit. You say that the requested Procrit is medically necessary. The Plan 
denied your request. The Plan says the Plan was unable to make a determination within the allotted time frame. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Procrit. Our reviewer says that the 
requested Procrit is not medically necessary. Our physician reviewer found the record indicates that the 
enrollee has a diagnosis of anemia in the setting of stage IV renal disease. The record indicates that the enrollee 
has iron deficiency, an elevated reticulocyte count and an above normal erythropoietin level although not being 
on the medication. The Food and Drug Administration has stated that the requested drug is indicated for the 
enrollee's condition. The record provided does not support the medical necessity of the requested service at this 
time. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Procrit have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Procrit.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pancreatic elastase coded 82656 and the immunoassay 
services coded 83520 provided on February 14, 2021. 
 
You asked the Plan to pay for the pancreatic elastase and the immunoassay services. You say that you would 
like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable 
as billed. 
 The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the pancreatic elastase and the immunoassay services have not been met. Specifically, this claim 
was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory 
setting. Therefore, we decided that the Plan does not have to pay for the pancreatic elastase coded 82656 and 
the immunoassay services coded 83520 provided on February 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a guided tissue regeneration (D4266), a bone 
replacement graft (D7953 and D4263), and gingival flap procedure (D4241), provided by a participating 
provider. 
 
You asked the Plan to pre-approve a guided tissue regeneration, a bone replacement graft, and gingival flap 
procedure. You say that you would like the Plan to pay for this. The Plan denied your request. The Plan says 
the requested dental services are not covered 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 
guided tissue regeneration (D4266), a bone replacement graft (D7953 and D4263), and gingival flap procedure 
(D4241), provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services provided by a participating provider. 
 
You asked the Plan to pre-approve dental services. You say that you feel like the Plan should pay for this. The 
Plan denied your request. The Plan says the maximum benefit allowance amount for dental services has been 
met. 
 
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 dental 
services up to a $2,000 maximum benefit allowance. 
 
We looked at the file and Medicare rules. The requested services will max out the remaining dental maximum 
allowance amount; therefore, anything over $2,000 is not covered by the Plan. Based on this information, we 
decided that the Plan's rules for coverage of dental services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve dental services provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary implant/abutment supported removable 
denture for edentulous arch (D6110) and a mandibular implant/abutment supported removable denture for 
edentulous arch (D6111). 
 
You asked the Plan to pre-approve the implant/abutment supported removable dentures. The Plan denied your 
request. The Plan says these services are allowed one time in 5 calendar years. The Plan also says that you have 
already received these services within the past 5 years and have reached the limits for these services. 
 
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, maxillary dentures and mandibular 
dentures are each limited to 1 per 5 calendar years. The record shows that the enrollee received a complete 
maxillary denture (D5110) and a complete mandibular denture (D5120) on March 19, 2019 and the enrollee's 
maxillary and mandibular denture benefits have been exhausted. Therefore, we decided that the Plan does not 
have to pre-approve a maxillary implant/abutment supported removable denture for edentulous arch (D6110) 
and a mandibular implant/abutment supported removable denture for edentulous arch (D6111).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composite (D2331) on tooth #10 provided on 
January 27, 2022. 
 
You asked the Plan to pay for the resin-based composite. You say that tooth #10 was filled on two different 
sides of the tooth. You also say that you are confused because your yearly dental allowance is $2,000. The Plan 
denied your request. The Plan says your benefit maximum has been met. 
 
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, resin-based composite (D2331) is 
limited to 1 per tooth every year. The record shows that you received two resin-based composites (D2331 x2) 
on tooth #10 on January 27, 2022, one of which was covered by the Plan, and your resin-based composite 
(D2331) benefit for tooth #10 has been exhausted. Therefore, we decided that the Plan does not have to pay for 
the resin-based composite (D2331) on tooth #10 provided on January 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cone beam computed tomography (CT) capture and 
interpretation (D0364) and consultation (D9310) provided on December 21, 2021. 
 
You asked the Plan to pay for the cone beam CT capture and interpretation and consultation. You say that you 
previously had a root canal that needed retreatment and your dentist recommended you see an endodontist. You 
also say that the endodontist did an x-ray and evaluation, and you could not have had the retreatment without 
these services. The Plan denied your request. The Plan says these services are not covered benefits under your 
dental plan. 
 
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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the cone 
beam computed tomography (CT) capture and interpretation (D0364) and consultation (D9310) provided on 
December 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance (D4910) provided by a network 
provider on September 22, 2021. 
 
You asked the Plan to pay for the periodontal maintenance (D4910). You say that the periodontal maintenance 
qualifies for 100% coverage under your preventive coverage. The Plan denied your request. The Plan says the 
treatment of gums and bones supporting teeth and periodontal cleaning in the presence of inflamed gums is 
considered a basic service, and that the service was covered. 
 
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 rules say a plan 
must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 30% 
coinsurance for periodontics after you pay the $100 deductible. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the periodontal maintenance (D4910) 
is among those covered under this benefit. The record shows the periodontal maintenance (D4910) is 
considered a comprehensive service and you have been charged the correct cost sharing amount. See chart 
below. 
 
Date of Service Service Allowed Amount Deductible/ 
Coinsurance 
Member Liability 
September 22, 2021 Periodontal 
maintenance 
(D4910) 
$83.00 $100 $17 - This was the 
amount applied to 
your deductible. 
  $66.00 - This is the 
remaining allowed 
amount after the 
applied deductible 
30% $19.80 
Total    $36.80 
 
Therefore, we decided that the Plan does not have to pay for periodontal maintenance (D4910) provided by a 
network provider on September 22, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pharmacy compounding and dispensing services coded 
S9430 provided on November 16, 2021. 
 
You asked the Plan to pay for the pharmacy compounding and dispensing services. You say that you would 
like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable 
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 S9430 is pharmacy compounding and dispensing 
services. 
 
We find that CPT code S9430 is not supported in the medical record. Specifically, this code has a status code 
of "I". This means this code is not valid for Medicare purposes. Medicare uses another code for reporting and 
payment of these services. Based on this information, we decided that Medicare rules for coverage of the 
pharmacy compounding and dispensing services have not been met.  
 Therefore, we decided that the Plan does not have to pay for the pharmacy compounding and dispensing 
services coded S9430 provided on November 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the BinaxNow COVID-19 antigen self-test (A9900) 
purchased on January 15, 2022. 
 
You asked the Plan to pay for the COVID-19 self-test. You say that you were being possibly exposed to the 
transmission of the disease on a daily basis being around your grandkids and daughter. So out of the abundance 
of caution you purchased 3 tests so you can test at home The Plan denied your request. The Plan says testing is 
covered when medically necessary and ordered by a physician. 
 
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. 
 
In this case, you purchased the tests out of precaution. The tests were not ordered by a physician or medically 
necessary. The Plan did not pre-approve the item/service at issue.  Medicare does not pay for OTC items and 
the COVID-19 self-tests is an OTC item. 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 BinaxNow COVID-19 antigen 
self-test (A9900) purchased on January 15, 2022.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that the requested Prolia is medically necessary. The Plan 
denied your request. The Plan says that the enrollee must try and fail Zoledronic acid first. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Prolia. Our reviewer says that the 
requested Prolia is medically necessary. Our physician reviewer found based on the documentation provided, 
the enrollee has been using the requested drug since December 2021.  As such, the health plan cannot apply 
step-therapy restrictions. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have been met. Therefore, we decided that the Plan has to pre-approve 
Prolia.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Mycophenolate mofetil. 
 
You asked the Plan to pre-approve this drug. You say that this is medically necessary for the treatment of the 
enrollee's bullous pemphigoid. The Plan denied your request. The Plan says that this is not covered under Part 
B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Mycophenolate mofetil.  
 
Benefits for this drug 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CancerTYPE ID test provided on February 26, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee is an 84-year-old female with cervical cancer. She also has a history of stage IV colon 
cancer with right cecal segmental resection grade II cecal adenocarcinoma. The enrollee has no history of 
breast cancer. CancerTYPE ID is a standardized, objective molecular test based on the differential expression 
of 92 genes that classifies tumors by comparing the gene expression in a patient's tumor tissue to a database of 50 known tumor types and subtypes. The gene test ordered far exceeds what is necessary for the enrollee's case. 
The requested test is not 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 the testing have not been met. Therefore, we decided that the Plan does not have 
to pay for the CancerTYPE ID test provided on February 26, 2021.