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

 
We decided that the Plan does not have to pay for the BlephEx treatment provided on February 24, 2022. 
 
You asked the Plan to pay for the treatment. 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 treatment. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee has a diagnosis of bilateral Meibomian gland dysfunction (MGD) of the upper and 
lower eyelids. On November 17, 2021, the ophthalmologist recommended hot compresses followed by forceful 
lid squeezing, as well as fish oil daily. "If no improvement in 3 months, RTC to discuss procedural options of 
BlephEx, Meibomian gland probing, IPL, or lipiflow." No more recent medical records are identified. The available documentation in the case file does not support that the requested BlephEx treatment is medically 
reasonable and necessary for the enrollee in this case. 
 
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 treatment have not been met. Therefore, we decided that the Plan does not 
have to pay for the BlephEx treatment provided on February 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on January 22, 
2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says no payment is recognized for code 85060 furnished to hospital outpatients or non-hospital 
patients. 
 
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 85060 is "Blood smear, peripheral, interpretation by 
physician with written report." 
 
We find that CPT code 85060 is not supported in the medical record. Specifically, this code cannot be billed for 
outpatient claims. Based on this information, we decided that Medicare rules for coverage of the services have 
not been met.  
 
 
 
 
  
Therefore, we decided that the Plan does not have to pay for laboratory services provided to the enrollee on 
January 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the removal of an impacted tooth-partially bony for 
tooth number 32 (D7230) and the removal of an impacted tooth-soft tissue for tooth number 17 (D7220). 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plans denial. The Plan denied your request. The Plan says these services are not a covered benefit under the 
enrollees contractual policy.  
 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 services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the removal 
of an impacted tooth-partially bony for tooth number 32 (D7230) and the removal of an impacted tooth-soft 
tissue for tooth number 17 (D7220).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infusion services rendered on October 18, 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 procedure codes are not supported. 
 
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 J3490 is unclassified drugs. The definition of code J7999 
is compounded drug, not otherwise classified. 
 
We find that CPT codes J3490 and J7999 are not supported in the medical record. Specifically, the records 
show that a nutria-pharmaceutical blend was administered and each component cannot be billed separately. 
Based on this information, we decided that Medicare rules for coverage of these services have not been met. 
Therefore, we decided that the Plan does not have to pay for the infusion services rendered on October 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an out-of-network provider on 
March 1, 2022. 
 
You asked the Plan to pay for dental services. You say that you were never told that this dentist was 
temporarily out-of-network. The Plan denied your request. The Plan says services provided by an out-of-
network provider 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. The Plan covers covered 
dental services when the services are provided by an in-network provider.  
 
We looked at the file and Medicare rules. 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 pay for 
dental services provided by an out-of-network provider on March 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (83970, 82310, and 84100) provided 
on December 8, 2021. 
 
You asked the Plan to pay for the laboratory services. 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. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the laboratory services (83970, 82310, and 84100) provided on December 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal scaling (D4341), gingival irrigation (D4921), and 
medicaments dispensed in the office (D9630) provided on December 29, 2021. 
 
You asked the Plan to pay for periodontal scaling, gingival irrigation, and medicaments. You say that these are 
covered dental services. The Plan denied your request. The Plan says periodontal scaling (D4341), gingival 
irrigation (D4921), and medicaments dispensed in the office (D9630) are not covered by your supplemental 
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 pay for 
periodontal scaling (D4341), gingival irrigation (D4921), and medicaments dispensed in the office (D9630) 
provided on December 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for panoramic imaging (D0330) and the re-cement of post and 
core (D2915), provided by a participating provider on January 4, 2022, to January 20, 2022. 
 
You asked the Plan to pay for panoramic imaging and the re-cement of post and core. You say that you would 
like the Plan to reprocess and pay these services. The Plan denied your request. The Plan says the services 
being appealed have been 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. The Plan covers panoramic 
imaging and the re-cement of post and core when the services are medically necessary and reasonable.  
 
We looked at the file and Medicare rules. Evidence was provided to show that D0330 was previously provided 
on February 14, 2019. Based on this information, we decided that the Plan's rules for coverage of panoramic 
imaging have not been met. D2915 is not a covered dental benefit. Therefore, we decided that the Plan does not 
have to pay for panoramic imaging (D0330) and the re-cement of post and core (D2915), provided by a 
participating provider on January 4, 2022, to January 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on 
December 6, 2018, and closed mandible reduction (D7640), deep sedation (D9223), and therapeutic parenteral 
(D9610) provided on December 13, 2018. 
 
You asked the Plan to pay for an evaluation, reduction, sedation, and therapeutic parenteral. You say that you 
thought the provider was in-network and the services were medically necessary. The Plan denied your request. 
The Plan says this provider has opted out of Medicare and is not eligible for payment. 
 The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided by a provider who has opted out of the Medicare program. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) 
provided on December 6, 2018, and closed mandible reduction (D7640), deep sedation (D9223), and 
therapeutic parenteral (D9610) provided on December 13, 2018.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve clinical crown lengthening (D4249). 
 
You asked the Plan to pre-approve the dental service. You say that you have already had the root canal 
procedure done on this tooth. You say that your previous plan would have covered this procedure. You say that 
you have had issues getting an appointment due to the pandemic. You also say that you do not want to lose this 
tooth. The Plan denied your request. The Plan says clinical crown lengthening is not listed as a covered service. 
 
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 clinical crown 
lengthening is not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pre-approve clinical crown lengthening (D4249).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on August 3, 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 were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.  
 
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and 
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on August 3, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing (code 81291) provided on October 5, 2021. 
 
You asked the Plan to pay for the genetic testing. The Plan denied your request. The Plan says modifier -GZ 
indicates a service is not reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that claim line items submitted with a -GZ modifier 
shall automatically be denied.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the genetic testing have not been met. Specifically, claim line items submitted with a -GZ modifier 
are automatically denied. Therefore, we decided that the Plan does not have to pay for the genetic testing (code 
81291) provided on October 5, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the immunohistochemistry or immunocytochemistry, per 
specimen coded 88341 provided on April 27, 2021. 
 
You asked the Plan to pay for the immunohistochemistry or immunocytochemistry, per specimen. You say that 
you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services 
rendered are not separately payable.  
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 the 
immunohistochemistry or immunocytochemistry, per specimen is an add-on code and has not been billed with 
an appropriate primary procedure code. 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 immunohistochemistry or 
immunocytochemistry, per specimen coded 88341 provided on April 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept intraosseous basivertebral nerve ablation 
procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this is a necessary procedure for those 
with back pain who do not get relief from conservative measures but do not meet criteria for spinal fusion. The 
Plan denied your request. The Plan says this procedure is experimental at this time. 
 
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 Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Intracept procedure is experimental. More research is needed. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept intraosseous basivertebral nerve ablation procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an additional periapical x-ray (D0230) provided on 
December 2, 2021. 
 
You asked the Plan to pay for an x-ray. You say that the dentist office never told you what services were going 
to be performed. The Plan denied your request. The Plan says this service is covered by the Plan's dental 
benefits; however, your benefit for one periapical x-ray every three years has 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. The Plan covers one periapical 
x-ray every three years. 
 
We looked at this case file, the Plans rules, and Medicare rules. The record shows the Plan paid for a 
periapical x-ray on December 2, 2021; therefore, the benefit for a periapical x-ray has been exhausted. 
Therefore, we decided that the Plan does not have to pay for an additional periapical x-ray (D0230) provided 
on December 2, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injection services. 
 
You asked the Plan to pre-approve facet joint injection services. You say that the first injection helped. You say 
that you can hardly walk and are having issues getting out of bed. The Plan denied your request. The Plan says 
the request is not medically necessary because the records show that the enrollee is currently under good pain 
control with the medications and treatments that have happened so far. 
 
The Plan follows Medicare rules. Medicare rules say that facet joint interventions are covered when considered 
medically reasonable and necessary and for certain clinical indications.  
 
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 facet joint injection services. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found there is no 
documentation indicating that the enrollee's pain has been present for minimum of 3 months with documented 
failure to respond to non-invasive/conservative management (as tolerated). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of facet joint injection services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve facet joint injection services.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services (99285) provided December 19, 
2021. 
 
You asked the Plan to pay for the emergency room services. You say that this service was medically necessary. 
The Plan denied your request. The Plan says the billed code is not separately payable. 
 
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 code 99285 is not supported in the medical record. Specifically, the billed code is mutually 
exclusive to another code billed and is not separately payable. Based on this information, we decided that 
Medicare rules for coverage of the emergency room services have not been met.  
 
 
 
 
 
  
 
Therefore, we decided that the Plan does not have to pay for emergency room services (99285) provided 
December 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a negative pressure wound pump. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says you do 
not have a documented need for accelerated formation of granulation tissue. 
 
The Plan follows Medicare rules. Medicare rules say that negative pressure wound therapy pumps are only 
covered under certain medical indications.  
 
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 requested services. Our physician 
reviewer found that the enrollee has a surgical wound of the abdomen, which is healing with healthy tissue 
throughout. The records do not show that there is a medical necessity for accelerated formation of granulation 
tissue which cannot be achieved by other available topical wound treatments. The review has determined that 
the records do not show that the requested treatment is indicated for the enrollee's condition. 
 
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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a negative pressure wound pump.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the culture coded 87150 and the infectious agent detection by 
nucleic acid coded 87641 provided on September 20, 2021. 
 You asked the Plan to pay for the culture and the infectious agent detection by nucleic acid. You say that you 
would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed 
are not separately payable. 
 
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 87150 
is a column II code to column I code 87500. We have confirmed that code 87641 is a column II code to column 
I code 87150.  
 
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 
culture coded 87150 and the infectious agent detection by nucleic acid coded 87641 provided on September 20, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Percutaneous transcatheter placement of intracoronary 
stent(s) (92929) provided on September 20, 2021. 
 You asked the Plan to pay for code 92929. 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. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 92929 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 92929 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of code 92929 have not been met. Therefore, we decided that the Plan does not have to pay for the 
Percutaneous transcatheter placement of intracoronary stent(s) (92929) provided on September 20, 2021.