Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for general anesthesia (D9222, D9223) provided on March 7, 2022. 
 
You asked the Plan to pay for anesthesia. You say that you cannot afford to pay to be put to sleep each time 
you need to have a tooth removed. The Plan denied your request. The Plan says general anesthesia (D9222, 
D9223) 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 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 general 
anesthesia (D9222, D9223) provided on March 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal scaling and root planing (D4341) provided on 
January 7, 2021, periodontal scaling and root planing (D4341) provided on February 11, 2021, prophylaxis 
(D1110) and periodic oral evaluation (D0120) provided on June 8, 2021, and prophylaxis (D1110), periodic 
oral evaluation (D0120), and resin-based composite filling (D2330) provided on November 23, 2021. 
 
You asked the Plan to pay for periodontal scaling, prophylaxis, evaluations, and a filing. You say that your 
policy should cover preventive care services. The Plan denied your request. The Plan says you do not have 
non-Medicare covered dental benefits. 
 
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 periodontal scaling and root 
planing (D4341) provided on January 7, 2021, periodontal scaling and root planing (D4341) provided on 
February 11, 2021, prophylaxis (D1110) and periodic oral evaluation (D0120) provided on June 8, 2021, and 
prophylaxis (D1110), periodic oral evaluation (D0120), and resin-based composite filling (D2330) provided on 
November 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services provided on November 11, 2021. 
 You asked the Plan to pay for the genetic testing services. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says this claim has not been billed in 
accordance with 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. 
 
We looked at the file and Medicare rules. In this case, the services provided should have been billed as a single 
procedural service. Based on this information, we decided that Medicare rules for coverage of the genetic 
testing services have not been met. Therefore, we decided that the Plan does not have to pay for the genetic 
testing services provided on November 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral - complete series of radiographic images 
(D0210) and comprehensive oral evaluation - new or established patient (D0150) provided March 14, 2022. 
 
You asked the Plan to pay for the complete series of x-rays and comprehensive oral exam. You say that you 
believe you were only going to receive a standard cleaning. The Plan denied your request. The Plan says you 
have exceeded the frequency limit 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 Plans coverage rules apply in this case. The Plan covers the complete 
series of x-rays once every 5 calendar years and the comprehensive oral exam once every 3 calendar years. 
 
We looked at the file and Medicare rules. The Plan provided documentation showing that a comprehensive 
exam and panoramic x-rays were previously covered on January 8, 2020. Based on this information, we 
decided that the Plan's frequency limits for coverage of the complete series of x-rays and comprehensive oral 
exam have been exceeded. Therefore, we decided that the Plan does not have to pay for the intraoral - complete series of radiographic images (D0210) and comprehensive oral evaluation - new or established patient (D0150) 
provided March 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for moderate sedation services (99153) provided on September 
16, 2021. 
 
You asked the Plan to pay for moderate sedation services (99153). You say that the medical records support the 
denied charges. The Plan denied your request. The Plan says CPT code 99153 may not be paid if furnished to a 
hospital inpatients or patients in a hospital outpatient department.  The Plan must follow Medicare rules. Medicare 
rules say that carriers may not pay for the technical component (TC) of radiology services furnished to hospital patients.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of moderate sedation services (99153) have not been met. CPT code 99153 is a TC only code. The 
technical component will not be paid to the physician when performed in a facility setting. This means that 
payment for this service is the responsibility of the facility to any vendor. Therefore, we decided that the Plan 
does not have to pay for moderate sedation services (99153) provided on September 16, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for molecular pathology testing provided March 14, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you request reconsideration of this 
determination and coverage of the Tempus Gene Panel test at the in-network benefit level. The Plan denied 
your request. The Plan says does not meet Medicare NCD/LCD criteria. 
 
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 find that CPT code 81206, 81292, 81311, 81162 and 81301 is not supported in the medical 
record. Specifically, Medicare denies coverage when a laboratory assays two or more genes in a patient in 
parallel. Those two or more genes will be considered part of the same panel. A panel constitutes a single 
procedural service, so one CPT code must be submitted for the panel. Based on this information, we decided 
that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the 
Plan does not have to pay for molecular pathology testing provided March 14, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nursing care in the home (S9123). 
 
You asked the Plan to pre-approve nursing care in the home. The Plan denied your request. The Plan says the 
provider is not Medicare certified. 
 
The Plan must follow Medicare rules. Medicare rules say that to receive payment for covered Medicare items 
or services, a provider or supplier must be enrolled in the Medicare program. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of nursing care in the home have not been met. This provider is not part of the Medicare program and 
is not payable. Therefore, we decided that the Plan does not have to pre-approve nursing care in the home 
(S9123).
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for porcelain/ceramic crowns (D2740) for tooth #28 and #29 received on 
January 12, 2022. 
 
You asked the Plan to pay for the services. You say that this was the least costly (two visits, instead of four) 
and most convenient method of treatment. The Plan denied your request. The Plan says that benefits have been 
paid on the least costly method of treatment. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Our Maximus dental reviewer found that the request was for two crowns, on 
one #28 and one on #29.  There were no x-rays provided with the records for review. The claim information 
indicated there was extensive prior restoration of the teeth and that 80% of the tooth was restored such that a 
crown would be the more appropriate restoration.  The Plan has not provided any medical records as to dispute 
the claim and support the original denial of the crowns. Given there are no records to dispute the request, the 
denial must be overturned and the crowns allowed as meeting criteria. Therefore, we decided that the Plan has 
to pay for porcelain/ceramic crowns (D2740) for tooth #28 and #29 received on January 12, 2022.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital discharge day management (99239) provided on 
August 25, 2021. 
 
You asked the Plan to pay for hospital discharge day management (99239). You say that the service was 
medically necessary, and the attached medical records support the claim was originally billed. You say that the 
enrollee was in need of care and the claim should be reprocessed for payment. The Plan denied your request. 
The Plan says the submitted discharge summary does not support hospital discharge management of more than 
30 minutes 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 99239 is hospital discharge day management; more than 
30 minutes. 
 
We find that CPT code 99239 is not supported in the medical record. Specifically, the documentation does not 
support hospital discharge management services of more than 30 minutes as required by the CPT code billed. 
Based on this information, we decided that Medicare rules for coverage of hospital discharge day management 
(99239) have not been met. Therefore, we decided that the Plan does not have to pay for hospital discharge day 
management (99239) provided on August 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller with accessories (E2377, 
E2313, E2311) and power seat elevation feature (E2300). 
 
You asked the Plan to pre-approve power wheelchair accessories. You say that these accessories are medically 
necessary for operating the power wheelchair. The Plan denied your request. The Plan says the criteria for 
coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that an expandable controller is subject to the criteria 
listed in the Medicare rules section. Medicare rules say that a power seat elevation feature is statutorily non-
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 expandable controller. Our reviewer 
says that the medical records do not support the medical necessity of the expandable controller and accessories. 
Our physician reviewer found that you do not require a separate display (i.e., for alternate control devices), 
other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive 
control), or an attendant control. You have 3 power options of tilt, recline, and power elevating leg rests but the 
patient does not need to control the power options through a joystick. Your upper extremity strength and 
function support that the patient can control any power options through their own switches. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of power wheelchair accessories have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an expandable controller with accessories (E2377, E2313, E2311) and power 
seat elevation feature (E2300).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like to appeal the denial of the claim. The 
Plan denied your request. The Plan says the requested IRF care is not considered medically necessary. 
 
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 complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for kyphoplasty of a lumbar fracture after a fall. Medical problems are stable. There are no complex 
nursing or rehabilitation needs.  
 
The patient does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided in a different level of care. 
 
There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. 
 
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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve LTACH services. You say that LTACH admission is medically necessary as 
the care and services required by the enrollee exceeds the clinical capabilities of all lower levels of care in her 
geographical location. The Plan denied your request. The Plan says the enrollee is receiving appropriate 
inpatient care at the current hospital and can remain there until ready for discharge to a lower level of care such 
as at a skilled nursing facility. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where she is currently receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing coded 80053 and 82306 provided on 
August 17, 2021 
 
You asked the Plan to pay for the genetic testing. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says screening services with no relation to a 
medical diagnosis of disease for the health of the patient are not covered. The Plan must follow Medicare rules. 
Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary 
or carrier sufficient information to determine whether payment is due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the genetic testing coded 80053 and 
82306 provided on August 17, 2021, have been met. Specifically, no clinical records have been provided to 
determine whether the services were medically reasonable and necessary. Therefore, we decided that the Plan 
does not have to pay for the genetic testing coded 80053 and 82306 provided on August 17, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the deep sedation/general anesthesia-first 15 minutes 
(D9222), deep sedation/general anesthesia-each subsequent 15 minute increment (D9223), and the therapeutic 
parenteral drugs, two or more administrations, different medications (D9612) provided on April 6, 2022. 
 
You asked the Plan to pay for these items. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says these items are not a covered benefit under your 
contractual policy. 
 
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 items provided in this case are not 
among those covered under this benefit.  Therefore, we decided that the Plan does not have to pay for the deep sedation/general anesthesia-first 15 minutes (D9222), deep sedation/general anesthesia-each subsequent 
15 minute increment (D9223), and the therapeutic parenteral drugs, two or more administrations, 
different medications (D9612) provided on April 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (0202U) provided on December 12, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a covered 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that code 0202U is not covered.  
 
We looked at the file and Medicare rules. Per LCA A57338, the billed code, 0202U, is a non-covered code. 
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 the services (0202U) provided on December 12, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on December 13, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the coverage criteria are 
not met. 
 
The Plan must follow Medicare rules. Medicare rules say that if one laboratory procedure evaluates multiple 
genes using a next generation sequencing procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, ultianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis CPT code.  
 
We looked at the file and Medicare rules. In this case, the requested genetic testing was billed with multiple 
codes. Per Medicare rules, the testing should be reported with one unit of one CPT code. 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 genetic testing provided on December 13, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiovascular genetic testing provided on October 13, 
2021. 
 
You asked the Plan to pay for the cardiovascular genetic testing. 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 a covered 
benefit. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. Cardiovascular risk assessment panels are only 
covered for certain indications. 
 
While cardiovascular risk assessment panels are covered for certain indications, the file does not support that 
the enrollee met criteria for these services. This means that the testing at issue in this appeal was requested 
solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we 
decided that the Plan does not have to pay for the cardiovascular genetic testing provided on October 13, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Methotrexate. 
 
You asked the Plan to pre-approve Methotrexate. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested drug is not a covered benefit. 
 
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 Methotrexate.  
 
 
 
 
  
Benefits for Methotrexate may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.