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

 
We decided that the Plan does not have to waive the coinsurance for resin-based composite fillings (D2391, 
D2392, D2393) provided on December 23, 2021. 
 
You asked the Plan to waive the coinsurance for the fillings. You say that you want a refund so you can start 
seeing a new dentist. The Plan denied your request. The Plan says you have been charged the correct cost 
sharing amount. 
 
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 20% 
coinsurance for restorative services, including fillings.  You have been asked to pay a total of $64.08, which is 20% coinsurance for each filling received on December 23, 2021. Fillings fall within the Dental Services benefit category.  
 
Code Allowed Amount 20% Coinsurance 
D2392 $109.13 $21.82 
D2393 $130.71 $26.14 
D2391 $80.61 $16.12 
Total  $64.08 
 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the coinsurance for resin-based composite fillings (D2391, D2392, D2393) 
provided on December 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), prophylaxis (D1110), 
and bitewing x-rays (D0274) provided on May 17, 2022. 
 
You asked the Plan to pay for the dental services. You say that switching dentists would be detrimental to your 
mental health. 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 a periodic oral evaluation (D0120), prophylaxis (D1110), and bitewing x-rays (D0274) provided on 
May 17, 2022.
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 the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 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 you have stabilized medically and are ready for discharge from the hospital.  You do 
not require skilled nursing and/or skilled therapy services on a daily basis. You do not have any parental 
medication; complex wound care or nutrition given via a feeding tube. You are medically stable without any 
acute exacerbations of chronic medical problems. Your physical function is at or near your baseline. Although 
further rehab services would be appropriate to improve function, as a practical matter, the intermittent skilled 
services can be provided at a lower level of care than a skilled nursing facility. 
 
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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 99152 billed for date of service September 17, 2021. 
 
You asked the Plan to pay for procedure code 99152. You say that this code should be paid. The Plan denied 
your request. The Plan says that procedure codes 99213, 62323, 64483 and 72275 were overturned. The Plan 
also says procedure code 99152 remains denied as the medical records submitted do not include documentation 
of moderate sedation services. 
 
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 99152 is moderate sedation services provided by the same physician or other qualified health care 
professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence 
of an independent trained observer to assist in the monitoring of the patient's level of consciousness and 
physiological status; initial 15 minutes of intra-service time, patient age 5 years or older.  
 
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 99152. Our reviewer says that procedure 
code 99152 is supported in the medical record. Our reviewer found the medical documentation does support the 
use of procedure code 99153 as the patient received awake sedation for the procedures being performed and 
there was a total of 23 minutes of inter-service time with the provider. 
 
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 99152 have been met. Therefore, we decided that the Plan has 
to pay for procedure code 99152 billed for date of service September 17, 2021.  
 
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: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the Tempus xF liquid biopsy testing provided on April 5, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that this is medically necessary and should be paid. 
The Plan denied your request. The Plan says that the date of service was not reported as the date the specimen 
was collected as required. There is nothing to support the use of the reported DOS. 
 
The Plan must follow Medicare rules. Medicare rules say that the DOS for molecular pathology testing 
performed by a laboratory should be the date the testing was performed when the criteria listed in the Medicare 
rules section are met. 
 
We looked at the file and Medicare rules. This is a molecular pathology test and was performed following an 
outpatient hospital encounter in which the sample was appropriately collected. The results were not used to 
guide treatment during the encounter. The DOS was correctly reported as the date the testing was rendered. 
Based on this information, we decided that Medicare rules for coverage of the genetic testing have been met. 
Therefore, we decided that the Plan has to pay for the Tempus xF liquid biopsy testing provided on April 5, 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee orthosis (KO), single upright, thigh and calf, 
with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with 
or without varus/valgus adjustment, prefabricated item that has been trimmed, bent, molded, assembled, or 
otherwise customized to fit a specific patient by an individual with expertise (L1843). 
 
You asked the Plan to pre-approve a knee orthosis. You say that you are unable to walk. You need a knee 
brace. The Plan denied your request. The Plan says your request is not medically necessary because your 
records do not show that you have had a recent injury or surgery to your knee and the notes do not show that 
your knee is unstable on exam. 
 
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 knee orthosis. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the documentation does not reveal objective physical exam evidence of knee instability. There 
is no evidence of recent injury or surgery to the knees. You are documented to be ambulatory however the 
criteria for the requested knee orthosis have not been met, Medicare does not pay for any items or services that 
are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the 
functioning of a malformed body member. The requested orthosis exceeds your medical need at this time. The 
documentation does not reveal outcome of the 8/22/22 hyaluronan injection to the right knee. The knee brace 
customization form (undated) notes the justification is joint osteoarthrosis and joint laxity. There is no 
physician signature on this form. The physician documents do not support joint laxity on an objective exam. 
 
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 knee orthosis have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a knee orthosis (KO), single upright, thigh and calf, with adjustable flexion and extension 
joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, 
prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific 
patient by an individual with expertise (L1843).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481, 87640, 87641, 87651, 87653, and 
the multiple units of 87798 billed for date of service May 10, 2021. 
 
You asked the Plan to pay for procedure codes 87481, 87640, 87641, 87651, 87653, and the multiple units of 
87798. You say that this is correctly billed and should be paid. The Plan denied your request. The Plan says 
payment for codes 87481, 87640, 87641, 87651, 87653, and the multiple units of 87798 is bundled into 
payment for code 87801. 
 
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 codes 
87481, 87640, 87641, 87651, 87653, and the multiple units of 87798 are column II codes to column I code 
87801.  
 
Although these codes were billed with modifier -59, we find that this is not clinically appropriate. There is no 
evidence that these tests are considered separate or distinct as they were performed as part of a single panel. 
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 codes 87481, 87640, 87641, 87651, 87653, and the multiple units of 87798 
billed for date of service May 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the imaging interpretation provided on April 25, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the OON imaging interpretation. You say that you do not physically see the 
patient and cannot request referral to interpret the imaging ordered by the treating physician. The Plan denied 
your request. The Plan says the ordering provider is not in-network with the Plan and was not authorized. This 
was also not an emergency request. 
 
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, nor was the ordering provider. 
There is no evidence of emergency or urgently needed care. 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 imaging interpretation provided on April 25, 2022, by an out-
of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care (99309) provided on February 24, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the nursing facility care. You say that it is the responsibility of the hospital staff 
to obtain authorization. The Plan denied your request. The Plan says the services were provided out-of-network 
and were not approved in advance. 
  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 nursing facility care (99309) provided on 
February 24, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oncology (urothelial), mRNA, gene expression profiling by 
real-time quantitative PCR of five genes (MDK, HOXA13, CDC2, IGFBP5, and CXCR2), utilizing urine, 
algorithm reported as a risk score for having urothelial carcinoma (0012M) provided on October 12, 2021. 
 
You asked the Plan to pay for the CxBladder laboratory test. You say that the requested test is medically 
necessary. The Plan denied your request. The Plan says CxBladder Detect is not an approved test. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the CxBladder laboratory test have not been met. Specifically, the requested test is not an approved 
test and was reaffirmed by Medicare. Therefore, we decided that the Plan does not have to pay for oncology 
(urothelial), mRNA, gene expression profiling by real-time quantitative PCR of five genes (MDK, HOXA13, 
CDC2, IGFBP5, and CXCR2), utilizing urine, algorithm reported as a risk score for having urothelial 
carcinoma (0012M) provided on October 12, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous vertebral augmentation. 
 
You asked the Plan to pre-approve percutaneous vertebral augmentation. You say that the enrollee has 
increased pain and x-rays show T12 compression deformity. The Plan denied your request. The Plan says the 
records do not show that the enrollee has a fracture that is less than three months old.  
Medicare rules state that PVA is coverable for patients with acute and symptomatic vertebral compression 
fracture. 
 
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 percutaneous vertebral augmentation. 
Our reviewer says that PVA is not medically necessary for this patient. Our physician reviewer found that this 
58-year-old female was being treated for collapsed vertebra not elsewhere classified thoracic spine. She 
presented with low back pain that is continuous. The pain is sharp, aching, tingling, hot-burning, and throbbing. 
The pain radiates to the bilateral lower extremities. The current pain level is 4/10. The thoracic spine exam 
reveals atrophied and asymmetrical thoracic spine noted on inspection. There is tenderness noted at paraspinal 
muscle and facet joint lines. T12 tenderness is noted. There is evidence of crepitation noted in the thoracic 
spine. Hyperextension of the thoracic spine caused increased pain. Imaging is noted as above. However, 
detailed documentation is not evident regarding an acute or subacute osteoporotic vertebral compression 
fracture (VCF) at T1-L5 by recent (within 30 days) advanced imaging. The lumbar x-ray dated March 31, 
2022, noted the compression of T12 is of an indeterminate age. There were no other imaging studies provided. 
Therefore, the enrollee does not meet the LCD coverage criteria for a percutaneous vertebral augmentation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of percutaneous vertebral augmentation have not been met. Therefore, we decided 
that the Plan does not have to pre-approve percutaneous vertebral augmentation.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing (0037U) provided on March 31, 2022. 
 
You asked the Plan to pay for the genetic testing. 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 to report a Molecular Diagnostic Test service, the 
appropriate claim information must be submitted. 
 
We looked at the file and Medicare rules. In this case, the claim was submitted without an appropriate DEX Z-
Code as required by LCA A56853. 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 genetic testing 
(0037U) provided on March 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the extraction of tooth #31 (D7210) and deep sedation 
(D9222, D9223). 
 
You asked the Plan to pre-approve an extraction and sedation. You say that you disagree with the denial of 
dental services. The Plan denied your request. The Plan says an extraction (D7210) and deep sedation (D9222, 
D9223) 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 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 pre-approve the 
extraction of tooth #31 (D7210) and deep sedation (D9222, D9223).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Saxenda. 
 
You asked the Plan to pre-approve Saxenda. You say that you would like the Plan to reconsider their denial. 
The Plan denied your request. The Plan says Saxenda is not covered under the enrollee's Medicare Part B 
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 Saxenda.  
 
Benefits for Saxenda 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a biopsy of hard oral tissue (D7285) and a biopsy of soft oral 
tissue (D7286) provided on February 26, 2021. 
 
You asked the Plan to pay for biopsies. You say that you were told by the nurse that the procedure was fully 
covered. The Plan denied your request. The Plan says a biopsy of hard oral tissue (D7285) and a biopsy of soft 
oral tissue (D7286) are not covered by your routine 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 a biopsy 
of hard oral tissue (D7285) and a biopsy of soft oral tissue (D7286) provided on February 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150). 
 
You asked the Plan to pre-approve an evaluation. You say that the pain is getting worse. The Plan denied your 
request. The Plan says that services must be performed by a participating general dentist. 
 
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 when received by an endodontist. Therefore, we decided that the Plan 
does not have to pre-approve a comprehensive oral evaluation (D0150).