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

 
We decided that the Plan does not have to pre-approve an additional (3rd level) bilateral facet joint injection. 
 
You asked the Plan to pre-approve an additional bilateral facet joint injection. You say that the additional 
bilateral facet joint injection beyond 2 levels is medically necessary. The Plan denied your request. The Plan 
says the additional bilateral facet joint injection beyond 2 levels 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 pre-approve an additional bilateral facet joint 
injection. Our reviewer says that the additional bilateral facet joint injection beyond 2 levels is not medically 
necessary. Our physician reviewer found the request exceeds 2 levels that are allowed by the LCD. The third 
level is deemed not medically reasonable and necessary 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 an additional bilateral facet joint injection have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an additional (3rd level) bilateral facet joint injection.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care provided on November 08, 2022. 
 
You asked the Plan to pay for wound care. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for wound care provided on 
November 08, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for debridement provided on November 09, 2022. 
 
You asked the Plan to pay for debridement. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for debridement provided 
on November 09, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone graft at time of implant placement (D6104) Tooth 
#22 and 27, dental implant (D6010) Tooth #22 and 27 and overdenture  complete mandibular (D5864). 
 
You asked the Plan to pre-approve dental services. You say that you do not agree with the denial. The Plan 
denied your request. The Plan says these services are not covered under your Plan. 
 
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. Bone graft at time of implant 
placement (D6104), dental implant (D6010) and overdenture  complete mandibular (D5864) are not covered 
under the Plans dental benefits. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D6104, D6010 and 
D5864 are not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pre-approve bone graft at time of implant placement (D6104) Tooth #22 and 27, dental implant (D6010) Tooth 
#22 and 27 and overdenture  complete mandibular (D5864).
Appeal type: Outpatient Mental Health
Decision: Favorable

 
We decided that the Plan has to pay for medication assisted treatment, methadone; weekly bundle including 
dispensing and/or administration, substance use counseling, individual and group (code G2067) provided on 
April 11, 2022. 
 
You asked the Plan to pay for medication assisted treatment, methadone; weekly bundle including dispensing 
and/or administration, substance use counseling, individual and group. You say that you have been enrolled in 
the Medicare program to provide Opioid Treatment Program (OTP) services since January 1, 2020. The Plan 
denied your request. The Plan says that the claim for these drugs was billed by the physician, not the opioid 
treatment program (OTP) facility. The rules say that only an entity enrolled with Medicare as an OTP can bill 
these codes. 
 
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. Specifically, the OTP is the billing provider and is Substance Abuse and Mental 
Health Services Administration (SAMHSA) certified. The rules cited by the Plan do not provide a valid reason to deny this claim given that the OTP meets the Medicare coverage criteria. This provider continues to use the 
professional claim, which is allowed under Medicare rules. Therefore, we decided that the Plan has to pay for 
medication assisted treatment, methadone; weekly bundle including dispensing and/or administration, 
substance use counseling, individual and group (code G2067) provided on April 11, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia (denosumab) (J0897). 
 
You asked the Plan to pre-approve Prolia. You say that the requested drug is medically necessary. The Plan 
denied your request. The Plan says the requested drug is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that Prolia for postmenopausal women with opsteoporosis 
is allowed when certain criteria are met. 
 
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 drug, Prolia, is not medically necessary. Our physician reviewer found the provided documentation 
does not indicate that the enrollee failed or is intolerant of other available osteoporotic therapy. Therefore, the reviewer found that the requested drug is not medically 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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia (denosumab) (J0897).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chiropractic care to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve chiropractic care. You say that you are requesting reconsideration. The Plan 
denied your request. The Plan says the enrollee must receive their care from a network provider (for more 
information about this, see Section 2 in Chapter 3). In most cases, care the enrollee receives from an out-of-
network provider (a provider who is not part of the plans network) will not be covered. This means that the 
enrollee will have to pay the provider in full for the services furnished. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
chiropractic care to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an upper partial denture (D5213) provided on April 26, 2022. 
 
You asked the Plan to pay for an upper partial denture. You say that you believe the professional opinion of the 
provider, as stated on the submitted claim, should be honored. You say if the provider did not believe the 
procedure was needed, they would not have done it. The Plan denied your request. The Plan says you must be 
enrolled in the Plan for 24 consecutive months before coverage applies for prosthetic 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, the Plan's rules for coverage of an 
upper partial denture have not been met. Specifically, the 24 month waiting period for prosthetics had not 
passed. Therefore, we decided that the Plan does not have to pay for an upper partial denture (D5213) provided 
on April 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing services provided on February 24, 2022. 
 
You asked the Plan to pay for genetic testing services. You say that these services were medically necessary. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for genetic testing services 
provided on February 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental implants. 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they do 
not fall within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
dental implants.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pontics (D6245) provided on March 23, 2022. 
 
You asked the Plan to pay for the dental services. You say that if you knew your insurance would not pay for 
this dental work, you would have gone to a university dental program to get this work done. You say the dentist 
knew you could not afford this. The Plan denied your request. The Plan says there is no coverage for pontics 
(D6245) 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 
pontics (D6245) provided on March 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Tempus xF liquid biopsy testing (81455) provided on 
October 28, 2022. 
 
You asked the Plan to pay for Tempus xF testing. You say that this test was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says the criteria for coverage of this 
test have not been met, as the enrollee does not have recurrent, relapsed, refractory, metastatic or advanced 
stage cancer and because this test is not approved by the FDA. 
 
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 Tempus xF testing. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the records provided in this case do not document that the enrollee had either recurrent, 
relapsed, refractory, metastatic, or advanced stage III or IV cancer. The latest clinical note of January 06, 2022, 
reports, "no evidence of residual disease [skin cancer]." 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Tempus xF testing have not been met. Therefore, we decided that the Plan does 
not have to pay for Tempus xF liquid biopsy testing (81455) provided on October 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the specialist visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the specialist visit. You say that you would like to see this out-of-network 
provider. The Plan denied your request. The Plan says you must receive your care from a network provider. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the specialist visit to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Group 3 power wheelchair with multiple power options 
(power tilt and power recline K0861 
 
You asked the Plan to pre-approve the power wheelchair. You say that new medical equipment is necessary to 
meet the enrollee's needs in the home and to access the community. The Plan denied your request. The Plan 
says the request for K0861 Group 3 power wheelchair with Multiple Power Options is not reasonable and 
necessary. As the Group 3 Power Wheelchair with multiple power options is not reasonable and necessary, 
none of the requested accessories can be covered. 
 
The Plan follows Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for 
enrollees who have a mobility limitation that is due to: a neurological condition, myopathy or congenital 
skeletal deformity. 
 
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 power wheelchair. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found in this case the enrollee has a neurologic disorder with functional deficits. The 
documentation does not indicate that the enrollee has any pressure injuries or requires intermittent 
catheterization of the bladder or have spasticity that would necessitate power tilt or recline. Although the 
enrollee's condition may meet criteria for a PWC, the criteria for this specifically requested PWC with multiple 
power options including power tilt and recline are not met. 
 
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 power wheelchair have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Group 3 power wheelchair with multiple power options (power tilt and power 
recline K0861
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the sales tax (S9999) provided on December 7, 
2022. 
 
You asked the Plan to reimburse you for the sales tax. You say that you have no vocal cords. You say that there 
are no network suppliers that carry this item. You also say that you have had 2 others that were purchased out-
of-network and they were covered. The Plan denied your request. The Plan says sales tax is not covered by 
Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that sales taxes are included in the calculation of the 
Medicare fee schedule. For this reason, Medicare does not make separate payment for sales tax.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the sales tax have not been met. Therefore, we decided that the Plan does not have to reimburse 
you for the sales tax (S9999) provided on December 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on December 19, 2022. 
 
You asked the Plan to pay for lab services. You say that these services were medically necessary. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for lab services provided on 
December 19, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76642 billed for date of service December 
13, 2022. 
 You asked the Plan to pay for procedure code 76642. You say that the claim was billed correctly and should be 
paid. The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 76642 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
Based on this information, we decided that Medicare rules for coverage of procedure code 76642 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 76642 billed for date of 
service December 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the tongue (41530). 
 
You asked the Plan to pre-approve RFA of the tongue. You say that the services are necessary. The Plan denied 
your request. The Plan says the requested services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that submucosal ablation of the tongue base, 
radiofrequency, one or more sites, per session. will be denied as investigational and experimental. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of RFA of the tongue have not been met. Therefore, we decided that the Plan does not have to pre-
approve radiofrequency ablation (RFA) of the tongue (41530).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64479 provided on September 14, 2022. 
 
You asked the Plan to pay for procedure code 64479. 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. 
 
Medicare guidelines also state that modifiers -LT and -RT are to be used to identify procedures, which can be performed on paired organs, e.g., ears, eyes, nostrils, kidneys, lungs, and ovaries. Modifiers -LT and -RT 
should be used whenever a procedure is performed on only one side. Hospitals use the appropriate -LT or -RT 
modifier to identify which of the paired organs was operated upon. In this case, the file shows that procedure 
code 64479 was not billed with an appropriate modifier. Therefore, we decided that the Plan does not have to 
pay for procedure code 64479 provided on September 14, 2022.