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

 
We decided that the Plan does not have to pay for a complete denture - maxillary (D5110) provided on October 
13, 2022. 
 
You asked the Plan to pay for the dental services. You say that the amount owed was paid in full and you are 
asking for a reimbursement. 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 complete denture - maxillary (D5110) provided on October 13, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate (20939) for a spinal surgery. 
 
You asked the Plan to pre-approve bone marrow aspirate. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested services are 
experimental/investigational. 
 
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 bone marrow aspirate. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there is a lack of large-volume, long-term, peer-reviewed outcome studies to 
support the use of bone marrow aspirate for the enrollee's medical condition. There is no compelling rationale 
presented or extenuating circumstances noted to support the medical necessity of this request as an exception.  

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bone marrow aspirate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone marrow aspirate (20939) for a spinal surgery.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gingival irrigation - per quadrant (D4921), and topical 
application of fluoride varnish (D1206) provided on November 9, 2022. 
 
You asked the Plan to pay for codes D4921, and D1206. You say that the benefit guide does not state the 
waiting period for the D4910. You also say that you went to an in-network provider. The Plan denied your 
request. The Plan says these services are not covered under the benefit package. 
 
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 gingival 
irrigation - per quadrant (D4921), and topical application of fluoride varnish (D1206) provided on November 
9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
October 14, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service October 14, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95909 billed for date of service August 24, 
2022. 

You asked the Plan to pay for procedure code 95909. You say that the claim was billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 95909 is bundled into payment for code 
95861. 
 
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 95909 
is a column II code to column I code 95861 with a modifier indicator of 0. The column II code is therefore not 
payable. 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 code 95909 billed for date of service August 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical placement of implant body, endosteal (D6010), 
custom fabricated abutment, includes placement (D6057), abutment supported porcelain/ceramic crown 
(D6058), guided tissue regeneration (D4266), radiographic/surgical implant index (D6190), sinus augmentation 
via a vertical approach (D7952), and bone replacement graft for ridge preservation (D7953) for tooth #5. 
 
You asked the Plan to pre-approve the dental services. You say that you are in need of tooth removal because 
you are at high risk for infection that is very dangerous to you. You say the implant is a medical need to help 
you chew properly so you do not choke when eating. The Plan denied your request. The Plan says you do not 
meet the criteria for coverage of the implant. 
 
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 a dental 
implant only when the services are medically necessary and reasonable. 
 
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 surgical placement of implant body, 
endosteal (D6010), custom fabricated abutment, includes placement (D6057), and abutment supported 
porcelain/ceramic crown (D6058). Our reviewer says the documentation provided does not meet the criteria for 
coverage for implant services to replace missing tooth #5. Our physician reviewer found that a review of the 
documentation indicates that you are missing posterior maxillary teeth bilaterally. Other methods of replacing 
these teeth can be used to give you good masticatory function bilaterally. There was no documentation 
indicating that you had medical issues requiring a dental implant to replace the missing tooth. 
 
We looked at the physicians review, the file, and Medicare rules. Based on this information, we decided that 
the Plans rules for coverage of implant services have not been met for D6010, D6057, and D6058. Though the 
Plan offers a dental benefit in excess of Medicare coverage, D4266, D6190, D7952, and D7953 are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve surgical 
placement of implant body, endosteal (D6010), custom fabricated abutment, includes placement (D6057), 
abutment supported porcelain/ceramic crown (D6058), guided tissue regeneration (D4266), 
radiographic/surgical implant index (D6190), sinus augmentation via a vertical approach (D7952), and bone 
replacement graft for ridge preservation (D7953) for tooth #5.
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) 81479. We decided that the 
Plan does not have to pay for the services described by procedure code(s) 81314.  
 
You asked the Plan to pay for laboratory services provided on August 29, 2022. You say that these services 
were necessary and are supported as billed. The Plan says that you billed with an incorrect place of service on 
the claim. 
 
We decided that the Plan has to pay for the services described by procedure code(s) 81479.  
 
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 Plan did not make an appeal decision for the codes listed in this 
section. The Plan is not allowed to reopen any determinations while an appeal is pending and must issue a 
determination on all appealed services within the appeal time frame. As the Plan forfeited its opportunity to 
provide a denial rationale for these services, we find that the denial of payment is not supported. Therefore, we 
decided that the Plan has to pay for the services described by procedure code(s) 81479.  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 
81314. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Specifically, this claim was billed with the laboratory POS code. The 
records do not support that the sample was taken in a laboratory setting. Based on this information, we decided 
that Medicare rules for coverage of the services described by procedure code(s) 81314 have not been met. 
Therefore, we decided that the Plan does not have to pay for the services described by procedure code(s) 
81314. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertebroplasty/kyphoplasty (22514, 22515). 
 
You asked the Plan to pre-approve the Vertebroplasty/kyphoplasty. You say that the service is medically 
necessary. The Plan denied your request. The Plan says the service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that vertebroplasty/kyphoplasty is covered when acute 
(less than 6 weeks) or subacute (6-12 weeks). 
 
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 Vertebroplasty/kyphoplasty. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found there is no 
documentation that the fracture is less than 6 weeks old on recent imaging studies. 
 
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 Vertebroplasty/kyphoplasty have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the Vertebroplasty/kyphoplasty (22514, 22515).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87899 and 87900 provided on September 
30, 2022. 
 
You asked the Plan to pay for procedure codes 87899 and 87900. You say that the medical records support the 
billing of codes 87899 and 87900. The Plan denied your request. The Plan says the medical records do not 
support the billing of codes 87899 and 87900. 
 
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 87899 is Infectious agent antigen detection by 
immunoassay with direct optical (ie, visual) observation; not otherwise specified. The definition of code 87900 
is Infectious agent drug susceptibility phenotype prediction using regularly updated genotypic bioinformatics. 
 
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 codes 87899 and 87900. Our reviewer says that 
the medical records do not support the billing of codes 87899 and 87900. Our reviewer found procedure code 
87899 is not supported. The records do not contain results of infectious agent detection with direct optical 
observation. It cannot be verified that this test was performed. Procedure code 87900 is also not supported. The 
record does not contain results of infectious agent drug susceptibility phenotype prediction using updated 
genotypic bioinformatics. It cannot be verified that this test was performed. 
 
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 codes 87899 and 87900 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 87899 and 87900 provided on September 30, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97010 billed for date of service November 
30, 2022. 
 
You asked the Plan to pay for procedure code 97010. You say that there is an authorization on file for these 
services. The Plan denied your request. The Plan says they have agreed to pay for the other therapy services; 
however, procedure code 97010 is considered bundled and 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 procedure code. 
 
We find that procedure code 97010 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 97010 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 97010 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 97010 billed for date of service November 30, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the vacuum assisted suspension system (VASS) 
(L5781). 
 
You asked the Plan to pre-approve the vacuum socket system. You say that the socket does not fit properly and 
needs to be replaces. The leg has come off three times already. The Plan denied your request. The Plan says 
this vacuum socket is experimental and cannot be approved. there are not enough studies to show vacuum 
socket is safe and effective for the enrollee's condition. 
 
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 vacuum socket system have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the vacuum assisted suspension system (VASS) (L5781).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the electronic connection device (E2310). 
 
You asked the Plan to pre-approve the electronic connection device. You say that the requested item is 
medically necessary. The Plan denied your request. The Plan says there is not a medical need to control the 
power option through the joystick. 
 
The Plan follows Medicare rules. Medicare rules say that the electronic components are medically necessary 
when the enrollee needs to control two or more of the following motors from a single interface (joystick). 
 
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 electronic connection device. Our 
reviewer says that the coverage criteria has not been met. Our physician reviewer found that the enrollee has 
adequate upper body strength and coordination to manage standard power drive 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 the electronic connection device have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the electronic connection device (E2310).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on August 25, 2022, billed with 
codes 81225, 81230, 81231, 81232, 81306, 81355, 81335, 0031U, 0032U, 0033U, 81227, 81291, 81407, 81408 
and 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was necessary and is 
supported in the medical record. The Plan denied your request. The Plan says panel testing should be billed 
using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
August 25, 2022, billed with codes 81225, 81230, 81231, 81232, 81306, 81355, 81335, 0031U, 0032U, 0033U, 
81227, 81291, 81407, 81408 and 81479.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 13, 2022, billed with 
codes 0031U, 0032U, 0033U, 81227, 81230, 81231, 81232, 81291, 81306, 81328, 81335, and 81355. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the denial. The Plan 
denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
May 13, 2022, billed with codes 0031U, 0032U, 0033U, 81227, 81230, 81231, 81232, 81291, 81306, 81328, 
81335, and 81355.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on August 29, 2022, billed with 
codes 81162, 81201, 81292, 81295, 81298, 81307, 81317, 81321, 81334, 81218, 81314, 81479 and 81351. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was necessary and is 
supported as billed. The Plan denied your request. The Plan says panel testing should be billed using one CPT 
code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
August 29, 2022, billed with codes 81162, 81201, 81292, 81295, 81298, 81307, 81317, 81321, 81334, 81218, 
81314, 81479 and 81351.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a soft interface for molded plastic, below knee section 
(L2820), and soft interface for molded plastic, above knee section (L2830). 
 
You asked the Plan to pre-approve the molds. You say that the enrollee needs this. You also say that 
authorization was denied. The Plan denied your request. The Plan says the requested components are not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that addition codes which describe components or 
features that can be physically incorporated in the specified custom fabricated bases orthosis but that are 
considered to be included in the allowance for the orthosis.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the molds have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
soft interface for molded plastic, below knee section (L2820), and soft interface for molded plastic, above knee 
section (L2830).