Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat facet joint injection. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requested facet joint injections do not meet the Medicare LCD coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that in this case, the documentation indicates that the previous medical branch blocks provided no 
significant pain relief. The review has determined that the requested facet joint injections do not meet the 
Medicare LCD coverage criteria. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a repeat facet joint injection.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (procedure code 22633) provided to the 
enrollee on March 24, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says CPT code 22633 cannot be verified. 
 
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 22633 is "Arthrodesis, combined posterior or 
posterolateral technique with posterior interbody technique including laminectomy and/or discectomy 
sufficient to prepare interspace (other than for decompression), single interspace, lumbar." 
 
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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the operative note does not 
contain documentation for CPT 22633 for interbody fusion. 
 We looked at this coder's review, the file, and Medicare rules. 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 surgical services (procedure code 22633) provided to the enrollee on March 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Caris Panel Molecular Intelligence test (MI) Profile assay 
(81479) provided June 10, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that please find attached the applicable 
documentation to support this request. The Plan denied your request. The Plan says this test is considered 
investigative and experimental. Enrollees must receive their medical services from an in-network provider. 
Non-emergent services with non-contracted providers require prior authorization before services being 
rendered. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules say that experimental and investigational devices are 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 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. Based on this 
information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, 
we decided that the Plan does not have to pay for the Caris Panel Molecular Intelligence test (MI) Profile assay 
(81479) provided June 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair with a single power option 
and expandable controller. 
 
You asked the Plan to pre-approve the group 3 power wheelchair with a single power option and expandable 
controller. You say that this power wheelchair is medically necessary. The Plan denied your request. The Plan 
says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair with Single Power 
Option (K0856-K0860) or with Multiple Power Options (K0861- K0864) is covered if coverage criteria is met 
for a group 3 power wheelchair, and coverage criteria is met for a group 2 power wheelchair with single power 
options. 
 
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 group 3 power wheelchair with a 
single power option and expandable controller. Our reviewer says that the requested power wheelchair is not 
medically necessary. Our physician reviewer found records show that the enrollee is not at high risk for skin 
breakdown. She does not use intermittent catheterization or have significant spasticity. She does not require a 
power tilt and recline. An expandable controller 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 the group 3 power wheelchair with a single power option and expandable 
controller have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 
power wheelchair with a single power option and expandable controller.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the foot orthotics provided on October 23, 2021. 
 
You asked the Plan to pay for the foot orthotics. You say that the orthotics are very helpful. 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 the foot orthotics 
provided on October 23, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pyschiatric evaluation provided on June 15, 2022. 
 
You asked the Plan to pay for a pyschiatric evaluation. You say that out-of-network providers should be paid at 
a reduced rate. 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 a pyschiatric evaluation 
provided on June 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a Chiropractic visit provided on November 12, 2021. 
 
You asked the Plan to pay for a Chiropractic visit. You say that you would like a reconsideration of coverage 
for Chiropractic care. 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 a Chiropractic visit 
provided on November 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the guided tissue regeneration (D4266 x 2) provided on July 
21, 2022. 
 
You asked the Plan to pay for the dental services. You say that this claim should be paid in full. The Plan 
denied your request. The Plan says this service is not a covered benefit 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage certain limitations apply, the requested 
items or services are not covered under these circumstances. Therefore, we decided that the Plan does not have 
to pay for the guided tissue regeneration (D4266 x 2) provided on July 21, 2022.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
You asked the Plan to pay for extractions with removal of bone (D7210), radical resection of mandible or 
maxilla (D7490), incision/drainage of abscesses (D7521), and extractions (D7140) provided from July 19, 
2022, to October 17, 2022.  You say that you are on a fixed income and are unable to afford to pay this on your own. The Plan says that 
there is a more appropriate code to use than D7210, codes D7490 and D7521 are not covered, and coinsurance 
was applied to code D7140. 
 
We decided that the Plan has to pay for dental code D7210.  
 
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. The Plan claims that there is a more appropriate code to use for this service than 
code D7210. However, the Plan did not submit any supporting medical records to review the code at issue. 
Without this information, we cannot determine whether code D7210 is appropriate for this claim or if another 
code would have been more appropriate. Therefore, the Plan has not shown that its decision to deny payment 
for code D7210 is correct or justified. Therefore, we decided that the Plan has to pay for dental code D7210.  
 
We also decided that the Plan does not have to pay for dental codes D7490, D7521, and D7140. 
 
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, dental service codes D7490 and D7521 
are not among those covered by the Plans dental benefits. 
 
Additionally, your contract with the Plan clearly says you must pay 50% coinsurance for in-network covered 
extractions. The allowed amounts of the covered extractions total $328, resulting in a coinsurance amount of 
$164. 
 
Therefore, we decided that the Plan does not have to pay for dental codes D7490, D7521, and D7140. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the quantitative calcium scoring (75571) provided on May 
26, 2022. 
 
You asked the Plan to pay for the diagnostic testing. You say that the service was medically necessary. The 
Plan denied your request. The Plan says quantitative calcium scoring is not a covered service. 
 
The Plan must follow Medicare rules. Medicare rules say that quantitative calcium scoring is not a covered 
service and will be denied as not medically necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the diagnostic testing have not been met. Therefore, we decided that the Plan does not have to pay 
for the quantitative calcium scoring (75571) provided on May 26, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a single photon emission computed tomography 
(SPECT) scan (78803). 
 
You asked the Plan to pre-approve a SPECT scan. The Plan denied your request. The Plan says this service 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 a SPECT scan. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the records do not show evidence of ATTR (amyloid transthyretin). Our reviewer also found 
that there is no clinical evidence provided to support the performance of SPECT imaging in this enrollee 
according to current guidelines. 
 
 
  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 SPECT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a single photon emission computed tomography (SPECT) scan (78803).
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Percepta Bronchial Genomic Classifier test (81479) 
provided on October 7, 2021. 
 
You asked the Plan to pay for the laboratory test. You say that this service is covered. You also say that this 
should be reprocessed at the in-network rate. The Plan denied your request. The Plan says the enrollees claim 
would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the 
date of election until the last day of the month in which hospice is revoked. The Plan also says it is the 
providers responsibility to verify the enrollees coverage before rendering services and to know proper billing 
procedures for a Medicare Advantage member on hospice. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the Percepta Bronchial Genomic Classifier test (81479) 
provided on October 7, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from May 12, 2022 to 
June 10, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from May 12, 2022 to June 
10, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the individual psychotherapy services (90832) provided June 
8, 2022. 
 
You asked the Plan to pay for the psychotherapy services. You say that your physician provided medically 
necessary services to the enrollee in good faith. In consideration of the services rendered, you feel your doctor 
is entitled to reimbursement. The Plan denied your request. The Plan says Original Medicare would be 
responsible for payment of all Medicare covered services related or unrelated to the members terminal 
condition.  
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the individual psychotherapy services (90832) provided June 
8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve therapeutic CGM. You say that the enrollee needs this to monitor blood 
sugar levels. The Plan denied your request. The Plan says the enrollee does not meet criteria for a CGM. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of therapeutic CGM have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services (G0299). 
 
You asked the Plan to pre-approve home health services. You say that you are concerned for your health and 
safety if you are to go out of your house. The Plan denied your request. The Plan says the services are not 
medically necessary. 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found you do not 
have documented skilled nursing needs. Our reviewer also found that you do not have documented skilled 
therapy needs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services (G0299).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the hospital bed mattress purchased August 4, 
2022. 
 
You asked the Plan to reimburse you for the mattress. You say that your mom was being discharged and you 
did not have time to get a prescription or deal with a DME store. You are asking to be reimbursed for this 
mattress because your mom needed it for comfort and the ability to transfer out of bed. The Plan denied your 
request. The Plan says the item was purchased from a supplier that does not participate with Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to reimburse you for the hospital bed mattress 
purchased August 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a dental re-evaluation (D0171) provided on July 21, 2022. 
 
You asked the Plan to pay for 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 pay for a dental 
re-evaluation (D0171) provided on July 21, 2022.