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

 
We decided that the Plan does not have to pay for the genetic testing services coded 81323 and 81351 provided 
on August 12, 2021. 
 
You asked the Plan to pay for the genetic testing services as billed. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says this claim has not been 
billed in accordance with Medicare coding regulations. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
 
We looked at the file and Medicare rules. In this case, the services provided should have been billed as a single 
procedural service. Based on this information, we decided that Medicare rules for coverage of the genetic 
testing services as billed have not been met. Therefore, we decided that the Plan does not have to pay for the 
genetic testing services coded 81323 and 81351 provided on August 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an unspecified endodontic procedure (D3999) provided by 
an out-of-network provider on February 28, 2022. 
 
You asked the Plan to pay for an unspecified endodontic procedure. You say that this should be covered. The 
Plan denied your request. The Plan says D3999 is not a covered benefit. 
 
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 an unspecified endodontic procedure (D3999) 
provided by an out-of-network provider on February 28, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of an implantable loop recorder (ILR). 
 
You asked the Plan to pre-approve placement of an ILR. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 placement of an ILR. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is insufficient documentation to support the medical necessity for insertion of 
an ILR in this enrollees clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of placement of an ILR have not been met. Therefore, we decided that the Plan 
does not have to pre-approve placement of an implantable loop recorder (ILR).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Pegfilgrastim-cbqv. 
 
You asked the Plan to pre-approve Pegfilgrastim-cbqv. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
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 Pegfilgrastim-cbqv. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found Gemcitabine is associated with a 
low risk of neutropenia. This enrollee is also not being treated for curative intent and if neutropenia develops 
the doses can be lowered. The service is not reasonable or 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 Pegfilgrastim-cbqv have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Pegfilgrastim-cbqv.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the removal of torus palatinus (D7472) and removal of 
torus mandibularis (D7473). 
 
You asked the Plan to pre-approve the removals. You say that you would like these services to be covered by 
this out-of-network provider. The Plan denied your request. The Plan says these services are not covered when 
received by an out-of-provider. 
 
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 when received by an out-of-provider.  
  
Therefore, we decided that the Plan does not have to pre-approve the removal of torus palatinus (D7472) and 
removal of torus mandibularis (D7473).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service July 13, 2021. 
 
You asked the Plan to pay for procedure code 99100. You say that this claim was denied in error and you have 
provided medical records to support payment. The Plan denied your request. The Plan says this service is 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 CPT code. 
 
We find that CPT code 99100 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99100 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 99100 billed for date of service July 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pontics on tooth #20, 28, and 30 (D6241). 
 
You asked the Plan to pre-approve pontics. You say that the broker who sold you the insurance told you the 
insurance would pay 50% of the procedure costs. The Plan denied your request. The Plan says pontics (D6241) 
are not covered by your supplemental 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 
pontics on tooth #20, 28, and 30 (D6241).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal services (D4910) provided on April 11, 2022. 
 
You asked the Plan to pay for the periodontal 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 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 
periodontal services (D4910) provided on April 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve mandibular partial denture (D5214). 
 
You asked the Plan to pre-approve denture. You say that your lower dentures broke. The Plan denied your 
request. The Plan says this service is covered by your Plan's routine dental benefits; however, your benefit for 
one lower partial denture every five years has been exhausted. 
 
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 one lower 
partial denture (D5214) every five years. 
 
We looked at this case file, the Plans rules, and Medicare rules. The record shows the Plan paid for a lower 
partial denture provided on September 13, 2021; therefore, the benefit for a lower partial denture has been 
exhausted. Therefore, we decided that the Plan does not have to pre-approve mandibular partial denture 
(D5214).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT 
code 22869). 
 
You asked the Plan to pre-approve the surgery. You say that the enrollee has been suffering from this lumbar 
spinal stenosis since the year of 2015. The Plan denied your request. The Plan says experimental and 
investigational procedures are not covered by Medicare. 
 
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 surgery. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Vertiflex device is experimental. More research is needed to show safety and efficacy. 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 surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Vertiflex superion device placement surgery (CPT code 22869).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on October 5, 2021. 
 
You asked the Plan to pay for the services provided. You say that there is no agreement that the codes are 
included in the dialysis rate. The Plan denied your request. The Plan says the services are the responsibility of 
the dialysis center. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the lab services provided on October 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for resin-based composites for teeth #13, #24, #25, and #31 
provided by a participating provider on February 17, 2022, to February 25, 2022. 
 
You asked the Plan to pay for resin-based composites. You say that these services were medically necessary. 
The Plan denied your request. The Plan says the benefit limit for a resin-based composite has already been met 
and exhausted. 
 
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 two resin-
based composites per year.  
 
We looked at the file and Medicare rules. Evidence was provided to show that a resin-based composite was 
provided for teeth #11 on February 17, 2022, and #31 on January 19, 2022. Based on this information, we 
decided that the Plan's rules for coverage of resin-based composites have not been met. Therefore, we decided 
that the Plan does not have to pay for resin-based composites for teeth #13, #24, #25, and #31 provided by a 
participating provider on February 17, 2022, to February 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pathology services provided on December 28, 2021. 
 
You asked the Plan to pay for the services provided. You say that the medical records provide evidence of 
medical necessity. The Plan denied your request. The Plan says the claim processed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
 We looked at the file and the rules. We find that CPT code 85060 was billed with 22, an outpatient place of 
service code. No payment is recognized for code 85060 furnished to hospital outpatients or non-hospital 
patients. Based on this information, we decided that Medicare rules for coverage of the services provided have 
not been met. Therefore, we decided that the Plan does not have to pay for the pathology services provided on 
December 28, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene panel provided on September 16, 2021. 
 
You asked the Plan to pay for the testing services. You say that the medical records support the billed charges. 
The Plan denied your request. The Plan says one code must be submitted for the panel. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
 We find that the pharmacogenomic testing was billed with multiple codes. If a single procedure is performed, 
only one code with one unit of service may be reported for the procedure. Based on this information, we 
decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan 
does not have to pay for the gene panel provided on September 16, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 21, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the billed code 
cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that 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. The claim in this case 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 lab services have not been met. Therefore, we decided that the Plan 
does not have to pay for lab services provided on June 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray services coded 71046 provided on November 12, 
2021. 
 
You asked the Plan to pay for the x-ray services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 71046 is not supported in the medical record. Specifically, the documentation shows 
that this service was billed twice. The documentation does not support that two separate services were 
performed. This means this code is not payable. Based on this information, we decided that Medicare rules for 
coverage of the x-ray services have not been met. Therefore, we decided that the Plan does not have to pay for 
the x-ray services coded 71046 provided on November 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99214) provided September 3, 2021. 
 
You asked the Plan to pay for the office visit. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the number of units billed are not supported in the records. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
We find that 2 units of CPT code 99214 are not supported in the medical record. The medical record only 
supports 1 unit of CPT code 99214. Based on this information, we decided that Medicare rules for coverage of 
the office visit have not been met. Therefore, we decided that the Plan does not have to pay for an office visit 
(99214) provided September 3, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (88341, 88342, 88360, 88381) provided August 
12, 2021. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the codes billed are 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 CPT code. 
 
We find that CPT code 88341, 88342, 88360 and 88381 is not supported in the medical record. Specifically, 
the code billed has a professional component / technical component identifier of 1 and is not eligible for 
separate payment in this place of service without a required modifier. Based on this information, we decided 
that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan 
does not have to pay for lab services (88341, 88342, 88360, 88381) provided August 12, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (83789) provided December 8, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 83789 is not supported in the medical record. Specifically, this code is included in 
G0480 and 80307. Insufficient records were provided to support the use of modifier 59. Based on this 
information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we 
decided that the Plan does not have to pay for lab services (83789) provided December 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for neuromonitoring services (95907, 95885, 95999) provided 
November 3, 2021. 
 
You asked the Plan to pay for the neuromonitoring services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the records do not support the billed 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. 
 
We find that CPT codes 95907, 95885, & 95999 are not supported in the medical record. Specifically, the 
procedure report does not support the codes billed. Nerve conduction studies are not supported by the 
documents provided. Based on this information, we decided that Medicare rules for coverage of the 
neuromonitoring services have not been met. Therefore, we decided that the Plan does not have to pay for 
neuromonitoring services (95907, 95885, 95999) provided November 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections. 
 
You asked the Plan to pre-approve facet joint injections. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that facet joint injections are covered when specific 
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 facet joint injections. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found there is a lack of documentation of 
the percentage and duration of the pain relief the enrollee received after the first set of diagnostic medial branch 
block (MBBs). Therefore, the request is considered not medically reasonable or 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 facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve crowns on teeth #7, 8, 9, and 10 (D2740). 
 
You asked the Plan to pre-approve the crowns. You say that the crowns are medically necessary. The Plan 
denied your request. The Plan says that the crowns (D2740) are not medically necessary. The Plan also says 
that teeth # 7, 8, 9, and 10 can be restored with a tooth-colored filling. 
 
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 did not provide the medical records they used in their review. The Plan 
has not supported their decision to deny your request. Therefore, we decided that the Plan has to pre-approve 
crowns on teeth #7, 8, 9, and 10 (D2740).  
 
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.