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

 
We decided that the Plan does not have to pay for the pain management services rendered on September 1, 
2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim is a duplicate. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. 
 
 
 
 
 
 
 We looked at the file and Medicare rules. The file shows that the services at issue were previously paid by the 
Plan on a separate claim for the same date of service. Based on this information, we decided that Medicare 
rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to 
pay for the pain management services rendered on September 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional taxi transportation (A0100) and ground 
mileage (A0425) provided on July 20, 2021. 
 
  You asked the Plan to pay for the additional taxi transportation and ground mileage. You say that your 
scheduling for the rides was not rejected, and you feel this trip should be covered. The Plan denied your 
request. The Plan says the maximum calendar year supplemental Non-Emergency Medical Transportation 
benefit is 24 one-way trips per year. The Plan also says that you reached that limit on April 15, 2021, and the 
maximum benefit was paid at that time. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of up to 24 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pay for the additional taxi transportation (A0100) and ground mileage 
(A0425) provided on July 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hereditary assessment/screening for cardiac conditions 
(81401, 81403, 81404, 81405, 81406, 81407, 81408, and 81479) provided on September 14, 2021. 
 
You asked the Plan to pay for hereditary assessment for cardiac conditions. You say that these services were 
medically reasonable and necessary. The Plan denied your request. The Plan says these services were not 
medically necessary and do not meet the criteria for coverage. 
 
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 hereditary assessment for cardiac conditions. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found this test is described as a genetic-based cardiovascular risk factor 
screening test in which multiple genes are assessed using genomic DNA extracted from patient sampling. It 
assesses the presence of pathogenic or likely pathogenic variants in genes known to be associated with 
increased cardiac risk. It is not a diagnostic test. There is no evidence to support its role in this enrollee's 
clinical management. In summary, the requested testing is not considered 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 hereditary assessment for cardiac conditions have not been met. Therefore, we 
decided that the Plan does not have to pay for hereditary assessment/screening for cardiac conditions (81401, 
81403, 81404, 81405, 81406, 81407, 81408, and 81479) provided on September 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS device. 
 
You asked the Plan to pre-approve the CardioMEMS device. You say that this device is medically reasonable 
and necessary. The Plan denied your request. The Plan says the requested CardioMEMS device is 
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 the CardioMEMS device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found at issue is the medical appropriateness and necessity of implantation of the wireless 
pulmonary artery pressure monitoring system (CardioMEMS) for management of congestive heart failure 
(CHF) in this patient. The CardioMEMS device was approved by the Food and Drug Administration (FDA) in 
2014 and consists of a sensor device placed in the pulmonary artery to allow measurement of pulmonary artery 
pressure in the management of patients with CHF. The clinical study on which FDA approval was based 
showed improved clinical outcomes and decreased hospitalizations in patients in whom the CardioMEMS system was implanted, reflecting a patient population with preserved ejection fraction and was somewhat 
limited in scope. Subsequent follow-up studies remain encouraging and suggest an improvement in heart 
failure symptoms with the use of the device. In addition, published expert opinion in the cardiology literature is 
supportive of the clinical usefulness of CardioMEMS. Nonetheless, there remains a dearth of randomized, 
blinded clinical studies examining long-term clinical outcomes establishing the value of CardioMEMS in 
patient management. As a result, at this time the CardioMEMS system would not be considered medically 
appropriate and necessary in this patients 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 the CardioMEMS device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the CardioMEMS device.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the retroperitoneal ultrasound rendered on January 3, 2022.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim is a duplicate.

The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied.

We looked at the file and Medicare rules. The file shows that the services at issue were previously paid by the Plan on a separate claim for the same date of service. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the retroperitoneal ultrasound rendered on January 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing rendered on November 12, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code G0483 is not supported. 
 
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 G0483 is definitive drug testing, 22 or more classes. 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, there is no documentation 
of testing of 22 or more drug classes. Based on this information, we decided that Medicare rules for coverage 
of these services have not been met. Therefore, we decided that the Plan does not have to pay for the drug 
testing rendered on November 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950) 
provided on November 1, 2021. 
 
You asked the Plan to pay for the core buildup. You say that you would like to know why this service was 
denied. The Plan denied your request. The Plan says this service is 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.  
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 core 
buildup, including any pins when required (D2950) provided on November 1, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for computed tomography (CT) of the Thorax (71260) provided 
on November 28, 2021 
 
You asked the Plan to pay for the CT of the Thorax. You say that you would like reconsideration because this 
claim denied as a duplicate in error. The Plan denied your request. The Plan says the submitted documentation 
supports 1 (one) unit of 71260-26, which was previously approved/paid. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of computed tomography (CT) of the 
Thorax (71260) provided on November 28, 2021 have been met. Specifically, the documentation submitted 
shows that the Plan paid for one unit of CPT code 71260. The record does not indicate that this service was 
rendered more than once on the billed date of service.. Therefore, we decided that the Plan does not have to pay 
for computed tomography (CT) of the Thorax (71260) provided on November 28, 2021
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that you are experiencing an increase in heart rate 
and do not have assistance at home. You say that SNF care is medically necessary. The Plan denied your 
request. The Plan says the enrollee has not had a change in function that needs daily skilled therapy services. 
The Plan says that the enrollee does not have any daily skilled nursing needs. The Plan says that the enrollee's 
needs can be met at a lower level of care.  
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee has stabilized medically and 
is ready for discharge from the hospital. The enrollee does not require skilled nursing and/or skilled therapy 
services on a daily basis.  He is medically stable and can receive further rehabilitation services at a lower level 
of care. Although further rehabilitation services would be appropriate to improve function, as a practical 
matter, the intermittent skilled services can be provided at a lower level of care than a skilled nursing facility. 
The enrollee does not have any parental medication, complex wound care or nutrition given via a feeding tube. 
He is medically stable without any acute exacerbations of chronic medical problems. His physical function is at 
or near his baseline and he can receive services at a lower level of care. Admission to a SNF for inpatient 
skilled rehabilitation services 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown (D2740) provided on December 20, 2021. 
 
You asked the Plan to pay for the crown. You say that the Plan should pay for this service because they 
approved it. You also say that the Plan should have denied one crown if there was a frequency limitation 
instead of approving it. The Plan denied your request. The Plan says an approval is not a guaranty of payment; 
payment is made in accordance with the benefit plan coverage and frequency limits. The Plan also says that a 
third crown is not a covered benefit under your plan or Medicare. 
 
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, you are limited to 2 caps (or crowns) 
per year. The record shows that you received two crowns (D2740 x2) prior to this December 20, 2021 date of 
service and your crowns benefit has been exhausted. Therefore, we decided that the Plan does not have to pay 
for the crown (D2740) provided on December 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for the crown (D2740), and core build up 
(D2950) provided on November 1, 2021. 
 
You asked the Plan to pay an additional amount for the dental services. You say that you had root canal work 
done at a out of network provider. You say that you were not able to find an in network provider in your area. 
You also say that you were not advised you need prior authorization for the services. The Plan denied your 
request. The Plan says there is a 50% coinsurance for comprehensive dental services, including crown and core 
build up. 
 
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 and crown and core build up are listed 
as covered, there is a 50% coinsurance that applies to these comprehensive dental services. This is a contractual 
obligation you agreed to when you enrolled in the Plans dental coverage. Additionally, the record shows that the services in this case were processed as in network. Therefore, we decided that the Plan does not have to pay 
an additional amount for the crown (D2740), and core build up (D2950) provided on November 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the endodontic therapy, premolar tooth (excluding final 
restoration) (D3320) provided September 8, 2021. 
 
You asked the Plan to pay for the root canal. You say that you don't feel you owe the bill because the provider 
has not followed up to help with your services. The Plan denied your request. The Plan says this service is not 
covered under your 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 the 
endodontic therapy, premolar tooth (excluding final restoration) (D3320) provided September 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve laboratory services to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the OON laboratory services. You say that the medical records provided 
support the need for the services requested. The Plan denied your request. The Plan says the services are 
available from network providers. 
 
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 
laboratory services 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 the prophylaxis (D1110) provided on October 6, 2021. 
 
You asked the Plan to pay for the dental service. You say that due to the enrollee's poor dental hygiene 
resulting from their delayed development, it is recommended they receive 4 cleanings per year. You also say 
that this should be covered. The Plan denied your request. The Plan says 2 prophylaxis procedures are covered 
per plan year. The Plan also says that the frequency limit has been exceeded. 
 
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 and 2 prophylaxis procedures are 
covered per plan year, the frequency limit has been exceeded. The record shows that the Plan paid for 
prophylaxis that you received on February 10, 2021, and June 23, 2021. Therefore, we decided that the Plan 
does not have to pay for the prophylaxis (D1110) provided on October 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical extraction (D7210) provided on December 27, 
2021 by a Medicare opt out provider. 
 
You asked the Plan to pay for the extraction. You say that prior to receiving this service, you contacted the Plan 
and were told you could use any provider that you chose. You also say that you received information that the 
treating provider was on the approved list with your Plan through Medicare and were provided with 
misinformation. The Plan denied your request. The Plan says you received this service from a provider who 
chose not to receive Medicare funds. The Plan also says that during your call with the Plan on September 7, 
2021, you were advised that you could use any dentist as long as they are not opted out of Medicare, and no 
misinformation was given. 
 
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 
covered when they are received by a provider who has opted out of Medicare. Therefore, we decided that the 
Plan does not have to pay for the surgical extraction (D7210) provided on December 27, 2021 by a Medicare 
opt out provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial maxillary denture (D5213), and a partial 
mandibular denture (D5214) to be provided by a contracted provider. 
 
You asked the Plan to pre-approve a partial maxillary denture and a partial mandibular denture. You say that 
you cannot chew properly, and you are currently in pain. The Plan denied your request. The Plan says the 
benefit limit for D5213 and D5214 have already been exhausted. 
 
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. The Plan covers a partial 
maxillary denture and a partial mandibular denture once every five years.  
 
We looked at the file and Medicare rules. D5213 and D5214 was previously provided on October 25, 2019. 
Based on this information, we decided that the Plan's rules for coverage of a partial maxillary denture and a partial mandibular denture have not been met. Therefore, we decided that the Plan does not have to pre-approve a partial maxillary denture (D5213), and a partial mandibular denture (D5214) to be provided by a contracted provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power operated vehicle. 
 
You asked the Plan to pre-approve a power operated vehicle. You say that this is necessary to participate in 
independent trips outside. The Plan denied your request. The Plan says the requested power wheelchair is not 
necessary because it is requested for use outside of the home. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a power operated vehicle.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a full mouth debridement (D4355). 
 
You asked the Plan to pre-approve a full mouth debridement. You say that you hardly used your dental limit, 
and cannot afford this service. The Plan denied your request. The Plan says this service is not covered. 
 
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 a full 
mouth debridement (D4355).