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

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve an Intracept procedure. 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 thermal destruction of the intraosseous BVN will be 
considered medically reasonable and necessary for the treatment of cLBP in patients who meet certain criteria. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an Intracept procedure. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found the magnetic resonance 
imaging (MRI) shows foraminal stenosis. The cause of back pain remains unclear. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the breast cancer (BRCA) 1 and 2 comprehensive 
analysis panel (81162, 81292, 81294, 81295, 81297, 81298). 
 
You asked the Plan to pre-approve the genetic testing. You say that the medical records provided support the 
necessity of the services in dispute. The Plan denied your request. The Plan says under Medicare rules the 
request for this genetic testing is not a covered benefit. These tests are considered screening since there is no 
personal diagnosis of cancer. 
 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 genetic testing. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found genetic panel testing including BRCA 1 and 2 is recommended in patients at high 
risk for carrying genetic mutations. Established guidelines help determine eligible patients for testing. Medicare 
requires a personal history of breast cancer as well as family history. This enrollee does not have a personal 
history of breast cancer and no family history is provided. 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 the genetic testing have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the breast cancer (BRCA) 1 and 2 comprehensive analysis panel (81162, 81292, 
81294, 81295, 81297, 81298).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on September 29, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that your 
benefit is $250.00 and since you have coverage, the claim should have paid. The Plan denied your request. The 
Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on December 4, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on September 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the AVISE CTD test panel (0312U) provided June 1, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that please see the attached documents regarding 
the test that was deemed medically necessary by the physician. The Plan denied your request. The Plan says the 
AVISE CTD test panel is considered experimental and investigational, as it is unproven to alter disease 
prognosis or treatment outcomes and has not been proven to be superior to alternative tests and measures of 
disease activity. 
 
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 the laboratory service. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the AVISE Connective Tissue Disease (CTD) test uses autoantibody, erythrocyte-
bound C4d (EC4d) and B-cell-bound C4d (BC4d) levels to aid in diagnoses of systemic lupus erythematosus 
(SLE), other connective tissue diseases (CTD) and fibromyalgia. The AVISE CTD test panel is considered 
experimental and investigational, as it is unproven to alter disease prognosis or treatment outcomes and has not 
been proven to be superior to alternative tests and measures of disease activity. The review has determined that 
the items/services at issue in this case are 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 the laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pay for the AVISE CTD test panel (0312U) provided June 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care supplies provided on November 03, 2022. 
 
You asked the Plan to pay for wound care supplies. You say that these items were medically necessary. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for wound care supplies 
provided on November 03, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for a magnetic resonance imaging (MRI) of pelvis without contrast 
material provided on April 14, 2022, billed with procedure code 72195. 
 
You asked the Plan to pay for the MRI. You say that the claim should be covered by the health plan. The Plan 
denied your request. The Plan says that the claim was submitted with the incorrect payor ID. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for the MRI by a contract provider. The file does not show that the Plan provided notice that 
the MRI would not be covered. Under Medicare rules, this means the MRI is considered approved by the Plan. 
Therefore, we decided that the Plan has to pay for a magnetic resonance imaging (MRI) of pelvis without 
contrast material provided on April 14, 2022, billed with procedure code 72195.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve CT scan of the thorax. 
 
You asked the Plan to pre-approve CT scan of the thorax. You say that the enrollee has a smoking history and 
quit in 2011. The Plan denied your request. The Plan says a CT scan of the thorax is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically 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 CT scan of the thorax. Our reviewer 
says that the requested CT scan of the thorax is not medically necessary. Our physician reviewer found that a 
low dose screening CT should be ordered, as it will be a lower cost and expose the enrollee to less radiation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CT scan of the thorax have not been met. Therefore, we decided that the Plan 
does not have to pre-approve CT scan of the thorax.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 72170 billed for date of service December 4, 
2022. 
 You asked the Plan to pay for procedure code 72170. You say that the service is coded appropriately. The Plan 
denied your request. The Plan says payment for code 72170 is bundled into payment for code 73502. 
 
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 72170 
is a column II code to column I code 73502. This claim has not been billed with an appropriate modifier to 
bypass the edit. 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 72170 billed for date of service December 4, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral radiographic images (D0220 and D0230) 
provided on November 30, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to cover the amount 
that was charged on the claim. The Plan denied your request. The Plan says your benefit for the requested items 
or services has 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 Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested items or services was exhausted on the date of service of May 4, 2022. 
Therefore, we decided that the Plan does not have to pay for the intraoral radiographic images (D0220 and 
D0230) provided on November 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bone replacement graft and therapeutic parenteral drugs 
(D7953, D9612) provided on November 23, 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 bone 
replacement graft and therapeutic parenteral drugs (D7953, D9612) provided on November 23, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the observation room service provided on 
October 25, 2022. 
 
You asked the Plan to waive the coinsurance for the observation room service. You say that you were not 
aware there was a coinsurance. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for in-network outpatient surgery, including services provided at hospital outpatient facilities.  
You have been asked to pay 20% coinsurance for the observation room service. This item/service falls within 
the in-network outpatient surgery, including services provided at hospital outpatient facilities benefit category. 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. The total you owe is 
$33.48 ($167.38 allowed amount x 20% = $33.48). Therefore, we decided that the Plan does not have to waive 
the coinsurance for the observation room service provided on October 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a palliative treatment of dental pain (D9110) provided by an 
out-of-network provider on December 23, 2022. 
 
You asked the Plan to pay for the dental service. You say that you were told that you had out-of-network 
coverage and it was an emergency situation to see the specialist. 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. Also, it was verified the enrollee did not ask about out-of-network coverage or confirmed the 
provider's contract status. 
 
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 palliative treatment of dental pain (D9110) provided by an out-of-network provider on December 
23, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 26145-F2, 26145-59-F2, and 26145-59-F3 x 
2 provided on December 2, 2022. 
 
You asked the Plan to pay for procedure codes 26145-F2, 26145-59-F2, and 26145-59-F3 x 2. You say that the 
medical records support the billing of codes procedure codes 26145-F2, 26145-59-F2, and 26145-59-F3 x 2. 
The Plan denied your request. The Plan says the medical records do not support the billing of codes procedure 
codes 26145-F2, 26145-59-F2, and 26145-59-F3 x 2. 
 
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 26145 is Synovectomy, tendon sheath, radical 
(tenosynovectomy), flexor tendon, palm and/or finger, each tendon. 
 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 26145-F2, 26145-59-F2, and 26145-59-F3 x 
2. Our reviewer says that the medical records do not support the billing of codes procedure codes 26145-F2, 
26145-59-F2, and 26145-59-F3 x 2. Our reviewer found per the reviewed documentation, procedure code 
26145-F2 is not supported by the medical records submitted. The operative report did not include 
documentation of a radical (tenosynovectomy) flexor tendon sheath synovectomy, for each tendon of the palm 
and/or finger; therefore, this code cannot be verified. Procedure code 26145-59-F2 is not supported by the 
medical records submitted. The operative report did not include documentation of a radical (tenosynovectomy) 
flexor tendon sheath synovectomy, for each tendon of the palm and/or finger; therefore, this code cannot be 
verified. Procedure code 26145-59-F3 x2 is not supported by the medical records submitted. The operative 
report did not include documentation of a radical (tenosynovectomy) flexor tendon sheath synovectomy, for 
each tendon of the palm and/or finger; therefore, this code cannot be verified. 
 
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 26145-F2, 26145-59-F2, and 26145-59-F3 x 2 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes 26145-F2, 26145-59-F2, and 
26145-59-F3 x 2 provided on December 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for debridement procedures on the skin provided on January 02, 
2023. 
 
You asked the Plan to pay for debridement procedures on the skin. You say that these services are medically 
necessary. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for debridement procedures 
on the skin provided on January 02, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from May 19, 2021, to 
June 17, 2021. 
 
You asked the Plan to pay for the home health services as billed. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says there is not plan of care or 
valid order for the dates of service billed. 
 
The Plan follows Medicare rules. The rules say that HHAs may not submit a claim until after all services are 
provided for the period and the physician has signed the plan of care and any subsequent verbal order. 
 
We looked at the file and Medicare rules. The file shows that there is no plan of care or valid order for the dates 
of service at issue. Therefore, we decided that the Plan does not have to pay for the home health services 
provided from May 19, 2021, to June 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation, intraoral x-rays, and a crown 
(D2740, D0140, D0230, D0220) provided on January 3, 2023. 
 
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 limited 
oral evaluation, intraoral x-rays, and a crown (D2740, D0140, D0230, D0220) provided on January 3, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service September 
10, 2022, to October 7, 2022. 
 
You asked the Plan to pay for procedure code S9328. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the billed code is invalid for Medicare 
purposes. 
 
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 S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service September 10, 2022, to October 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. 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 ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found a home ventilator is not medically necessary. There is no arterial blood gas (ABG) done while stable to confirm chronic carbon dioxide (CO2) 
retention. If that is confirmed, the enrollee may benefit from bilevel positive airway pressure (BiPAP) with 
average volume-assured pressure support (AVAPS) during sleep as an outpatient. Medicare does not cover a 
home ventilator when used at settings that can be provided with BiPAP. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.