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

 
We decided that the Plan does not have to pay for procedure code 76642 billed for date of service September 
21, 2022. 
 
You asked the Plan to pay for procedure code 76642. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed.  
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 76642 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
Based on this information, we decided that Medicare rules for coverage of procedure code 76642 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 76642 billed for date of 
service September 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a dental filling (D2392) provided on October 22, 2022, by an 
out-of-network provider. 
 
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 dental services were received from an out-of-
network provider and are not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a dental filling (D2392) provided on October 22, 2022, by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a tooth extraction (D7210) provided on October 5, 
2022. 
 
You asked the Plan to pay more 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 you are responsible for any charged 
amount above the Plans cost-sharing amount when your services are received from an out-of-network 
provider. 
 
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. 
 
 
  You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to pay more for a tooth extraction (D7210) provided on 
October 5, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Repatha Sureclick. 
 
You asked the Plan to pre-approve Repatha Sureclick. You say that the patient has tried and failed multiple 
statins and cannot tolerate them. The Plan denied your request. The Plan says this drug is not covered under the 
patient's medical benefits. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Repatha Sureclick.  
 
Benefits for Repatha Sureclick may be available under Medicare Part D. Contact the Plan that administers Part 
D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental code D9310 (Consultation- diagnostic service 
provided by a dentist or physician). 
 
You asked the Plan to pre-approve code D9310. You say that you have provided x-rays to support 
authorization. The Plan denied your request. The Plan says the service represented by this dental code is not 
covered under the patient's 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 
dental code D9310 (Consultation- diagnostic service provided by a dentist or physician).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service October 19, 
2022. 
 
You asked the Plan to pay for procedure code 76641. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed. 
 The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
Based on this information, we decided that Medicare rules for coverage of procedure code 76641 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 76641 billed for date of 
service October 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intraoperative neuromonitoring (IONM) services 
provided during a spinal cord stimulator placement procedure on June 1, 2022. 
 
You asked the Plan to pre-approve the IONM services. You say that these services were medically necessary 
and were billed correctly. The Plan denied your request. The Plan says the criteria for IONM testing were not 
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 the IONM services. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found intraoperative neurophysiological monitoring is generally not considered medically necessary 
during placement of a spinal cord stimulator. The available clinical documentation in the case file does not 
support that intraoperative neurophysiological monitoring was medically necessary for the enrollee in this case. 
 
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 IONM services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the intraoperative neuromonitoring (IONM) services provided during a spinal cord 
stimulator placement procedure on June 1, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service October 26, 
2022. 
 
You asked the Plan to pay for procedure code 76641. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed.  
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
Based on this information, we decided that Medicare rules for coverage of procedure code 76641 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 76641 billed for date of 
service October 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on October 20, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the service 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 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 dental 
services on October 20, 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 follows Medicare rules. Medicare rules say that cardiac event monitors 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 placement of an ILR. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found there is no documentation provided 
to suggest a history of unexplained syncope or any other apparent indication for an ILR. In summary, 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: Favorable

 
We decided that the Plan has to pre-approve Ruxience. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says that medical studies have not proven that this drug is helpful for treatment of 
autoimmune neutropenia. 
 
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 the drug. Our reviewer says that the 
requested drug is medically reasonable and necessary. Our physician reviewer found that autoimmune 
neutropenia is a rare disorder. There are no established guidelines for treatment. This patient has been on 
steroids with significant side effects and now no longer effective. Rituximab has been shown to be effective in 
numerous case reports and is supported by the medical literature. The service is reasonable and medically 
necessary. Rituximab is likely to be safe and effective given multiple indications in other autoimmune 
disorder.  
 
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 drug have been met. Therefore, we decided that the Plan has to pre-approve 
Ruxience.  
 
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 waive the copayment for Medicare Part B injections provided from 
July 25, 2022, to September 26, 2022. 
 
You asked the Plan to waive the copayment for Medicare Part B injections. You say that you are unable to 
afford the monthly cost share for the Part B injections. 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 Medicare Part B chemotherapy and non-chemotherapy prescription drugs.  
 
 
 
 
 You have been asked to pay a total coinsurance of $744.17, which is 20% of the allowed amount for Medicare 
Part B injections.  
 
Date of Service Procedure Amount Allowed Amount Per 
Contract 
Amount Owed 
07/25/22 Bevacizumab Injection 
(J9035) 
$69.23 20% coinsurance $13.85 
08/22/22 Aflibercept Injection 
(J0178) 
$1,825.78 20% coinsurance $365.16 
09/26/22 Aflibercept Injection 
(J0178) 
$1,825.78 20% coinsurance $365.16 
Total    $744.17 
 
This item/service falls within the Medicare Part B prescription drugs 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. Therefore, we decided that the Plan 
does not have to waive the copayment for Medicare Part B injections provided from July 25, 2022, to 
September 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) and segmental 
pneumatic appliance (E0673) provided May 27, 2022. 
 
You asked the Plan to pay for a pneumatic compression device and appliance. You say that you are not 
contracted with the facility or the prescribing physician and do not receive payment from either provider. The 
Plan denied your request. The Plan says pneumatic compression device is not covered by Medicare to prevent 
deep vein thrombosis during and/or following surgery. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675) and segmental pneumatic appliance (E0673) provided May 
27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endoskeletal system, below knee, alignable system 
(L5910). 
 
You asked the Plan to pre-approve the service. You say that the item is medically necessary. The Plan denied 
your request. The Plan says the notes do not show why the enrollee's current alignable system cannot be used 
with the new socket 
 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 service. Our physician reviewer 
found the documentation indicates that the enrollee requires a new socket that has been authorized by the Plan. 
There is no indication that the prosthesis requires a new alignable system. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve endoskeletal system, below knee, alignable system (L5910).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. 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. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
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 Prolia. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found in this case, the enrollee has not tried and 
failed the required drugs. There is no documentation provided indicating that the plans required drugs would 
likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoperative neurological testing provided on 
November 23, 2021, billed with codes 95870 and G0453. 
 
You asked the Plan to pay for the testing as billed. You say that this was billed correctly for medically 
necessary monitoring services. The Plan denied your request. The Plan says the diagnosis code reported is not 
valid for these services. 
 
The Plan must follow Medicare rules. Medicare rules say that codes G0453 and 95870 are covered when 
provided for a diagnosis which supports medical necessity. The reported diagnosis code is not among the covered diagnoses. Therefore, we decided that the Plan does not have to pay for the intraoperative neurological 
testing provided on November 23, 2021, billed with codes 95870 and G0453.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service October 19, 
2022. 
 
You asked the Plan to pay for procedure code 76641. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed.  
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
Based on this information, we decided that Medicare rules for coverage of procedure code 76641 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 76641 billed for date of 
service October 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on October 12, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory 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 laboratory services related to end-stage renal disease (ESRD) provided on October 
12, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service October 13, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service October 13, 
2022.
Appeal type: Drugs
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 based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that cardiac event monitors 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 placement of an ILR. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found there is no documentation provided 
to suggest a history of unexplained syncope or any other apparent indication for an ILR. In summary, 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).