Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (code D0150), a panoramic 
film (code D0330) provided on March 29, 2022 and does not have to waive the coinsurance for surgical 
removal of erupted tooth (code D7210) provided April 11, 2022. 
 
You asked the Plan to pay for the dental services. You say that you have dental insurance and these services 
should be covered. The Plan denied your request. The Plan says your benefit for a comprehensive oral 
evaluation and a panoramic film has already been exhausted and the Plan has paid the claim correctly for 
surgical removal of erupted tooth. 
 
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, certain limitations apply. The record 
shows your benefit for a comprehensive oral evaluation (code D0150) and a panoramic film (code D0330) was 
exhausted on April 29, 2021. The records shows that the Plan paid the claim correctly for surgical removal of 
erupted tooth. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation 
(code D0150), and a panoramic film (code D0330) and does not have to waive the coinsurance for the surgical 
removal of erupted tooth (code D7210) provided on April 11, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a third level of facet joint injection. 
 
You asked the Plan to pre-approve the additional facet joint injection level. You say that these injections have 
helped you to be at a higher level of function with less pain. The Plan denied your request. The Plan says the 
first two spinal levels are approved for injection. However, there is no medical necessity for the additional 
requested level. 
 
The Plan follows Medicare rules. Medicare rules say that facet joint injections are covered for patients with 
certain types of pain. Up to two levels are covered, and additional levels may only be covered when supporting 
information is submitted on appeal. 
 
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 additional facet joint injection level. 
Our reviewer says that the requested third level of injection is not considered medically reasonable and 
necessary. Our physician reviewer found the enrollee is a female with back pain without radicular components. 
She has had chiropractic therapy and continues with physical therapy. On February 8, 2022, she received intra-
articular lumbar facet joint injection L3-4, L4-5, and L5-S1(lidocaine plus depo Medrol injected in each facet 
joint). She gets 3-4 months of relief when she is able to get the injections. 
 
The patient meets the criteria for 2 levels of facet injections. The third level exceeds utilization criteria and 
therefore is considered not medically reasonable or necessary. There is no compelling rationale to bypass this 
limitation. 
 
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 additional facet joint injection level have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a third level of facet joint injection.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Infuse allograft services. 
 
You asked the Plan to pre-approve Infuse allograft services. You say that the records provided support the need 
for Infuse allograft services. The Plan denied your request. The Plan says the clinical value and effectiveness of 
Infuse allograft in the setting of posterior spinal fusion with the Medtronic Crescent cage have not been 
demonstrated in the peer-reviewed literature. 
 
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 Infuse allograft services. Our reviewer 
says that Infuse allograft services are not considered medically reasonable and necessary in this case. Our physician reviewer found Infuse is not FDA approved to be used in a posterior TLIF approach to the spine. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Infuse allograft services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Infuse allograft services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the four localized deliveries of antimicrobial agents (D4381 
x4), four gingival irrigations (D4921 x4), and drugs or medicaments dispensed in the office for home use 
(D9630) provided from March 30, 2022, to April 11, 2022. 
 
You asked the Plan to pay for the localized deliveries of antimicrobial agents, gingival irrigations, and drugs or 
medicaments. You say that you would like to be reimbursed for these services. The Plan denied your request. 
The Plan says these services are 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 pay for the four 
localized deliveries of antimicrobial agents (D4381 x4), four gingival irrigations (D4921 x4), and drugs or 
medicaments dispensed in the office for home use (D9630) provided from March 30, 2022, to April 11, 2022.  
 
Your complaint about how upset you are with the Plan is not a valid appeal for medical coverage. This part of 
your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 20930 and 20936 billed for date of service 
February 11, 2022. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says procedure 
codes 20930 and 20936 are considered bundled and 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 procedure code. 
 
We find that procedure codes 20930 and 20936 have a status indicator of B on the Physician Fee Schedule. 
This means that the procedure codes are not separately payable. Based on this information, we decided that 
Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure codes 20930 and 20936 billed for date of service February 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve infrared therapy services. 
 
You asked the Plan to pre-approve infrared therapy services. You say that this is medically reasonable and 
necessary for the enrollee's condition. The Plan denied your request. The Plan says this service is not covered 
by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that there is sufficient evidence to conclude the use of 
infrared therapy devices and any related accessories is not reasonable and necessary. Based on this information, 
we decided that Medicare rules for coverage of infrared therapy services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve infrared therapy services.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the crown - porcelain/ceramic (D2740) provided January 12, 2022. 
 
You asked the Plan to pay for the crown. You say that this service was necessary. The Plan denied your 
request. The Plan says that this service is not covered when necessary as a result of abrasion or attrition. 
 
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. Specifically, no medical records or x-rays have been provided to review whether 
the Plans denial is correct. Therefore, we decided that the Plan has to pay for the crown - porcelain/ceramic 
(D2740) provided January 12, 2022.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on October 28, 2021 billed with 
codes 81206 and 81292. 
 
You asked the Plan to pay for the genetic testing billed. 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. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code.  
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
October 28, 2021 billed with codes 81206 and 81292.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an expandable controller and related accessories (E2377, E2313, 
E2311). 
 
You asked the Plan to pre-approve an expandable controller and related accessories. You say that these items 
are medically necessary. The Plan denied your request. The Plan says that there is no medical need for the 
expandable controller. 
 
The Plan follows Medicare rules. Medicare rules say that an expandable controller is subject to the rules listed 
in the Medicare rules section. 
 
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 expandable controller and related 
accessories. Our reviewer says that the requested expandable controller is medically reasonable and necessary. 
Our physician reviewer found the enrollee is a 68-year-old male with past medical history of cerebrovascular 
accident with left sided weakness requiring power wheelchair for mobility. Authorization for group 3 power 
chair with 2 power functions and electronic connection to controller is being requested. In this case, the clinical 
documentation states that the enrollee requires the electronic connection of power functions to the expandable 
controller because of limited range of motion in upper limbs. Therefore, the requested items are 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 an expandable controller and related accessories have been met. Therefore, we 
decided that the Plan has to pre-approve an expandable controller and related accessories (E2377, E2313, 
E2311).   
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 14 additional physical therapy visits. 
 
You asked the Plan to pre-approve additional physical therapy visits. You say that the additional physical 
therapy visits are medically reasonable and necessary. The Plan denied your request. The Plan says beyond the 
physical therapy visits that have been approved, the additional services are not medically reasonable and 
necessary.  
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 additional physical therapy visits. Our 
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration 
of the enrollee's condition. Our physician reviewer found that the enrollee is an 81-year-old male with a past 
medical history including previous stroke with hemiplegia who has been receiving outpatient therapy to help 
their mobility and their ability to accomplish self-care tasks. The documentation indicates the enrollee is able to 
ambulate with a walker and has had improved ability to dress themselves.   
 
In this case, the enrollee has previously been treated with outpatient therapies and should be independent with a 
home exercise program. There is no documentation of a recent injury or decline in function. The additional 
therapy services are not an appropriate duration and frequency for treatment of the enrollees medical condition 
and therefore are 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 additional physical therapy visits have not been met. Therefore, we decided that 
the Plan does not have to pre-approve 14 additional physical therapy visits.
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 records provided support the need for 
the requested drug. The Plan denied your request. The Plan says the requested drug is self-administered and is 
excluded from coverage under Part B. The Plan says that the enrollee does have a pharmacy drug benefit 
administered. 
 
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 pay for the crowns - porcelain fused to high noble metal (D2750) 
provided April 22, 2022. 
 
You asked the Plan to pay for the crowns. You say that you were in pain and the crowns were necessary to eat. 
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 
crowns - porcelain fused to high noble metal (D2750) provided April 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for diabetic supplies (K0553) provided September 26, 2021.
You asked the Plan to pay for the diabetic supplies. You say that the items were medically necessary. The Plan denied your request. The Plan says this brand is not covered.
The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred brands. We looked at the file and Medicare rules. The diabetic supplies provided were not the plan's preferred brand. The record does not show a medical exemption. Based on this information, we decided that Medicare rules for coverage of the diabetic supplies have not been met. Therefore, we decided that the Plan does not have to pay for diabetic supplies (K0553) provided September 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an additional unit of chemotherapy administration (96413) 
billed for date of service January 12, 2022. 
 You asked the Plan to pay for additional chemotherapy administration. You say that the service at issue was a 
medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not 
been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
CPT code 96413 has an MUE of 1. This means that 1 unit of service is supported and has been approved by the 
Plan. Any further units of service are not supported. Based on this information, we decided that Medicare rules 
for coverage of additional chemotherapy administration have not been met. Therefore, we decided that the Plan 
does not have to pay for an additional unit of chemotherapy administration (96413) billed for date of service 
January 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for implant maintenance (D6080) provided on January 18, 2022. 
 
You asked the Plan to pay for implant maintenance. You say that you disagree with the denial of dental 
services. The Plan denied your request. The Plan says implant maintenance (D6080) is not covered by 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 implant 
maintenance (D6080) provided on January 18, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Kanjinti. 
 
You asked the Plan to pre-approve Kanjinti. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested drug is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Kanjinti. Our reviewer says that the 
documentation does not support that the requested drug is medically reasonable or necessary. Our physician 
reviewer found the enrollee has a diagnosis of metastatic gastroesophageal junction adenocarcinoma. The 
documentation indicates that the enrollee has a score of 0 and has had disease progression on 
previous checkpoint inhibitor therapy. The Food and Drug Administration has 
not stated that the requested drug regimen is indicated for the enrollee's condition. The Medicare approved cancer drug compendia do not contain a supportive citation for the use of the requested drug regimen in the 
enrollee's clinical situation. Therefore, the enrollee does not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Kanjinti have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Kanjinti.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unspecified mass spectrometry provided along with drug 
testing on October 6, 2021, billed with code 83789. 
 
You asked the Plan to pay for the unspecified mass spectrometry. You say that this testing was medically 
necessary. The Plan denied your request. The Plan says the drug testing itself has been approved, but the code 
83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the unspecified mass spectrometry have not been met. Specifically, we find that the testing 
described by the billed code is considered specimen validity testing which is not separately payable. Therefore, 
we decided that the Plan does not have to pay for the unspecified mass spectrometry provided along with drug 
testing on October 6, 2021, billed with code 83789.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Orthotic(s) management and training (97760) provided 
on February 22, 2021. 
 You asked the Plan to pay for code 97760. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. The rules say that outpatient rehabilitation claims must include one of 
the GN, GO, or GP modifiers. 
 
We looked at the file and Medicare rules. The file shows that the claim was not billed with one of the required 
GN, GO, or GP modifiers. 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 Orthotic(s) 
management and training (97760) provided on February 22, 2021.